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Am Fam Physician. 1998;57(5):1132

Although antibiotics are the standard therapy for acute otitis media in most developed countries, in the Netherlands and Iceland the routine initial approach to therapy is symptomatic treatment. This strategy has been credited with a decrease in antimicrobial resistance. In contrast, about 30 percent of British children less than three years of age visit their family physician because of otitis media every year, and 97 percent receive antibiotics. Between 1990 and 1995, British strains of Streptococcus pneumoniae have shown increasing rates of resistance to penicillin (from 1.5 to 3.9 percent) and erythromycin (from 2.8 to 8.6 percent). An international network of primary care researchers reviewed previous studies to evaluate whether the use of antimicrobial therapy for the management of otitis media should be reassessed.

The researchers were unable to find compelling evidence to support recommendations that antibiotic treatment in children with acute otitis media improved outcomes, although the great variations in study design and quality made this analysis very complex. They were also unable to confirm that antibiotic treatment prevented complications, particularly mastoiditis or meningitis. Previous studies have shown that children younger than two years of age and those attending day care centers are at increased risk of adverse consequences from otitis media; however, no studies have shown that antibiotic treatment improves outcome in children at risk. Studies of different types of antibiotics and regimens have also been inconclusive. Treatment periods ranging from two to 10 days have been shown to be comparable.

The researchers found that the use of antibiotics in patients with otitis media does not appear to dramatically relieve the duration of symptoms, reduce the number of recurrences or improve long-term outcomes when compared with patients who do not receive them.

The Dutch protocol for the treatment of acute otitis media includes use of acetaminophen for at least the first 24 hours (longer in older children without risk factors) and frequent re-evaluation. This approach has resulted in significantly lower rates of resistance to common antibiotics in isolates of S. pneumoniae and Haemophilus influenzae in the Netherlands, compared with other European countries. Similarly, there has been a documented decline in antibiotic resistance in children attending day care centers in Iceland since the country adopted the Dutch protocols for treatment of acute otitis media. When initial management of otitis media emphasizes pain and symptom relief with careful follow-up as in the Dutch system, less than 3 percent of children had persistent symptoms after three days and the outcomes at two months were similar when compared with outcomes in other countries where physicians routinely use antibiotic therapy.

The researchers conclude that more than 80 percent of children with acute otitis media recover with the use of symptomatic treatment and good follow-up care. Measures to prevent otitis media infection in children include breast feeding, avoidance of tobacco smoke and good hygiene to reduce viral transmission. The researchers recommend that the routine use of antibiotics be reconsidered and, if antibiotics are used, that the duration of therapy should be less than 10 days.

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Copyright © 1998 by the American Academy of Family Physicians.

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