What are the indications for prescribing antibiotics in cases of otitis media?

For cases of acute otitis media (AOM), antibiotics are not always immediately indicated, as many people, especially children, improve within three days without them NICE CKS. The decision to prescribe antibiotics should consider that they make little difference to symptoms or the development of common complications, which are rare with or without antibiotics, and the potential adverse effects of antibiotics NICE CKS. This approach aligns with the concept of delayed antibiotic treatment in pediatric acute otitis media Johnson & Holger 2007.

Indications for prescribing antibiotics in AOM include:

• If symptoms fail to improve or worsen NICE CKS. This is supported by a US guideline advising antibiotic treatment if a child with AOM worsens or does not improve within 48–72 hours of symptom onset Lieberthal 2013.
• For people who have not taken an antibiotic and symptoms are worsening despite initial management NICE CKS.
• If symptoms are worsening despite taking a first-line antibiotic for at least 2–3 days, a second-line antibiotic may be offered NICE CKS.
• Immediate specialist assessment and potential antibiotic use are indicated for people with a severe systemic infection or red flag symptoms suggestive of acute complications such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, or facial nerve paralysis NICE CKS.
• Children younger than 3 months of age with a temperature of 38°C or more should be admitted for immediate paediatric assessment, where antibiotic consideration would be part of their management NICE CKS.
• Children aged 3–6 months with a temperature of 39°C or more may also warrant consideration for admission and subsequent antibiotic treatment based on clinical judgment NICE CKS.

When an antibiotic is required, a 5–7 day course of amoxicillin is typically prescribed NICE CKS. For individuals with penicillin allergy or intolerance, clarithromycin or erythromycin (erythromycin preferred in pregnant women) are alternatives NICE CKS. If symptoms persist despite two courses of antibiotics, specialist advice from a local microbiologist or an Ear, Nose and Throat specialist should be sought, especially if the diagnosis is uncertain NICE CKS. Evaluating the need, timing, and best choice of antibiotic therapy is crucial Pichichero 2000.

It is important to note that antibiotics are not offered to treat otitis media with effusion (OME), also known as 'glue ear' NICE NG233.