Antibiotics or ‘watch and wait’ for acute otitis media

Clinical question: 
How should I treat uncomplicated acute otitis media (AOM)?
Bottom line: 
Immediate antibiotic treatment reduces earache/fever or both at 3-7 days: <2 years + bilateral AOM NNT* = 4 <2 years + unilateral AOM NNT = 20 ≥ 2 years + bilateral AOM NNT = 9 ≥ 2 yrs + unilateral AOM NNT = 15 Watch and wait may be appropriate for unilateral AOM except in children under 6 months of age. Most guidelines recommend routine antibiotics for children less than 6 months. *NNT = number needed to treat to benefit one individual.
Adverse events reported included diarrhoea (4-21% of children in the treatment groups, 2-14% in the control groups), and rash (1-8% in the treatment groups and 2-6% in the control groups). No serious adverse events were reported. Children with a temperature >37.5 C and vomiting are more likely to be distressed or have night disturbance after 3 days and would appear to benefit from antibiotics.¹ 1. Little P, et al. Predictors of poor outcomes and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ 2002;325:22-25. This is a single study involving 315 patients.
AOM is very common in preschool children, uncommon in older children and very rare in adults.
Review CD#: 
November, 2007
Authored by: 
Brian R McAvoy