Acute otitis media remains the most common diagnosis for which antibiotics are prescribed in children in the United States.^1,2 Approximately 15 million prescriptions are written every year, amounting to a cost conservatively estimated in the hundreds of millions of dollars.³

Acute otitis media (AOM) is defined in accordance with the Agency for Healthcare Research and Quality (AHRQ) as the acute onset of signs or symptoms of middle ear inflammation in association with a middle ear effusion.⁴ AOM is a disease predominately found in young children, with the incidence rate sharply declining after 5 years of age. The pathogens are primarily bacterial in origin, with viruses accounting for approximately one-third of cases.⁵

Historically in the United States, AOM always has been treated with antibiotics, even if the diagnosis is in question. Often, a child with a fever and runny nose whose tympanic membrane is only slightly erythematous will be diagnosed with AOM and given a 10-day course of antibiotics. Is this good medicine?

To answer that question, we must first understand the natural history of AOM. AOM is a disease that spontaneously resolves in more than 80% of children.^6-9 Appreciation of this fact is perhaps the single most important take-home point from this article, because the excessive and inappropriate use of antibiotics has been linked to a rising prevalence of penicillin-resistant S. pneumoniae.¹⁰ Penicillin-resistant S. pneumoniae increased from 27.5% in 1995 to 43.8% in 1997.¹¹

For more than 20 years, physicians in the Netherlands have used a treatment strategy for selected patients with AOM that withholds antibiotics for an initial observation period of 2-3 days. During that time, treatment is restricted to analgesics and antipyretics. Antibiotics are given only to those patients who fail to improve at the end of the observation period or whose condition worsens during the observation period.

As a result of this policy, the proportion of patients given antibiotics for AOM in the Netherlands is approximately 31%, and the resistance of S. pneumoniae remains below 1%.10,12

Although historically the standard approach to the treatment of AOM in the United States has been to administer antibiotics for all cases, concern about the rising rate of bacterial resistance and the success of the Dutch experience with initial observation have led to a shift in the treatment paradigm for AOM.

In the late 1990s, the New York State Department of Health assembled a committee of physicians whose purpose was to formulate a more judicious approach to the use of antibiotics for AOM. The culmination of the committee's work was a treatment strategy called the observation option, based closely on the Dutch model.