effect of antibiotics for otitis media on mastoiditis in children_ a ...课件

EffectofAntibioticsforOtitisMediaonMastoiditisinChildren ARetrospectiveCohortStudyUsingtheUnitedKingdomGeneralPracticeResearchDatabase PediatricResidents JournalClubFebruary5 2009SaraSzkola PaulaLouiseThompson RuthE Gilbert PaulF Long SoniaSaxena MikeSharland andIanChiKeiWongPediatrics2009 123 424 430 Background OtitismediaisthemainreasonchildrenvisittheirdoctorintheUKThoughmostcasesofotitismediaareself limiting rarelychildrencangoontodevelopcomplicationssuchasmastoiditisAntibioticprescriptionsforotitismediahavedecreasedinrecentyears andotherstudieshavedocumentedaconcurrentincreaseinhospitaladmissions 1 2 3 Thisstudyaimedtodetermineifthisisacausalrelationshipbetweendecreasedantibioticuseandincreasedcomplications ie mastoiditis orifitisduetochangesin accesstoservices referralpatternsandcodingofroutinedata Thatis doesitmakesensetogiveantibioticsforotitismediaforthepurposeofpreventingmastoiditis StudyDesign DataweredrawnfromtheGeneralPracticeResearchDatabase adatabasethatdrawsfrompracticesallovertheUKandincludesinformationonallactivepatientsChildrenaged3monthsto15yearswhowereinthisdatabasefrom1990 2006wereincluded2exclusions childrenwhoweren twith uptostandard practice MDnotrecordingalldata and temporarilyregistered children ie 1visittodifferentMDthantheirown StudyDesignContinued DataAnalysis Agespecificincidencerates alongwithcalendar yearspecificincidencerates formastoiditiswithandwithoutotitismediawerecalculatedper1000childyearsatriskIncidencerateswerealsocalculatedforotitismediaandforantibiotic prescribingforotitismediaThentheycalculatedtherelativeriskofchildrenwithotitismediadevelopingmastoiditiswithandwithoutantibiotctreatment Whatareallthesestatistics Incidencerateper1000childrenyearsmeansthenumberofnewcasesperunitofperson timeatrisk Thatis Iftheincidentrateis10per1000childrenyears theninapopulationof1000children 10wouldbeexpectedtodevelopotitismediain1year Ifyouobservedthepopulationfor2yearsinsteadof1 then20wouldbeexpectedtodevelopotitismedia youdividethenumberofcasesbythenumberofyears Whatdidtheyfindout Oftheapproximately2 6millionchildreninthedatabase 854hadmastoiditis Onlyabout1 3 288children ofthisgrouphadprecedingotitismedia Therewereapproximately1 2millionepisodesofotitismedia ofthesechildren 288wentontodevelopmastoiditis Forthechildrenwithotitismedia antibiotictreatmentloweredtheriskofmastoiditisfrom3 8 10 000to1 8per10 000 Moreinterestingtrends Theyalsofoundthatwhiletheincidenceofantibioticprescribingforotitismediasteadilydecreasedoverthetimeperiodofthestudy 1990 2006 theincidenceofmastoiditisremainedstable Whatdoesthismeanforme Youwouldhavetotreatanaverageof4831episodesofotitismediatopreventoneepisodeofmastoiditisDecreasedprescribingofantibioticsdidnotcauseanincreaseinmastoiditisAntibioticsshouldnotberoutinelygivenforotitismediaforthepurposeofpreventingmastoiditis CriticalReview Wasthetypeofstudystrong YesThisarticlecontainedacombinationofcohort otitismediagroup andcasecontrol mastoiditisgroup studies bothappropriatetolookforcausation Wastheassessmentofexposureandoutcomefreeofbias Mostly Theinvestigatorsweren tdeterminingwhohadmastoiditisorotitismedia andsocouldn tinfluencethoseresultsBut thecodinganddiagnosismayvaryamongpractices ie codingforotitismediavsURI Also noteveryonewhowasprescribedantibioticslikelytookthem Wastheassociationbothsignificantandclinicallyimportant Itwasstatisticallysignifcant but Astheauthorsclearlymention notveryclinicallyimportant becausethenumberneededtotreatforotitismediatopreventmastoiditisistoohightobepracticalWhiletheirresultswon tlikelychangethetrendofprescribinglessantibioticsforotitismedia theycanmakeusfeelbetterthatwearen tputtingpatientsatveryhighriskformastoiditis Wastheassociationconsistentacrossstudies YesandNoOtherstudiesfoundsimilarratesofmastoiditisintheUKHowever otherstudiesalsopointedtomastoiditispeakinginchildrenages1 4 whilethisstudyfoundthehighestincidentsinadolescents Wasthecauseshowntoprecedetheeffect YesInboththemastoiditisgroupandtheotitismediagroup otitismediawasclearlyshowntoprecedethemastoiditisInaddition antibioticadministrationforotitismediaprecededmastoiditis Wasthereadose responserelationship Notapplicabletothisarticle thoughitwouldhavebeeninterestingtoinvestigateincidenceofmastoiditiswithhigh dosevslow doseantibiotics orwithseverityofotitismedia StrengthsofthisArticle Largesamplesizeof2 6millionchildrenLongperiodoftimewhichalloweddocumentationoftrendofdecreasedantibioticusewithstablemastoiditisrates WeaknessesofThisArticle CodingpracticescanvaryamongpracticesDiagnosiscanvaryamongpracticesDidnotdefinehighriskgroupforwhichantibioticsshouldbegiventopreventmastoiditis TakeHomePoints Helpfularticlethatwillnotnecessarilychangepractice but Wecanbereassuredthatingeneralwearenotputtingchildrenatveryhighriskformastoiditisifwedonotgiveantibioticsforotitismedia Acknowledgments ThankyoutoDr QuinlanandDr Goldsteinfortheirhelpinthisjournalclub References 1 LittleP WatsonL MorganS WilliamsonI Antibioticprescribingandadmissionswithmajorsuppurativecomplicationsofrespiratorytractinfections adatalinkagestudy BrJGenPract 2002 52 476 187 1932 MajeedA WilliamsS JarmanB AylinP Prescribin