Otitis media. A scholarly review of the evidence

Antibiotic therapy remains the treatment of choice for otitis media in most countries despite persuasive evidence that antibiotic therapy provides limited clinical benefit and promotes bacterial resistance. Meta-analysis of randomized, placebo-controlled trials demonstrated that antibiotics increased resolution at 1 week by only 13%. Amoxicillin remains as effective as any other antibiotic, despite increasing resistance to amoxicillin among the major bacterial pathogens. Immediate antibiotic treatment has been shown to reduce the duration of symptoms by 1 day but not until after the first 24 hours when symptoms were already improving. A delayed prescribing strategy is currently utilized in most children for management of acute otitis media in the Netherlands; this method is now being evaluated elsewhere. Antibiotic therapy is delayed for 48-72 hours after diagnosis; thereafter, antibiotics are initiated only if symptoms persist or worsen. In 2 studies utilizing this strategy (England and the United States), only 24-30% of the patients in the delayed treatment group initiated antibiotic therapy; a majority of parents of children in the delayed group were satisfied with their child's treatment. Treatment of bacterial otitis media ("pus drum") with high dose amoxicillin (80-100 mg/kg/kd) is recommmended; for acute otitis media without bulging, watchful waiting with a delayed prescribing strategy and treatment of pain is preferred. Yearly administration of the influenza vaccine and/or treatment of influenza with an antiviral (oseltamivir) can significantly decrease the incidence of acute otitis media during influenza season. Although pneumococcal vaccination effectively reduces the incidence of acute otitis media due to vaccine-related serotypes, there is a significant increase in the number of episodes of acute otitis media due to other serotypes of S. pneumoniae such that the overall incidence of acute otitis media is reduced only minimally by pneumoccocal vaccine. The careful use of strict diagnostic criteria coupled with judicious use of antibiotic therapy will direct antibiotic treatment to only those patients likely to benefit.