Poor adherence to antibiotic prescribing guidelines in acute otitis media--obstacles, implications, and possible solutions

Abstract

Many countries now have guidelines on the clinical management of acute otitis media. In almost all, the public health goal of containing acquired resistance in bacteria through reduced antibiotic prescribing is the main aim and basis for recommendations. Despite some partial short-term successes, clinical activity databases and opinion surveys suggest that such restrictive guidelines are not followed closely, so this aim is not achieved. Radical new solutions are needed to tackle irrationalities in healthcare systems which set the short-term physician-patient relationship against long-term public health. Resolving this opposition will require comprehensive policy appraisal and co-ordinated actions at many levels, not just dissemination of evidence and promotion of guidelines. The inappropriate clinical rationales that underpin non-compliance with guidelines can be questioned by evidence, but also need specific developments promoting alternative solutions, within a framework of whole-system thinking. Promising developments would be (a) physician training modules on age-appropriate analgesia and on detection plus referral of rare complications like mastoiditis, and (b) vaccination against the most common and serious bacterial pathogens.

Fig. 1

Trends between 1999 and 2007 in penicillin-resistant Streptococcus pneumoniae by country. Reproduced with permission from European Antimicrobial Resistance Surveillance System Annual report 2007 [29]. Available at: http://www.earss.rivm.nl. Data retrieved February 2009. Each bar represents the findings from a single year. The arrows indicate the significant trends observed for all resistant strains (black arrows) or fully penicillin-resistant strains (red arrows). The stars indicate significant trends in the overall national data that were, non-significantly, supported by data from laboratories reporting all 9 years. IE Ireland, IL Israel, IT Italy, BE Belgium, NL Netherlands, DK Denmark, FI Finland, FR France, DE Germany, ES Spain, SE Sweden, UK United Kingdom

Fig. 2

Vicious seven-stage spiral of antibiotic resistance in a core transmission group of preschoolers illustrated in the contrast between France and Germany. The boxes indicate forces which would exist without the spiral but which help to drive it