Acute otitis media ( AOM ) and mastoiditis in adults - Primary Care

Publication: 30/09/2010  --
Last review: 05/09/2018  
Next review: 05/09/2021  
Clinical Guideline
CURRENT 
ID: 2225 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Acute otitis media (AOM) and mastoiditis in adults in Primary Care

Note: The treatment of AOM in adults is largely extrapolated from studies in children: Acute otitis media (AOM) occurs frequently in children but is less common in adults.

Adult patients [>16years old] with new/rapid onset earache and associated loss of hearing. Often preceding history of upper respiratory symptoms including cough and rhinorrhoea.

Admit for immediate specialist assessment if:

  • there are suspected serious acute complications of acute otitis media (AOM) such as meningitis, mastoiditis, brain abscess or facial nerve paralysis;
  • there are signs of sepsis/severe sepsis/septic shock.

Consider admitting:

  • people who are very systemically unwell, or;
  • those with and systemic symptoms of infection and risk factors for poor outcome/response:
    • Adults with serious craniofacial abnormalities
    • Immunocompromised patients
    • Diabetes mellitus
    • Frail/aged >80 years old
    • Treatment failure in the community.

For all other people with AOM:

  • Optimise analgesia     
  • Empirical antibiotics, targeted use, as below:A+ 

For most people, offer no antibiotics or give a back-up antibiotic prescription.

Antibiotics are not indicated in those with uncomplicated AOM, who are not systemically unwell, do not have severe local signs of infection and have had symptoms for <72 hours.

Consider 2 or 3-day back-up prescription A+, to start if symptoms worsen, or if not resolving by 4 days.

Consider immediate oral empirical antibiotics  if there are signs of severe local infection/ bilateral AOM or mild systemic features or those who are immunocompromised or at high risk of serious complications because of significant heart, lung, kidney, liver, or neuromuscular disease,  or if symptoms have persisted/worsened after 72 hours.

Consider immediate oral antibiotics for pain relief in patients of all ages with otorrhoea (NNT = 3). A+

Note that antibiotics to prevent mastoiditis has a NNT>4000.B-

 Preferred Option

Alternative Option

Notes

Offer analgesia if pain is present. A+
Paracetamol  1g 6-hourly PO
  
Antibiotics:
No antibiotics

Ibuprofen
400mg 8-hourly PO 

No antibiotic prescribing strategy — offer reassurance that antibiotics are not usually needed because they are likely to make little difference to symptoms, may have adverse effects and can contribute to antibiotic resistance.

Antibiotics are not indicated in patients with uncomplicated AOM, who are not systemically unwell, do not have severe local signs of infection and have had symptoms for <72 hours.

  • Uncomplicated AOM is defined as: Mild pain of <4 days duration and an absence of severe systemic symptoms, with a temperature of less than 39°C and no ear discharge.
  • Complicated AOM is defined as the presence of: severe pain, perforated eardrum and/or purulent discharge, bilateral infection, mastoiditis (pain and inflammation of the mastoid cavity), labyrinthitis, meningitis, intracranial sepsis, or facial nerve palsy.

AOM resolves in 60% of cases in 24 hours without antibiotics.A+ Antibiotics reduce pain only at two days (NNT = 15), and do not prevent deafness.A+

Consider back-up antibiotics
(see below)

 

 

 

 

Back-up antibiotic prescribing strategy — provide a back-up antibiotic prescription. Advise that antibiotics should be started if symptoms are not improving within 4 days of the onset of symptoms or if there is a significant worsening of symptoms at any time.

For both strategies, advise the person to re-consult if the condition worsens or if symptoms are not improving within 4 days of the onset of symptoms.

Offer an immediate antibiotic prescription to people:

  • Who are systemically unwell but do not require admission.
  • Who are at high risk of serious complications because of significant heart, lung, kidney, liver, or neuromuscular disease; or who are immunocompromised.
  • Severe local signs such as perforation with purulent discharge, bilateral AOM
  • Whose symptoms have lasted for 4 days or more and are not improving, or at any time if worsening.

