Background: Acute otitis media, one of the most common childhood infections, is the leading justification for antibiotic prescriptions to children. Nevertheless, antibiotic therapy is believed to provide only marginal benefit and to have several negative consequences (e.g., antibiotic resistance, encouraging more frequent physician visits). Current clinical guidelines stress selective use of antibiotics in children older than two years, but no consensus has been reached for younger children. Rovers and colleagues reviewed available evidence to better identify subgroups of children who might benefit from antibiotic therapy for otitis media.

The Study: The authors searched electronic databases and reviewed proceedings of international symposia to identify high-quality clinical trials of otitis media in children 12 years and younger. For the 10 trials that met inclusion criteria, original data were provided by six trials, covering 1,643 children. All data were validated and reanalyzed before entry into the meta-analysis. The primary outcome was pain, fever, or both persisting for three to seven days. Fever was defined as documented temperature of 100.4° F (38° C) or higher. Pain was assessed by parents and reported in symptom diaries. Any documented adverse effect of treatment also was recorded. The potential predictive features of age younger than two years, bilateral otitis media, and otorrhea were identified from previous studies.

Results: The statistical analysis concluded that the overall relative risk for an extended course of otitis media (persisting symptoms for three to seven days) with antibiotics was 0.83, representing a number needed to treat (NNT) of eight children for one additional child to benefit. For persisting fever, the NNT was 20; for pain, it was 10.

The effect of antibiotics was examined by age, bilateral disease, and the presence of otorrhea. The overall NNT for pain, fever, or both in children younger than two years was seven, compared with 10 for older children. The presence of otorrhea changed the NNT from eight to three, and bilateral infection changed the NNT from 17 to five. The effect of combining the two most common variables of age and unilateral versus bilateral disease is shown in the accompanying table.

Conclusion: The authors conclude that antibiotics are most beneficial in children younger than two years who have bilateral disease, and in children of any age who have otorrhea during acute infections. They do not believe that the current results indicate that all children younger than two years benefit more from antibiotics than older children, as has been previously suggested. The authors call for more specific selection of children for early antibiotic therapy and propose that observation and symptomatic relief is appropriate for most children with mild otitis media.