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Research

Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study

Rebecca Cushen and Nick A Francis
British Journal of General Practice 2020; 70 (693): e255-e263. DOI: https://doi.org/10.3399/bjgp20X708821
Rebecca Cushen
Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff; consultant in public health medicine, Cwm Taf Morgannwg Public Health Team, Public Health Wales, Glanrhyd Hospital, Bridgend.
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Nick A Francis
School of Primary Care, Population Sciences and Medical Education, Aldermoor Health Centre, Southampton.
Roles: Professor of primary care research
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    Figure 1.

    CONSORT flow diagram for acute otitis media (AOM). CONSORT = Consolidated Standards of Reporting Trials. CPRD = Clinical Practice Research Datalink.

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    Figure 2.

    CONSORT flow diagram for acute sinusitis (AS). CONSORT = Consolidated Standards of Reporting Trials. CPRD = Clinical Practice Research Datalink.

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    Concern about reducing the risk of serious complications can drive antibiotic prescribing for common infections, such as acute otitis media (AOM) and acute sinusitis (AS), and use of antibiotics is the major driver of antibiotic resistance. The association between use of antibiotics for AOM and AS, and the subsequent risk of acute mastoiditis, brain abscess, and orbital cellulitis, has not been adequately explored. This study demonstrates that these serious complications are extremely uncommon. Antibiotic use was associated with a lower risk of acute mastoiditis following AOM and brain abscess following AS, but for both conditions thousands of patients would need to be treated to prevent a single instance of one complication.
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    Table 1.

    Baseline characteristics of the acute otitis media cohort

    Characteristic, n (%)Whole sample, N = 286 574Prescribed antibiotics, N = 249 086 (86.9%)Not prescribed antibiotics, N = 37 488 (13.1%)
    Sex
    Male140 787 (49.1)122 352 (49.1)18 435 (49.2)
    Female145 787 (50.9)126 734 (50.9)19 053 (50.8)
    Age, years
    Mediana666
    Interquartile range3–203–193–23
    Age, years
    0–255 999 (19.5)49 262 (19.8)6737 (18.0)
    3–572 164 (25.2)62 704 (25.2)9460 (25.2)
    6–1055 968 (19.5)48 226 (19.4)7742 (20.7)
    11–2032 318 (11.3)28 577 (11.5)3741 (10.0)
    21–3016 050 (5.6)13 984 (5.6)2066 (5.5)
    31–4018 510 (6.5)16 029 (6.4)2481 (6.6)
    41–5014 040 (4.9)12 095 (4.9)1945 (5.2)
    51–6010 427 (3.6)8954 (3.6)1473 (3.9)
    61–706527 (2.3)5543 (2.2)984 (2.6)
    71–803334 (1.2)2731 (1.1)603 (1.6)
    ≥811237 (0.4)981 (0.4)256 (0.7)
    Asplenic47 (0.02)45 (0.02)2 (0.005)
    Chronic kidney disease95 (0.03)81 (0.03)14 (0.04)
    CSF shunt61 (0.02)49 (0.02)12 (0.03)
    HIV15 (0.005)14 (0.006)1 (0.003)
    Immunocompromised151 (0.05)137 (0.06)14 (0.04)
    Smoker14 990 (5.2)12 948 (5.2)2042 (5.4)
    Transplanted organ89 (0.03)78 (0.03)11 (0.03)
    Diabetes mellitus3485 (1.2)2980 (1.2)505 (1.3)
    • ↵a Median was used to describe summary of age as data were skewed to the left. CSF = cerebrospinal fluid.

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    Table 2.

    Baseline characteristics of the acute sinusitis cohort

    Characteristic, n (%)Whole sample N = 441 873Prescribed antibiotics N = 407 030 (92.1%)Not prescribed antibiotics N = 34 843 (7.9%)
    Sex
    Male124 781 (28.2)113 934 (28.0)10 847 (31.1)
    Female317 091 (71.8)293 096 (72.0)23 995 (68.9)
    Unknown1 (0.0002)0 (0)1 (0.002)
    Age, years
    Mean45.645.843.8
    SD16.416.416.4
    Age, years, n (%)
    0–2342 (0.1)314 (0.1)28 (0.1)
    3–5832 (0.2)732 (0.2)100 (0.3)
    6–102835 (0.6)2479 (0.6)356 (1.0)
    11–2022 281 (5.0)19 968 (4.9)2313 (6.6)
    21–3053 078 (12.0)47 976 (11.8)5102 (14.6)
    31–4099 511 (22.5)91 277 (22.4)8234 (23.6)
    41–5095 828 (21.7)89 020 (21.9)6808 (19.5)
    51–6081 055 (18.3)75 465 (18.5)5590 (16.0)
    61–7054 158 (12.3)50 442 (12.4)3716 (10.7)
    71–8024 418 (5.5)22 549 (5.5)1869 (5.4)
    ≥817535 (1.7)6808 (1.7)727 (2.1)
    Asplenic285 (0.1)266 (0.1)19 (0.1)
    Chronic kidney disease472 (0.1)437 (0.1)35 (0.1)
    CSF shunt102 (0.02)94 (0.02)8 (0.02)
    HIV73 (0.02)67 (0.02)6 (0.02)
    Immunocompromised681 (0.2)631 (0.2)50 (0.1)
    Smoker82 188 (18.6)76 006 (18.7)6182 (17.7)
    Transplanted organ326 (0.1)301 (0.1)25 (0.1)
    Diabetes mellitus19 477 (4.4)18 077 (4.4)1400 (4.0)
    • CSF = cerebrospinal fluid.

