51 Overuse of ceftriaxone in children with otitis media: experience at a Canadian tertiary care hospital
Bibliographic record
Abstract
Abstract Background Acute otitis media (AOM) is extremely common. In fact, most children experience at least one ear infection before starting school. It is also recognized as the most frequent reason to administer antibiotics in children. However, many advocate for limited use of antibiotics in healthy children over 6 months of age using a watchful waiting approach. This applies even more for broad-spectrum antibiotics in the context of antibiotic stewardship. The Canadian Paediatric Society (CPS) recommends using parenteral ceftriaxone only when oral drugs are not tolerated or amoxicillin-clavulanate fails. Objectives This primary aim of this study was to describe the use of ceftriaxone in the treatment of children with AOM. Secondary aims were to assess length of therapy and complications as well as determine if the use of ceftriaxone met the criteria of refractory AOM suggested by the CPS. Design/Methods We performed a retrospective observational cohort study of children aged between the ages of 6 months and 5 years with a diagnosis of AOM at a single tertiary care center. All children were seen between March 2017 and February 2019 in a pediatric outpatient medical day unit and received at least one dose of ceftriaxone. Chart review was performed and multiples variables were included in the analysis. Patients with insufficient chart data or with a congenital ear anomaly were excluded. Results A total of 276 patients were included. Patients were aged 17.5 ± 9 months and a majority were boys (N=160). Most patients were fully immunized (N=252). A history of penicillin allergy was reported for 59 patients. Previous AOM was common (N=205) while tympanostomy tubes were rare (N=12). With regards to the diagnosis of AOM, a majority (N=153) had bilateral AOM. Diagnosis of AOM was based on inflammation (N=204), bulging tympanic membrane (N=158) or middle ear effusion (N=118). Fourteen patients had a tympanic perforation. Almost all patients were febrile (N=266). One patient had a positive blood culture (streptococcus pneumoniae) and one had a mastoiditis. Among those who underwent bloodwork (N=212), white blood count was 15.2 ± 6.7 x 109. With regards to antibiotics, most patients (N=218) were initially given oral antibiotics, with amoxicillin given as a first line therapy for 99 patients. A minority of patients received amoxicillin-clavulanate prior to receiving ceftriaxone (N=105). Reasons for the use of ceftriaxone included intolerance to oral drugs (N=18), failure of (or recent exposure to) amoxicillin-clavulanate (N=89) and a history of penicillin allergy (N=50). Most patients were treated with a course of three days with only 51 patients receiving one or two doses. Conclusion In our cohort, the use of ceftriaxone was not limited to nonresponsive AOM. In fact, a minority of patients received ceftriaxone in the setting of intolerance to oral drugs or failure of amoxicillin-clavulanate. This goes against current CPS recommendations and suggests an overuse of broad-spectrum antibiotics. Obviously, this needs to be addressed in the context of antibiotic stewardship.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.002 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".