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Overview

This guideline sets out an antimicrobial prescribing strategy for acute otitis media (ear infection). It aims to limit antibiotic use and reduce antimicrobial resistance. Included are recommendations on antimicrobial prescribing, managing acute otitis media in children and young people, and choosing a treatment.

This guideline partially updates and replaces NICE guideline CG69.

For the complete set of recommendations, refer to the full guideline. 

View this summary online at guidelines.co.uk/454388.article

Antimicrobial prescribing

Algorithm 1: Otitis media (acute) antimicrobial prescribing visual summary

NICE otitis media (acute) antimicrobial prescribing v3

Managing acute otitis media

All children and young people with acute otitis media

  • Be aware that:
    • acute otitis media is a self-limiting infection that mainly affects children
    • acute otitis media can be caused by viruses and bacteria, and it is difficult to distinguish between these (both are often present at the same time)
    • symptoms last for about 3 days, but can last for up to 1 week
    • most children and young people get better within 3 days without antibiotics
    • complications such as mastoiditis are rare.
  • Assess and manage children under 5 who present with fever as outlined in the NICE guideline on fever in under 5s.
  • Give advice about the usual course of acute otitis media (about 3 days, can be up to 1 week).
  • Offer regular doses of paracetamol or ibuprofen for pain. Use the right dose for the age or weight of the child at the right time, and use maximum doses for severe pain.
  • Consider eardrops containing an anaesthetic and an analgesic for pain (see table 1 for choice of treatment) if:
    • an immediate oral antibiotic prescription is not given (see the sections, Children and young people who may be less likely to benefit from antibiotics, Children and young people who may be more likely to benefit from antibiotics, and Children and young people who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or who are at high risk of complications), 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.
  • Reassess at any time if symptoms worsen rapidly or significantly, taking account of:
    • alternative diagnoses, such as otitis media with effusion (glue ear)
    • any symptoms or signs suggesting a more serious illness or condition
    • previous antibiotic use, which may lead to resistant organisms.

Children and young people who may be less likely to benefit from antibiotics

  • Consider no antibiotic prescription or a back-up antibiotic prescription (see table 1 for choice of treatment), taking account of:
    • evidence that antibiotics make little difference to symptoms (no improvement in pain at 24 hours, and after that the number of children improving is similar to the number with adverse effects)
    • evidence that antibiotics make little difference to the development of common complications (such as short-term hearing loss [measured by tympanometry], perforated eardrum or recurrent infection)
    • evidence that acute complications such as mastoiditis are rare with or without antibiotics
    • possible adverse effects of antibiotics, particularly diarrhoea and nausea.
  • When no antibiotic prescription is given, give advice about:
    • an antibiotic not being needed
    • seeking medical help if symptoms worsen rapidly or significantly, do not start to improve after 3 days, or the child or young person becomes systemically very unwell.
  • When a back-up antibiotic prescription is given, as well as general advice, give advice about:
    • an antibiotic not being needed immediately
    • using the back-up prescription if symptoms do not start to improve within 3 days or if they worsen rapidly or significantly at any time
    • seeking medical help if symptoms worsen rapidly or significantly, or the child or young person becomes systemically very unwell.

Children and young people who may be more likely to benefit from antibiotics (those of any age with otorrhoea or those under 2 years with infection in both ears)

  • Consider no antibiotic prescription with advice (see the second recommendation in the section, Children and young people who may be less likely to benefit from antibiotics), a back-up antibiotic prescription with advice (see the third recommendation in the section, Children and young people who may be less likely to benefit from antibiotics) or an immediate antibiotic prescription (see table 1 for choice of treatment), taking account of:
  • evidence that acute complications such as mastoiditis are rare with or without antibiotics
  • possible adverse effects of antibiotics, particularly diarrhoea and nausea.
  • When an immediate antibiotic prescription is given, give advice about seeking medical help if symptoms worsen rapidly or significantly, or the child or young person becomes systemically very unwell.

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

  • Offer an immediate antibiotic prescription (see table 1 for choice of treatment) with advice (see the last recommendation in the section, Children and young people who may be more likely to benefit from antibiotics).
  • Refer children and young people to hospital if they have acute otitis media associated with:
    • a severe systemic infection (see the NICE guideline on sepsis)
    • acute complications, including mastoiditis, meningitis, intracranial abscess, sinus thrombosis or facial nerve paralysis.

Choice of treatment

  • Follow table 1 when prescribing treatment for children and young people with acute otitis media.
Table 1: Choice of treatment: children and young people under 18 years
Treatment[A]Dosage and course length[B]

[A] See the BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.

[B] The age bands apply to children of average size. In practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child’s size in relation to the average size of children of the same age. Doses given are by mouth using immediate-release medicines, unless otherwise stated.

Eardrops containing an anaesthetic and an analgesic

Phenazone 40 mg/g with lidocaine 10 mg/g

Apply 4 drops two or three times a day for up to 7 days

Use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea

First-choice oral antibiotic

Amoxicillin

1 to 11 months: 125 mg three times a day for 5 to 7 days

1 to 4 years: 250 mg three times a day for 5 to 7 days

5 to 17 years: 500 mg three times a day for 5 to 7 days

Alternative first choice oral antibiotic for penicillin allergy or intolerance (for people who are not pregnant)

Clarithromycin

1 month to 11 years:

  • Under 8 kg: 7.5 mg/kg twice a day for 5 to 7 days
  • 8 to 11 kg: 62.5 mg twice a day for 5 to 7 days
  • 12 to 19 kg: 125 mg twice a day for 5 to 7 days
  • 20 to 29 kg: 187.5 mg twice a day for 5 to 7 days
  • 30 to 40 kg: 250 mg twice a day for 5 to 7 days

12 to 17 years: 250 mg to 500 mg twice a day for 5 to 7 days

Alternative first choice oral antibiotic for penicillin allergy in pregnancy

Erythromycin

8 to 17 years: 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 to 7 days

Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy

Second choice oral antibiotic (worsening symptoms on first choice taken for at least 2 to 3 days) 

Co-amoxiclav

1 to 11 months: 0.25 ml/kg of 125/31 suspension three times a day for 5 to 7 days

1 to 5 years: 5 ml of 125/31 suspension three times a day or 0.25 ml/kg of 125/31 suspension three times a day for 5 to 7 days

6 to 11 years: 5 ml of 250/62 suspension three times a day or 0.15 ml/kg of 250/62 suspension three times a day for 5 to 7 days

12 to 17 years: 250/125 mg or 500/125 mg three times a day for 5 to 7 days

Alternative second choice oral antibiotic for pencillin allergy or intolerance

Consult local microbiologist

 

© NICE 2022. Otitis media (acute): antimicrobial prescribing. Available from: www.nice.org.uk/ng91. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 28 

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Lead image: photographee.eu/stock.adobe.com