regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain)
criteria for antibiotic use:
if otorrhoea or under 2 years with infection in both ears
then consider no antibiotic, back-up antibiotic or immediate antibiotic
if no otorrhoea or under 2 years with infection in one ear or 2 years or older with ear infection (in one or both ears)
then consider no antibiotic or back-up antibiotic
if systemically very unwell or high risk of complications
requires immediate antibiotic
choice of antibiotic:
First choice: amoxicillin for 5 to 7 days
Penicillin allergy: clarithromycin for 5 to 7 days (but erythromycin is preferred if pregnant)
Second choice: co-amoxiclav
NICE have produced a summary of antibiotic prescribing in otitis media (2)
Erythromycin is an alternative for penicillin allergic patients, although it is less effective against Haemophilus influenzae, which is the cause of AOM in around 25% of people (3)
azithromycin and clarithromycin are alternatives that are effective against all the main pathogens that cause AOM
Some studies suggest that antibiotics are associated with a reduction of middle ear effusions, particularly when they are unilateral, three months post treatment.
Antibiotics used in AOM do not affect:
the recurrence rate of otitis media
the referral rate for ENT problems
prevalance of middle ear effusions at one month
Pain and crying drops off markedly, whether or not the child is treated with antibiotic from the begining of the second day.
Effectiveness of antibiotic treatment in AOM
An extensive review of the use of antimicrobials in acute otitis media concluded that the evidence from randomised, placebo controlled trials that routine use of antimicrobials decreases the severity and duration of symptoms and prevents complications is weak (4)
two thirds of children had no pain 24 hours after treatment started, irrespective of whether they received antibiotics or not, and 80% of children receiving placebo had spontaneously recovered from pain at two to seven days
antibiotics achieved a further 7% absolute reduction in the risk of pain, or put another way, 15 children needed to be treated with antibiotics to prevent one extra child from having pain after two to seven days
Children under the age of 2 years (5)
meta-analysis (six RCTs, n=1,643) looked at the effects of antibiotics on pain, fever, or both, at three to seven days in children aged from 6 months to 12 years with otitis media to try to find which subgroups of children were most likely to benefit from treatment
found that, in children aged less than two years of age with bilateral AOM, 30% who were taking antibiotics had pain, fever or both at three to seven days, compared to 55% of controls (RR 0.64, 95%CI 0.52 to 0.80, NNT=4)
Delayed prescriptions (6)
a study in an American emergency department randomised children aged six months to 12 years (n=283) who were diagnosed with AOM to an immediate or delayed prescription (after 48 hours if required) for antibiotics
found that 62% of delayed prescriptions were not used compared with 13% of immediate prescriptions (P<0.001)
at four to six days, an immediate prescription reduced the mean number of days of earache by just 0.4 days compared with the delayed prescription group (2.0 days vs. 2.4 days, RR 0.43, 95% CI 0.07 to 0.80)
no statistically significant difference between the groups in the number of days of fever
In conclusion (3):
antibiotic treatment should not be offered routinely in children with AOM
parents can be reassured that AOM is a self-limiting illness and serious complications are rare
antibiotics may be useful for some patients where the benefits may outweigh the risks of adverse effects (e.g. children under two years of age, those who are systemically unwell, or those who have recurrent infections)
strategy of watchful waiting and use of delayed prescriptions may be appropriate for many children
paracetamol or ibuprofen can be used for symptomatic relief of pain and fever.
Notes:
a systematic review concluded that topical quinolones are better than systemic antbiotics for chronic suppurative ottitis media (7)
AOM resolves in 60% in 24hrs without antibiotics, which only reduce pain at 2 days (NNT 15) and does not prevent deafness (3)
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