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    Table 3.

    Association between antibiotic prescription and complications

    ComplicationComplications, nIncidencea (95% CI)OR (95% CI)
    TotalAntibioticsNo antibioticsOverall incidenceAntibioticsNo antibioticsCrudeAdjustedbNNT
    Brain abscess following AOM1100.03 (0.01 to 0.20)0.04 (0.03 to 0.05)N/AN/AN/AN/A
    Acute mastoiditis following AOM161125365.62 (4.81 to 6.56)5.02 (4.21 to 5.98)9.60 (6.94 to 13.29)0.52 (0.36 to 0.76)0.54 (0.37 to 0.79)2181 (1196 to 5709)
    Brain abscess following AS5320.11 (0.05 to 0.26)0.07 (0.03 to 0.22)0.57 (0.16 to 2.10)0.13 (0.02 to 0.77)0.12 (0.02 to 0.70)19 988 (4951 to 167 099)
    Orbital cellulitis following AS665791.50 (1.17 to 1.90)1.40 (1.08 to 1.81)2.58 (1.36 to 4.91)0.54 (0.27 to 1.10)0.56 (0.27 to 1.12)N/A
    • ↵a Per 10 000 AOM/AS primary care consultations.

    • ↵b Adjusted for patient’s age at the time of consultation. AOM = acute otitis media. AS = acute sinusitis. CI = confidence interval. N/A = not applicable. NNT = numbers needed to treat. OR = odds ratio.

    • View popup
    Table 4.

    Association between antibiotic prescription and complications in those aged ≤20 years and >20 years

    Patients aged ≤20 years
    ComplicationComplications, nIncidencea (95% CI)OR (95% CI)NNT (95% CI)
    TotalOn antibioticsNo antibioticsOverall incidenceOn antibioticsNo antibiotics
    Acute mastoiditis following AOM8161203.74 (3.01 to 4.65)3.23 (2.52 to 4.15)7.23 (4.68 to 11.16)0.45 (0.27 to 0.74)2504 (1251–7776)
    Brain abscess following AS0N/AN/AN/AN/AN/AN/AN/A
    Orbital cellulitis following AS13854.94 (2.89 to 8.46)3.41 (1.73 to 6.72)17.88 (7.64 to 41.78)0.19 (0.06 to 0.58)691 (260–2695)
    Patients aged >20 years
    ComplicationNumber of complicationsIncidencea (95% CI)OR (95% CI)NNT (95% CI)
    TotalOn antibioticsNo antibioticsOverall incidenceOn antibioticsNo antibiotics
    Acute mastoiditis following AOM80641611.41 (9.17 to 14.19)10.61 (8.31 to 13.55)16.31 (10.04 to 26.48)0.65 (0.37 to 1.13)N/A
    Brain abscess following AS5320.12 (0.11 to 0.13)0.08 (0.07 to 0.09)0.62 (0.54 to 0.72)0.13 (0.02 to 0.75)18 319 (4549–146 666)
    Orbital cellulitis following AS534941.28 (1.17 to 1.39)1.28 (1.17 to 1.40)1.25 (1.13 to 1.38)1.02 (0.37 to 2.84)N/A
    • ↵a Per 10 000 AOM/AS primary care consultations. AOM = acute otitis media. AS = acute sinusitis. CI = confidence interval. N/A = not applicable. NNT = numbers needed to treat.

    • OR = odds ratio.

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British Journal of General Practice: 70 (693)
British Journal of General Practice
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April 2020
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Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study
Rebecca Cushen, Nick A Francis
British Journal of General Practice 2020; 70 (693): e255-e263. DOI: 10.3399/bjgp20X708821

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Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study
Rebecca Cushen, Nick A Francis
British Journal of General Practice 2020; 70 (693): e255-e263. DOI: 10.3399/bjgp20X708821
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Keywords

  • acute otitis media
  • acute sinusitis
  • antibiotics
  • complications
  • general practice
  • retrospective studies

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