Immediate antibiotics

Amoxicillin A+
500mg TDS PO 5 days

Penicillin allergy:
Clarithromycin D 500mg BD PO 5 days

Penicillin allergy in pregnancy:
Erythromycin A+ 500mg QDS PO 5 days

Consider immediate antibiotics for pain relief (in all ages with otorrhoea, NNT3. A+)

Note: 5 days therapy is sufficient for most cases of otitis media. Immunocompromised patients/severe infections may need more prolonged antimicrobial therapy.

Failure of first-line antibiotic therapy:

Co-amoxiclav
500/125mg TDS PO 7 days

Penicillin allergy:
Discuss with microbiologist

Re-assess patient for complications/need for admission (as above)

The NICE otitis media in children guideline published March 2018 recommends second choice of co-amoxiclav if first choice antibiotics have not worked after 2-3 days.

PHE
LTHT secondary care guideline
NICE otitis media guidance

Background information:

Acute otitis media (AOM) is defined as the presence of inflammation in the middle ear, associated with an effusion and accompanied by the rapid onset of symptoms and signs of an ear infection.

Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear without symptoms and signs of an ear infection.

Acute otitis media (AOM) can be caused by both viruses and bacteria; often both are present at the same time

  • The most common bacterial pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus pyogenes
  • since the introduction of the pneumococcal conjugate vaccine, the most common bacterial pathogen may be changing from Streptococcus pneumoniae to Haemophilus influenza.
  • The most common viral pathogens associated with AOM are respiratory syncytial virus (RSV) and rhinovirus

Without antibiotic treatment: this is guidance for adults but please note the following, symptoms will improve within 24 hours in 60% of children with acute otitis media (AOM), and will settle spontaneously within 3 days in 80% of children.

A Cochrane systematic review (search date November 2012) identified 12 randomized controlled trials (n = 3317, 3854 AOM episodes) of antibiotic treatment for AOM in children. There was no good evidence for the routine use of immediate antibiotics:

  • Although antibiotic treatment led to a statistically significant reduction of children with AOM experiencing pain on days 2–7 compared with placebo, symptoms settled spontaneously in most children (82%), and 20 children needed to be treated to prevent one child experiencing pain on those days.
  • Antibiotic treatment led to a reduction of tympanic membrane perforations (numbers needed to benefit one person [NNTB] 33) and the development of AOM in the unaffected ear (NNTB 11), but the reviewers noted that for every 14 children treated with antibiotics, one child experienced an adverse event (such as vomiting, diarrhoea, or rash) that would not have occurred if antibiotics had been withheld.
  • The evidence, however, showed that antibiotics are most useful in children younger than two years of age with bilateral AOM, or with both AOM and ear discharge (irrespective of age).
  • The authors concluded that the benefits of antibiotic treatment must be weighed against possible harms, including adverse effects and the increased risk of antibiotic resistance in the community.
  • Complications of acute otitis media (AOM) include:
    • Recurrence of infection.
    • Hearing loss (usually conductive and temporary).
    • Tympanic membrane perforation.
    • Rarely, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.

Persistent or recurrent AOM

  • Routine follow up is not required in the absence of persistent symptoms of AOM.
  • Persistent AOM is defined as occurring when people return for medical advice with the same episode of AOM, either because symptoms persist after initial management or because symptoms are worsening.ie people with persisting symptoms despite antibiotic treatment
  • Recurrent AOM is generally defined as three or more well-documented and separate AOM episodes (with an absence of middle ear disease between episodes) in the preceding 6 months, or four or more episodes in the preceding 12 months with at least one episode in the past 6 months
  • Management of persistent or recurrent AOM involves:
    • Reassessing the person.
    • Considering the need for ENT referral or admission, depending on the clinical situation.
    • Considering a first-line antibiotic (if not already prescribed) or a second-line antibiotic if the initial treatment was ineffective.
  • Measures to prevent recurrent AOM in adults include avoiding smoking and/or passive smoking

Follow up in Primary Care is required when:

  1. no antibiotic prescribing strategy is adopted and there is significant worsening of symptoms or if symptoms are not starting to settle within 4 days of the onset of the illness
  2. an immediate antibiotic prescribing strategy is adopted and symptoms persist despite completing a course of antibiotics, or if there is significant worsening of symptoms while on therapy.
  3. If discharge from the ear canal (otorrhoea) persists for 2 weeks.
  4. If perforation of the tympanic membrane has occurred.
  5. If hearing loss persists in the absence of pain or fever.
  6. For recurrent acute otitis media.

