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Otitis Media – when to use antibiotics

This is a new guideline from NICE on when to use antibiotics for otitis media (March 2018). It doesn't change common practice, but I found some of the statistics really helpful for explaining why we prescribe in some groups and not others. There is an excellent patient leaflet explaining things too.

Some background info:

  • Most have cleared within 3 days, but it can last up to a week.
  • It can be viral or bacterial, or both can be present at the same time.
  • Complications are rare (for example the NNT with antibiotics to avoid one case of mastoiditis is 4,831).

Antibiotic effect on symptoms of Otitis Media

Antibiotics make little difference to symptoms. The NNT for an improvement at 2-3d is 24. Put another way, at 2-3d, 88% of kids in the antibiotic group had no pain, whereas 84% in the no antibiotic group had no pain.

The NNH (number needed to harm) with antibiotics is 13 (vomiting, diarrhoea or rash). So if you use antibiotics in most patients, you will harm more than you will help.

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Antibiotic effect on common complications:

Antibiotics make little difference to short term common complications:

  • Hearing loss - antibiotics do lead to a small but significant reduction in hearing loss at 2-4w (but not at 6-8w). NNT is 12.
  • Perforation - antibiotics lead to a small but significant reduction in perforations NNT is 33 (there is a reduction from 5% to 2%).
  • Late recurrence - there is no reduction.

What advice should we give to all patients about Otitis Media?

Apart from the obvious, advise that decongestants and antihistamines do not help symptoms. Advise that patients should be reassessed at any point if their symptoms worsen rapidly or significantly or if they become systemically very unwell (even if they have been given antibiotics).

Who may be more likely to benefit from antibiotics?

  • People of any age with otorrhoea (the NNT is 3 for symptom resolution).
  • Children < 2 yrs old with bilateral otitis media (the NNT is 4 for symptom resolution).
  • Those who are very unwell, may be more seriously ill or who are at higher risk of complications (eg due to co-morbidities such as significant CV, renal, lung, liver, neuromuscular or immunosuppressive conditions, or cystic fibrosis, or born prematurely).

How should you manage those more likely to benefit from antibiotics?

Consider no antibiotic prescription, a back-up antibiotic prescription, or an immediate antibiotic prescription.

How should you manage everyone else with Otitis Media?

Consider no antibiotic prescription or a back-up antibiotic prescription.

A back-up prescription should be used after 3d if symptoms do not start to improve, or at any time if they worsen significantly or rapidly. I actually found the guideline a little ambiguous. It seems to mean, from looking at the evidence, that patients should use the back-up script if they still have symptoms at day 3 of illness, not that they should use it 3 days after they are given the prescription. The rationale for this is because most infections are better by day 3.

What antibiotic should we use?

  • Amoxicillin for 5-7d (clarithromycin or erythromycin if allergic).
  • 2nd line (ie if worsening after 2-3d of amoxicillin) is co-amoxiclav.

They advise that they are continuing to suggest amoxicillin, even though penicillin is likely to be just as effective, because it only has TDS dosing and is more palatable to kids (who are the prime recipients of the antibiotics here).

How long should we treat for?

  • 5 days - for most people.
  • 7 days - for more severe or recurrent infection.

There are no studies comparing the efficacy of treating for 5d vs 7d. There may be more treatment failure at 5d, but the effect is small. 82% of those taking antibiotics for fewer than 7d were better by 8-9d. 86% of those taking antibiotics for 7d or more were better at 8-9d.

I’m a freelance GP locum in Winchester & Southampton.

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