EVIDENCE-BASED ANSWER
IN MOST CASES, NO. Antibiotics are not necessary to treat uncomplicated acute otitis media (AOM) in an otherwise healthy child (strength of recommendation [SOR]: A, systematic review). Children younger than 2 years and children with bilateral infection, high fever, or vomiting may experience modest symptom relief from antibiotics (SOR: B, cohort studies).
No evidence supports any of the commonly used antibiotic regimens over another (SOR: A, meta-analysis). Amoxicillin (80-90 mg/kg per day in 2 divided doses) is the recommended first-line regimen (SOR: C, expert consensus). In otherwise healthy children, 5 days of therapy should be sufficient (SOR: A; systematic review).
In managing AOM, we should use a comprehensive strategy, prescribing an antibiotic only when clinically indicated. Spend the time necessary to counsel parents about the benefits and adverse effects of an antibiotic while considering a watchful waiting approach, which has been found to be both safe and well-accepted by most parents.1
Discourage the use of antihistamines and decongestants because of their lack of efficacy and safety concerns, especially in children younger than 2 years.2 Pain control with acetaminophen and ibuprofen and topical analgesic ear drops should always be part of the treatment plan. Finally, counsel parents carefully, when indicated, about the significant harms of passive smoke.
Vincent Lo, MD
San Joaquin Family Medicine, French Camp, Calif
Evidence summary
Otitis media is the most common outpatient diagnosis in children.3 Although these infections usually resolve without treatment, it is common practice in the United States to prescribe antibiotics.4
Antibiotic benefits are small in uncomplicated disease
A Cochrane review of 8 randomized controlled trials (RCTs)—6 double-blinded, 2287 children total—compared antibiotics with placebo for uncomplicated AOM in otherwise healthy children.5 The review showed that children treated with antibiotics were no less likely to have pain at 24 hours after starting therapy than untreated children. However, 7% fewer children who received antibiotics had pain at 2 to 7 days than unmedicated children (number needed to treat [NNT]=15; 95% confidence interval [CI], 11-24).
Children treated with antibiotics had no significant decrease in recurrence of AOM (mean 0.70 vs 0.63; 95% CI, -0.22 to 0.34; odds ratio [OR]=0.99) or hearing loss (reported by a combination of tympanometry and audiometry). They did have an increase in nausea, diarrhea, and rash, however. Only 1 case of mastoiditis was reported in the included studies.5
Of note, 2 of the studies showed a modest increase in failure rates of placebo treatment for children younger than 2 years and children with bilateral disease. Antibiotics may benefit these groups. Overall, both the potential benefits and harms of antibiotics for AOM are small.5
More on which children may benefit from antibiotics
A secondary analysis of cohorts from 6 RCTs (a total of 824 children untreated for AOM) identified age younger than 2 years (OR=2.07; 95% CI, 1.47-2.91; P<.0001) and bilateral disease (OR=1.70; 95% CI, 1.19-2.41; P=.003) as independent risk factors for pain and fever at 3 to 7 days of illness. However, the study did not address whether antibiotics would actually mitigate the risk factors.6