PEARLS 49, November 2007, written by Brian R McAvoy

Clinical question
How should I treat uncomplicated acute otitis media (AOM)?

Bottom line
Immediate antibiotic treatment reduces earache/fever or both at 3-7 days: <2 years + bilateral AOM NNT* = 4 <2 years + unilateral AOM NNT = 20 =2 years + bilateral AOM NNT = 9 =2 yrs + unilateral AOM NNT = 15.1 Watch and wait may be appropriate for unilateral AOM except in children under 6 months of age. Most guidelines recommend routine antibiotics for children less than 6 months. *NNT = number needed to treat to benefit one individual.

Caveat
Adverse events reported included diarrhoea (4-21 per cent of children in the treatment groups, 2-14 per cent in the control groups), and rash (1-8 per cent in the treatment groups and 2-6 per cent in the control groups). No serious adverse events were reported. Children with a temperature >37.5°C and vomiting are more likely to be distressed or have night disturbance after 3 days and would appear to benefit from antibiotics.1

Context
AOM is very common in preschool children, uncommon in older children and very rare in adults.

Systematic Review
Rovers MM et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006;368:1429-35. Note: This review contains 6 studies involving 1643 patients.

Further references
1. Little P et al. Predictors of poor outcomes and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ 2002;325:22-25.This is a single study involving 315 patients.