Ceftriaxone for Refractory Acute Otitis Media Impact of a Clinical Practice Guideline

Objective: To determine the effect of a clinical practice guideline (CPG) on the use of ceftriaxone for the treatment of refractory acute otitis media (AOM) at a tertiary care pediatric hospital. Methods: Charts of all patients aged 3 to 60 months referred from an emergency department to a day treatment center for management of refractory AOM with ceftriaxone were reviewed. Data were collected during two 18-month periods before and after implementation of a CPG developed by a local group of experts. Ceftriaxone was indicated for children with symptomatic AOM despite 48 hours of treatment with high-dosage amoxicillin or amoxicillin-clavulanate (>75 mg/kg per day) or despite receiving I of these 2 antibiotics over the previous month. Overall treatment was considered adequate if patients met these indications for ceftriaxone, if at least 3 daily doses had been prescribed, and if all doses were within the 40- to 60-mg/kg range. Results: Thirty-two emergency physicians referred 127 patients to the day treatment center (60 preimplementation and 67 postimplementation of the CPG). The mean (SD) patient ages were 16.7 (7.4) and 19.7 (12.4) months in the preimplementation and postimplementation groups, respectively. Indications for prescription of ceftriaxone were adequate in 16.7% of the preguideline and 22.4% of the postguideline groups (P = 0.4). Physicians were twice as likely to use ceftriaxone adequately after the guideline's implementation, but this result was not statistically significant (crude odds ratio, 2.2; 95% confidence interval, 0.5-9.0). Conclusions: implementation of a CPG for the treatment of refractory AOM with ceftriaxone did not improve indications for its use.