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'Let patients register with several GPs'

ear

infections

Acute otitis media is the commonest reason for children to be prescribed antibiotics in developed countries. Inappropriate antibiotic use is likely to foster resistance and lead to serious infections becoming untreatable.

Patients with otitis media usually present with ear pain, fever and hearing loss. Younger children also have non-specific symptoms ­ irritability, vomiting and diarrhoea.

The ear drum should be examined for change in colour, opacity, bulging and/or perforation. Examination is also useful to exclude mastoiditis, and other causes (eg urinary tract infection).

US authorities argue for routine pneumatic otoscopy ­ but this is only likely to be useful in milder early cases.

In such cases (eg a pink drum with crying or fever) unless there is clearer evidence of significant tympanic membrane pathology, a diagnosis of otitis media should not be made.

What does not work?

There is no clear benefit from several trials and side-effects are more common.

Antibiotics should probably be in the category 'does not work very well'. A systematic review of controlled trials suggests 18 children have to be treated with antibiotics for one to see symptoms resolved between two and seven days, and treatment doubles the risk of side-effects.

This suggests that for most patients

antibiotics only work moderately well. There are similar findings from a recent trial in under-twos.

Although most children present within 24 hours, it seems sensible to build the average pre-consultation wait into the delayed prescription approach: children who have already had severe otalgia and fever for 72 hours should probably not wait and see for a further 72 hours.

Thus adding 24 hours (the average time to presentation) to the 72 hours approach used in the Dutch studies gives the average total wait and see time ­ 96 hours total for children aged two and over, or 48 hours for the under-twos.

There is some evidence from subgroup analysis of a trial that children with fever (>37.5°C) and/or vomiting are more likely to have more severe symptoms, and may benefit from antibiotics. This does not mean all such patients should have immediate antibiotics but that delayed antibiotics with a shorter delaying time (eg 36 hours) could be offered.

There is debate about 'otitis prone' children: more than two attacks in six months. Although recurrent attacks may be a risk factor for hearing impairment, it is unclear if antibiotics will prevent these sequelae. However, since this group are at higher risk, and they are a small minority, there is some argument for treating them with antibiotics more aggressively.

Antibiotic prophylaxis for otitis-prone children cannot be justified until there is more evidence.

What works?

Paracetamol and NSAIDs are effective, but NSAIDs are not shown to be better than paracetamol. Auralgan solution (antipyrine/ benzocaine/ glycerin) may also help.

A primary care trial in 315 children aged six months and over compared immediate antibiotics with a delayed approach (waiting 72 hours) and suggested little symptomatic relief from antibiotics in the first 24 hours, and that delayed prescribing was very acceptable.

The marginal advantages of immediate treatment for symptomatic relief have to be balanced against disadvantages ­ medicalisation of a self-limiting illness, diarrhoea (10 per cent of children), and antibiotic resistance.

There is no evidence that one antibiotic class is superior. A systematic review comparing short courses of treatment (five days) with longer courses (eight to 10 days) showed treatment failure, relapse or reinfection were slightly more likely with shorter courses at eight to 19 days ­ but not significant by 20 to 30 days ­ but that short courses had a lower incidence of diarrhoea.

Recent data suggests we should provide a safety-net prescription for children with otitis media: there is an inverse association between mastoiditis admissions and antibiotic prescribing at a health authority level, and mastoiditis has possibly become a little more common since the decline in antibiotic use in the mid-1990s.

However, mastoiditis is still very rare and a large case series from Holland in 5,000 children aged two and over demonstrated that a 72-hour wait-and-see policy is safe.

Antibiotics are advised for children with either significant otalgia and/or fever (>38°C) 72 hours after seeing the doctor, or discharge for more than 14 days.

One child had mastoiditis initially and was excluded. Another developed mastoiditis ­ randomised to receive myringotomy alone, he remained unwell for a week. With antibiotics he recovered.

The incidence of complications of not treating ­ even assuming that case is a complication ­ is the same as the major complication of treating, ie anaphylaxis.

Cost-effectiveness

It seems difficult to defend an important place for immediate antibiotic treatment for all patients with otitis media. Equally no offer of antibiotics is probably unsafe.

Advising patients to use full doses of paracetamol (and/or ibuprofen as necessary) and offering a 72-hour safety-net antibiotic prescription is likely to be efficient.

The most effective use of antibiotics is in patients with fever and/or vomiting, who could reasonably be advised to use antibiotics after 36 hours if symptoms are not settling. The most cost-effective antibiotic is likely to be amoxicillin.

The bottom line

1.If acceptable do not offer antibiotics immediately

2.Advise full doses of paracetamol and/or ibuprofen

3.Offer a prescription of amoxicillin (or erythromycin) if symptoms are not starting to settle after 72 hours ( or 36 for patients with fever or vomiting), or after 10 days of discharge.

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