Clinical practice guidelines for acute otitis media in children: A systematic review and appraisal of European national guidelines

Abstract

Objectives: To appraise European guidelines for acute otitis media (AOM) in children, including methodological quality, level of evidence and strength 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 was collected between January 2017-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 was extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. Level of Evidence (LoE) and Strength of Recommendations (SoR) were compared. Guidelines were assessed for principles of antibiotic stewardship. Results: AOM guidelines were obtained from 17 of the 32 EU/EFTA countries. The mean AGREE II score was ≤41% across most domains. Diagnosis of AOM was based upon 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 five to ten days. Seven countries advocated high dose (75-90mg/kg/day) and five low dose (30-60mg/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 often did not refer to country-specific antibiotic resistance patterns. Co-ordinating 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. Strengths and limitations of this study: • Strengths: The methodology includes the use of a comprehensive three-pronged search strategy with no language restrictions to identify guidelines from across Europe, the use of a standardized and internationally recognised guideline appraisal tool (AGREE II), the assessment of Leveles of Evidence and Strength of Recommendations, and the assessment of whether antibiotic stewardship, a key measure to reduce antimicrobial resistance (AMR), was considered. • Limitations: The review focused only on AOM without complications; guidelines for complex otitis media requiring specialist (Ear Nose Throat) input were not included. Another limitation is the consideration of whether guidelines developers used country-specific AMR patterns to assess if the recommendations of antibiotics were based on AMR data. However, there is often wide heterogeneity in terms of AMR patterns within each country.