CUTE OTITIS MEDIA (AOM) IS the most common childhood infection for which antibiotics are prescribed in the United States. 1-3 A study using 2006 Medical Expenditure Panel Survey data demonstrated an average expenditure of $350 per child with AOM, totaling $2.8 billion. 4 Timely and accurate diagnosis and appropriate management of AOM may have significant consequences for ambulatory health care utilization and expenditures. Multiple systematic reviews on AOM diagnosis and management have been conducted, 5-10 including our 2001 study, 11 which was the basis for the 2004 American Academy of Pediatrics and American Academy of Family Physicians joint practice guidelines. 12 Since then, new trials have been published, the heptavalent pneumococcal conjugate vaccine (PCV7) has become widely used, and clinician practice has changed regarding antibiotic choice for AOM. 13 Context Acute otitis media (AOM) is the most common condition for which antibiotics are prescribed for US children; however, wide variation exists in diagnosis and treatment. Objectives To perform a systematic review on AOM diagnosis, treatment, and the association of heptavalent pneumococcal conjugate vaccine (PCV7) use with AOM microbiology. Data Sources PubMed, Cochrane Databases, and Web of Science, searched to identify articles published from January 1999 through July 2010. Study Selection Diagnostic studies with a criterion standard, observational studies and randomized controlled trials comparing AOM microbiology with and without PCV7, and randomized controlled trials assessing antibiotic treatment. Data Extraction Independent article review and study quality assessment by 2 investigators with consensus resolution of discrepancies. Results Of 8945 citations screened, 135 were included. Meta-analysis was performed for comparisons with 3 or more trials. Few studies examined diagnosis; otoscopic findings of tympanic membrane bulging (positive likelihood ratio, 51 [95% confidence interval {CI}, 36-73]) and redness (positive likelihood ratio, 8.4 [95% CI, 7-11]) were associated with accurate diagnosis. In the few available studies, prevalence of Streptococcus pneumoniae decreased (eg, 33%-48% vs 23%-31% of AOM isolates), while that of Haemophilus influenzae increased (41%-43% vs 56%-57%) pre-vs post-PCV7. Short-term clinical success was higher for immediate use of ampicillin or amoxicillin vs placebo (73% vs 60%; pooled rate difference, 12% [95% CI, 5%-18%]; number needed to treat, 9 [95% CI, 6-20]), while increasing the rate of rash or diarrhea by 3% to 5%. Two of 4 studies showed greater clinical success for immediate vs delayed antibiotics (95% vs 80%; rate difference, 15% [95% CI, 6%-24%] and 86% vs 70%; rate difference, 16% [95% CI, 6%-26%]). Data are absent on long-term effects on antimicrobial resistance. Meta-analyses in general showed no significant differences in antibiotic comparative effectiveness. Conclusions Otoscopic findings are critical to accurate AOM diagnosis. AOM microbiology has changed with use of PCV7. Antibiotics are modestly mo...

No abstract

No abstract

Little improvement in physician documentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate housestaff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items.