The information below is based on NICE NG91 Otitis media (acute): antimicrobial prescribing (March 2018).

Acute otitis media is a self-limiting infection that mainly affects children; it can be caused by viruses and bacteria with symptoms lasting for about three days, but can last for up to one week.

Self-care advice:

• Consider paracetamol or ibuprofen for pain or fever

The following are not recommended due to a lack of evidence: decongestants or antihistamines.

The routine commissioning of Otigo (phenazone with lidocaine) ear drops is not accepted in Devon for the treatment of acute otitis media pain (see Commissioning Policy for more information).

Most children and young people get better within three days without antibiotics.

Antibiotics make little or no difference in reducing ear pain and their use should be balanced against the risk of causing adverse effects such as vomiting, diarrhoea or rashes. Antibiotics make little difference to the number of children with common complications of acute otitis media such as recurrence of infection, short term hearing loss and perforated eardrum; and make little difference to the number of children whose symptoms improve. Complications (such as mastoiditis) are rare with or without antibiotics.

Advise to seek medical help if symptoms do not start to improve after 3 days if the child or young person becomes very unwell.

For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021)

Consider a delayed prescription for use if symptoms do not start to improve within 3 days. Advise to seek medical help if symptoms worsen rapidly or significantly at any time.

Consider a delayed prescription or immediate prescription of antibiotics in:

• Children and young people with acute otitis media and otorrheoa (discharge following ear drum perforation)
• Children under 2 years of age with acute otitis media in both ears

Offer an immediate prescription in:

• Patients who are systemically very unwell
• Patients who show signs and symptoms suggestive of serious illness
• Children at high risk of serious complications because of pre-existing co-morbidity (e.g. significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely)

For children under 3 months, have a low threshold for prescribing antibiotics or admitting.

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

• Alternative diagnoses, such as otitis media with effusion (glue ear);
  • Western locality referral guideline
  • South Devon & Torbay referral guideline
• Any symptoms or signs suggesting a more serious illness or condition
• Previous antibiotic use, which may lead to resistant organisms

Where antibiotics are indicated

1st line

Amoxicillin

(including pregnancy)

• Children and young people under 18 years of age:
  • 1 month to 11 months: 125mg three times a day for 5 to 7 days
  • 1 to 4 years: 250mg three times a day for 5 to 7 days
  • 5 to 17 years: 500mg three times a day for 5 to 7 days

Penicillin allergy

Clarithromycin

• Children and young people 12 to 17 years of age:
  • 250mg to 500mg twice daily for 5 to 7 days
• Children 1 month to 11 years of age (doses given twice daily for 5 to 7 days):
  • Body-weight under 8 kg: 7.5mg/kg
  • Body-weight 8–11 kg: 62.5mg
  • Body-weight 12–19 kg: 125mg
  • Body-weight 20–29 kg: 187.5mg
  • Body-weight 30–40 kg: 250mg

Penicillin allergy in pregnancy

Erythromycin

• Children and young people:
  • 12 to 17 years: 250mg to 500mg four times a day or 500mg to 1,000mg twice daily for 5 to 7 days

See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides

2nd line

If worsening of symptoms on first choice taken for at least 2 to 3 days.

Co-amoxiclav

• Children 1 month to 17 years of age (doses given three times a day for 5 to 7 days):
  • 1 to 11 months: 0.25ml/kg (125/31mg/5ml suspension)
  • 1 to 5 years: 5ml or 0.25ml/kg (125/31mg/5ml suspension)
  • 6 to 11 years: 5ml or 0.15ml/kg (250/62mg/5ml suspension)
  • 12 to 17 years: 250/125mg or 500/125mg

If worsening of symptoms on second line treatment option, taken for at least 2-3 days, or penicillin allergy consult local microbiologist.

See 5.1.1 Penicillins