Otitis Media in Children - Diagnosis and Management of
|Last review: 22/08/2019|
|Next review: 01/08/2022|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Diagnosis and Management Acute Otitis Media in Children
Otitis Media in Children
AOM has a clinical spectrum extending from a benign self-limiting condition to a prolonged and sometimes complicated disease. For the purpose of this guideline:
Uncomplicated AOM is defined as: Mild pain of <4 days duration and an absence of any “red” or “yellow” alert symptoms (Table 1).
Complicated AOM is defined as: presence of any “red” or “yellow” alert symptoms (Table 1) or any of: severe pain, bilateral infection, mastoiditis, labyrinthitis, intracranial complications or facial nerve palsy.
4. Non-antimicrobial treatment
5. Empirical Antimicrobial Treatment
Antimicrobials should not be routinely prescribed for uncomplicated AOM. If antimicrobials are not indicated discuss the reasons and limitations/drawbacks of antimicrobials with child/parents/carer and advise re-consultation if worse/no better in 3 days or the child becomes systemically unwell.
Route: oral antimicrobials are appropriate in most cases but IV therapy may be necessary for more severe infection (e.g. “red features” or vomiting child) – as judged clinically.
Amoxicillin is first line therapy; second line (e.g. true penicillin allergy or recent (last 2 weeks) Amoxicillin treatment) is Clarithromycin .
Doses: Table 2.
7. Referral criteria
Acute otitis media is an inflammation of the middle ear, which can affect people of all ages, but is particularly common in young children. It usually causes some earache and temporary (occasionally permanent) hearing loss. Acute otitis media (AOM) is one of the most common diseases in infants and children with a peak incidence between 6 and 15 months of age. Over 75% of episodes of AOM occur in children younger than 10 years of age1.
AOM and otitis media with effusion (OME) are different stages of a continuum.
Children with OME experience up to 5 times more episodes of AOM than children without OME. Recurrent AOM is generally defined as three or more episodes of AOM in 6 months, or four or more episodes in a year, with an absence of middle ear disease between episodes.
Both viruses and bacteria can cause AOM and commonly both are present.2 3 There are too few reports to accurately estimate the proportions of each. However, respiratory viral infections usually precede or coincide with AOM in children. In 5-20% the cause of AOM is viral alone and in another 4-20% neither bacteria nor viruses can be isolated.2-4
The most common bacterial pathogens associated with AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.2 3 5 Following the introduction of pneumococcal vaccination, the most common bacterial pathogen may be changing from Streptococcus pneumoniae to Haemophilus influenza.6 When AOM is associated with Haemophilus influenzae, non-typable strains are most common.7
The most common viral pathogens associated with AOM are respiratory syncytial virus and rhinovirus 5.
Risk factors for AOM, besides young age, include 8
Severe complications such as mastoiditis (infection of the mastoid bone and air cells), labyrinthitis, meningitis, intracranial sepsis, or facial nerve palsy are rare in otherwise healthy patients from developed countries.9
Meningitis and brain abscesses should be managed according to LTHT guidelines with ENT input as required.
Definitions -for the purposes of this guideline.
Complicated AOM is defined as:
Acute otitis media is a clinical diagnosis (see diagnosis section), investigations are only required in selected circumstances to determine the extent of infection or to guide antimicrobial therapy.
Recommendation: send a sample of pus in a sterile sample container to microbiology if the tympanic membrane has perforated and pus is present in the ear canal and a patient is being admitted to hospital or has failed previous antimicrobial therapy (ideally collect a sample of pus using a sterile syringe -without a needle). [Evidence level C]
Recommendation: In patients who require intravenous antimicrobial therapy, the following baseline investigations should be performed and repeated according to clinical need: FBC, CRP, U&E
Recommendation: blood cultures should be taken in all children with complicated AOM and signs or symptoms of systemic infection. [Evidence level D]
Recommendation: When intracranial spread is suspected a CT head with contrast should be obtained as the imaging modality. MRI with gadolinium is useful when intracranial involvement is confirmed. [Evidence level B]
Recommendation: Treat pain and fever with paracetamol or ibuprofen if there are no contraindications.
Recommendation: When antimicrobials are not prescribed offer reassurance to child/parents/carers that antimicrobials are not usually needed because they are likely to make little difference to symptoms, may have adverse effects (for example, diarrhoea, vomiting, and rash), and can contribute to antibiotic resistance. [Evidence level C]
Recommendation: Advise the child/parents/carers to re-consult if the condition worsens or if symptoms are not starting to settle within 48 hours. 13 14
|Empirical Antimicrobial Treatment|
Recommendation: Antimicrobial treatment should be offered to the following groups15:
Recommendation: The decision to initially administer antimicrobials via the IV or oral route is a clinical one, based on the severity of infection and likely compliance/tolerance of oral therapy. Children with “red” features (Table 1) would normally require IV therapy.
