Acute otitis media

Key NICE recommendations on management

This summary covers antimicrobial prescribing recommendations for acute otitis media in children and young people.

Assess and manage children under 5 who present with fever as outlined in the NICE guideline Fever in under 5s: assessment and initial management (NG143).​

When managing acute otitis media, including when making decisions about antibiotic prescribing, you should take into account that:

• It is a self-limiting infection that mainly affects children, and it can be caused by viruses and bacteria (both are often present at the same time and it is difficult to distinguish between them)

• There is evidence that antibiotics make little difference to symptoms, or to the development of common complications (e.g., short-term hearing loss, perforated eardrum or recurrent infection). Most children and young people get better within 3 days without antibiotics.

Reassess at any time if symptoms worsen rapidly or significantly. Take account of:

• Alternative diagnoses (e.g., otitis media with effusion [glue ear]), and evaluate for any symptoms or signs suggesting a more serious illness or condition

• Previous antibiotic use, which may lead to resistant organisms.

Treating symptoms

Offer regular paracetamol or ibuprofen for pain. Use maximum doses for severe pain.

Consider eardrops containing an anaesthetic and an analgesic (phenazone with lidocaine for up to 7 days) for pain, only if an immediate oral antibiotic prescription is not given and there is no eardrum perforation or otorrhoea.​

• Review treatment if symptoms do not improve within 7 days or worsen at any time.

Explain that evidence suggests decongestants and antihistamines do not help symptoms.

Antibiotic treatment

Offer an immediate antibiotic prescription to children and young people who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications.​

• Refer children and young people to hospital if they have acute otitis media associated with a severe systemic infection or with acute complications, including mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis.

Consider offering a back-up or immediate antibiotic prescription to children and young people with otorrhoea or to those aged under 2 years with infection in both ears. You should still consider a back-up antibiotic prescription for children and young people that do not fit either of these criteria, but they may be less likely to benefit from antibiotics.

• Consider the potential adverse effects of antibiotics (particularly diarrhoea and nausea), and that acute complications of acute otitis media (e.g., mastoiditis) are rare with or without antibiotics.

Choice of antibiotic for children and young people under 18 years

Prescribe a 5 to 7 day course of oral amoxicillin as the first-choice oral antibiotic for children and young people with no penicillin allergy or intolerance.

• Prescribe the shortest course that is likely to be effective. This is to minimise the risk of antimicrobial resistance.

• A 5-day course may be sufficient for many children, reserving 7-day courses for those with a clinical assessment of more severe or recurrent infection.

For those with penicillin allergy or intolerance (who are not pregnant), prescribe a 5 to 7 day course of clarithromycin as an alternative first-choice antibiotic.

For those with penicillin allergy who are pregnant (and have a compelling clinical need for an antibiotic with no suitable alternatives to macrolides), prescribe a 5 to 7 day course of erythromycin as an alternative first-choice antibiotic after an informed discussion of the potential benefits and harms of treatment.

• Evidence is insufficient to confirm with certainty whether there is a small increased risk of birth defects or miscarriage when macrolides are taken in early pregnancy.

• Erythromycin is preferred if a macrolide is needed in pregnancy (e.g., if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms) because there is more documented experience of its use than for other macrolides.

If symptoms are worsening despite taking a first-choice antibiotic for at least 2 to 3 days:

• Change the antibiotic to a 5 to 7 day course of oral co-amoxiclav (amoxicillin/clavulanate), a second-choice oral antibiotic, for those with no penicillin allergy or intolerance

• Consult with your local microbiologist if an alternative second-choice antibiotic is required for those with penicillin allergy or intolerance.

Patient advice

Advise all children and young people about the usual course of acute otitis media (symptoms last for about 3 days, but up to 1 week) and to seek medical help if symptoms worsen rapidly or significantly, or if the child or young person becomes systemically very unwell.

Further tailored advice should be given depending on whether an antibiotic prescription is offered:

• Where no antibiotic prescription is given, advise that an antibiotic is not needed and to seek medical help if symptoms do not start to improve after 3 days

• Where a back-up antibiotic prescription is given, advise that an antibiotic is not needed immediately, and to use the back-up prescription if symptoms do not start to improve within 3 days or if they worsen rapidly or significantly at any time.

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