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Abstract
Objectives To appraise European guidelines for acute otitis media (AOM) in children, including methodological quality, level of evidence (LoE), astrength of recommendations (SoR), and consideration of antibiotic stewardship.
Design Systematic review of the literature.
Data sources Three-pronged search of (1) databases: Medline, Embase, Cochrane library, Guidelines International Network and Trip Medical Database; (2) websites of European national paediatric associations and (3) contact of European experts. Data were collected between January 2017 and February 2018.
Eligibility criteria National guidelines of European countries for the clinical management of AOM in children aged <16 years.
Data extraction and synthesis Data were extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. LoE and SoR were compared. Guidelines were assessed for principles of antibiotic stewardship.
Results AOM guidelines were obtained from 17 or the 32 countries in the European Union or European Free Trade Area. The mean AGREE II score was ≤41% across most domains. Diagnosis of AOM was based on similar signs and symptoms. The most common indication for antibiotics was tympanic membrane perforation/otorrhoea (14/15; 93%). The majority (15/17; 88%) recommended a watchful waiting approach to antibiotics. Amoxicillin was the most common first-line antibiotic (14/17; 82%). Recommended treatment duration varied from 5 to 10 days. Seven countries advocated high-dose (75–90 mg/kg/day) and five low-dose (30–60 mg/kg/day) amoxicillin. Less than 60% of guidelines used a national or international scale system to rate level of evidence to support recommendations. Under half of the guidelines (7/17; 41%) referred to country-specific microbiological and antibiotic resistance data.
Conclusions Guidelines for managing AOM were similar across European countries. Guideline quality was mostly weak, and it often did not refer to country-specific antibiotic resistance patterns. Coordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance.
- acute otitis media
- Europe
- guidelines
- children
- systematic review
- antibiotic stewardship
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Footnotes
Contributors SY conceived the study. HS, JED, RN and SY all contributed to the study design. HS was responsible for the systematic database search. JED, RN and SY all contacted experts in their scientific networks to obtain additional guidelines and check the use and validity of those identified. HS and JED were responsible for data extraction including LoE, SoR and antibiotic stewardship and AGREE II scoring. HS, JED, RN and SY all contributed to the interpretation of the results, the drafting and revision of the manuscript and they agree with the final version.
Funding RN was supported by NIHR Academic clinical fellowship and lectureship award programme. JED and SY are supported by PERFORM, a consortium funded by the European Union’s Horizon 2020 programme, under grant agreement No. 668303.
Disclaimer The funding sources did not take part in the design, analysis, interpretation of data, writing of the report or decision to submit the article for publication. All authors had full access to all the data, and they can take responsibility for the integrity of the data and the accuracy of the data analysis.
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Competing interests None declared.
Patient consent for publication Not required.
Ethics approval None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request. The primary data for this study was treatment guidelines, and these can be shared on request to the corresponding author.