Recommendation: if an antibiotic is required, amoxicillin is first line therapy. Clarithromycin is the recommended alternative for children who are allergic to penicillins or recently treated with penicillin (in past 2 weeks).
NB. In a setting with high prevalence of Streptococcus pneumoniae with reduced susceptibility to penicillin high dose amoxicillin (80 mg/kg/day three times a day) remained clinically effective in 82% (n=41) of children with culture-positive AOM caused by a variety of bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) - including Strep. pneumoniae with reduced susceptibility to penicillin and beta-lactamase-producing H. influenzae.16
Recommendation: For children who do not meet criteria for current antimicrobial therapy, observation for 3 days and reconsultation if worse or no better is advised.13 14
Directed antimicrobial treatment
Recommendation: If microbiological diagnosis becomes available e.g. via blood cultures or pus samples, therapy should be altered according to susceptibilities or discussed with a Microbiologist.
|Duration of Treatment|
Recommendation: 5-7 days course.
Evidence on antibiotic duration
|Switch to oral agent(s)|
Recommendation: When intravenous therapy has been commenced initially, switch to oral antimicrobials can usually be done safely after 48 hours, provided that local and systemic signs of infection are resolving and any co-morbidities are stabilised.
Recommendation: AOM not responding to first or second choice antimicrobial therapy or where these agents are contraindicated should be discussed with ENT and microbiology.
Recommendation: Routine follow-up is not required in the absence of persistent symptoms.
Recommendation: Follow up is required when:
To standardise care and define best practise in the diagnosis and management of acute otitis media in children.
Otitis media in Children
|Target patient group:||Infants and children with confirmed or suspected otitis media.|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
- Network SIG. Diagnosis and management of childhood otitis media in primary care: a national clinical guideline. 2003.
- Chonmaitree T. Acute otitis media is not a pure bacterial disease. Clin Infect Dis 2006;43(11):1423-5.
- Ruohola A, Meurman O, Nikkari S, Skottman T, Salmi A, Waris M, et al. Microbiology of acute otitis media in children with tympanostomy tubes: prevalences of bacteria and viruses. Clin Infect Dis 2006;43(11):1417-22.
- Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. The New England journal of medicine 1999;340(4):260-4.
- Rovers MM, Schilder AG, Zielhuis GA, Rosenfeld RM. Otitis media. Lancet 2004;363(9407):465-73.
- Block SL, Hedrick J, Harrison CJ, Tyler R, Smith A, Findlay R, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatr Infect Dis J 2004;23(9):829-33.
- Klein JO. Otitis externa, otitis media, mastoiditis. In: Mandell GL, Douglas RG, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 6th ed: Churchill Livingstone, 2005.
- Uhari M, Mantysaari K, Niemela M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis 1996;22(6):1079-83.
- O'Neill P, Roberts T, Bradley Stevenson C. Otitis media in children (acute). Clin Evid 2006(15):500-10.
- Takata GS, Chan LS, Shekelle P, Morton SC, Mason W, Marcy SM. Evidence assessment of management of acute otitis media: I. The role of antibiotics in treatment of uncomplicated acute otitis media. Pediatrics 2001;108(2):239-47.
- Bezakova N, Damoiseaux RA, Hoes AW, Schilder AG, Rovers MM. Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: survey of trial participants. Bmj 2009;338:b2525.
- Rothman R, Owens T, Simel DL. Does this child have acute otitis media? Jama 2003;290(12):1633-40.
- Spiro DM, Tay KY, Arnold DH, Dziura JD, Baker MD, Shapiro ED. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. Jama 2006;296(10):1235-41.
- Little P. Delayed prescribing--a sensible approach to the management of acute otitis media. Jama 2006;296(10):1290-1.
- Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006;368(9545):1429-35.
- Piglansky L, Leibovitz E, Raiz S, Greenberg D, Press J, Leiberman A, et al. Bacteriologic and clinical efficacy of high dose amoxicillin for therapy of acute otitis media in children. Pediatr Infect Dis J 2003;22(5):405-13.
- Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, Wincott JL, Sitar DS, Klassen TP, et al. Short course antibiotics for acute otitis media. Cochrane database of systematic reviews (Online) 2000(2):CD001095.
- Gulani A, Sachdev HP, Qazi SA. Efficacy of short course (<4 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials. Indian pediatrics 2010;47(1):74-87.
- NICE guideline NG91 - Otitis Media (Acute):antimicrobial prescribing. Published March 2018, reviewed by NICE April 2019 https://www.nice.org.uk/guidance/ng91
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
Improving Antimicrobial Prescribing Group
LHP version 2.0
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