Otitis Media: Antibiotics or Not?

Aug 22, 2024

We're back to an old question of should we give antibiotics for otitis media? The factors always being weighed up have been around the benefit which includes reduction in pain and resolution versus the side effects of the medication and the potential for infection to progress. (10 minutes read)

We review a recent systematic review(1) in the Annals of Emergency Medicine:

What They did

This was a systematic review which included studies of children between 1 month and 15 years of age, diagnosed with acute otitis media, which was defined as: "presence of a middle ear effusion along with ear pain, otorrhea, or fever".

13 randomised control trials, comparing antibiotics to placebo were included and 6 randomised control trials were included, which compared antibiotics vs expectant management.

Primary outcomes:

pain (24 hours, 2 to 3 days, 4 to 7 days, and 10 to 14 days)
adverse side effects (secondary to antibiotics), including rash and gastrointestinal upset.

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We review a recent systematic review(1) in the Annals of Emergency Medicine:

What They did

13 randomised control trials, comparing antibiotics to placebo were included and 6 randomised control trials were included, which compared antibiotics vs expectant management.

Primary outcomes:

pain (24 hours, 2 to 3 days, 4 to 7 days, and 10 to 14 days)
adverse side effects (secondary to antibiotics), including rash and gastrointestinal upset.

Secondary outcomes included:

abnormal tympanometry (effect on hearing),
tympanic membrane perforation,
contralateral acute otitis media,
recurrences,
serious complications ie., mastoiditis and meningitis
long-term side effects.

What They Found

Primary Outcomes:

Antibiotics reduced pain at 2 to 3 days and at 10-12 days compared to placebo, however they were associated with an increase in side effects such as diarrhoea, vomiting and rash.

Secondary Outcomes:

There was a decrease in abnormal tympanometry at 2 to 4 weeks,
Tympanic membrane perforation was reduced,
Rates of contralateral acute otitis media were reduced

Limitations

Patients in these studies were from high-income countries. We need to beware applying these results to low/middle income countries.
A substantial number of patients were lost to follow-up.
There was significant heterogeneity in the trials concerning the diagnostic criteria, treatment and adverse events.
The diagnosis of acute otitis media used in the various studies was poorly defined.
The antibiotics used, dosage and duration varied between studies.

My Take on This

We currently don't prescribe antibiotics for simple otitis media, in well children, who can be followed up. If the child is not unwell, but has pain, simple analgesia will be adequate to control the pain. The ability for the child to be followed up by a local doctor, becomes important and may determine if I give antibiotics in some cases.

We must ensure there are no red flags, for which the patient may need referral. These include(from Royal Children's Hospital Melbourne, Clinical Guidelines):