Consider acute referral via PCAL or routine ENT referral, dependent on clinical condition.

General Principles for Treating Infections in Primary Care (please see specific guidance regarding choices of antibiotics)

This guidance is based on the best available evidence but its application must be modified by professional judgement.

  1. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  2. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  3. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  5. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  6. Limit prescribing over the telephone to exceptional cases.
  7. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  8. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  9. In pregnancy, take specimens to inform treatment, use this guidance alternative or seek expert advice. Penicillins, cephalosporins and erythromycin are not associated with increased risks. If possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin, clarithromycin, high dose metronidazole (2g stat) unless the benefits outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist.
  10. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic medicines are similar cost. Use erythromycin in pregnancy.
  11. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record: 2225
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Acute Otitis Media (Adults)

Target patient group: Adults
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

Evidence base

Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation
grade

Good recent systematic review and meta-analysis of studies

A+

One or more rigorous studies; randomised controlled trials

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Non-analytic studies, eg case reports or case series

C

Formal combination of expert opinion

D

Most studies looked at otitis media in children only.

  1. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ. 2001 Feb; 322(7282):336-342. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC26576/.
  2. Sjoukes A, Venekamp RP, van de Pol AC, Hay AD, Little P, Schilder AG et al. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children (Review). Cochrane Database Syst Rev. 2016 Dec; 15(12):1-74. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011534.pub2/epdf.
  3. Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children (Review). Cochrane Database Syst Rev. 2015 Jun; 23(6):1-85. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000219.pub4/epdf.
  4. National Institute for Health and Care Excellence (NICE). Respiratory tract infections – antibiotic prescribing. 2008 Jul. Available from:
    https://www.nice.org.uk/guidance/cg69/evidence/full-guideline-196853293.
  5. Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotics for respiratory
    infections (Review). Cochrane Database Syst Rev. 2013 Apr; 30(4):1-65. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004417.pub4/pdf.
  6. Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA et al. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics. 2007 Mar; 119(3):579-585. Available from: http://pediatrics.aappublications.org/content/119/3/579.
  7. 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 Oct; 368(9545):1429-1435. Available from: http://www.sciencedirect.com/science/article/pii/S0140673606696062.
  8. Hoberman A, Paradise JL, Rockette HE, Shaikh N, Wald ER, Kearney DH et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011 Jan; 364(2):105-115.
    Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042231/pdf/nihms264759.pdf.
  9. Thompson PL, Gilbert RE, Long PF, Saxena S, Sharland M, Wong IC. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United Kingdom general practice research database. Pediatrics. 2009 Feb; 123(2):424-430. Available from: http://pediatrics.aappublications.org/content/123/2/424.
  10. Groth A, Enoksson F, Hermansson A, Hulcrantz M, Stalfors J, Stenfeldt K. Acute mastoiditis in children in Sweden 1993-2007: no increase after new guidelines. Int J Pediatr Otorhinolaryngol. 2011 Dec; 75(12):1496-1501. Available from: http://www.sciencedirect.com/science/article/pii/S0165587611004071.
  11. Shekelle PG, Takata G, Newberry SJ, Coker T, Limbos MA, Chan LS et al. Management of acute otitis media: update. Evid Rep Technol Assess (Full Rep). 2010 Nov; 1(198):1-426. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23126594.
  12. Courter JD, Baker WL, Nowak KS, Smogowicz LA, Desjardins LL, Coleman CI et al. Increased clinical failures when treating acute otitis media with macrolides: a meta-analysis. Ann Pharmacother. 2010 Mar; 44(3):471-478. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20150506.
  13. Clinical Knowledge Summaries (CKS). Otitis media – acute. 2015 Jul. Available from: https://cks.nice.org.uk/otitis-media-acute#!topicsummary.
  14. Thanaviratananich S, Laopaiboon M, Vatanasapt P. Once or twice daily versus three times
    daily amoxicillin with or without clavulanate for the treatment of acute otitis media (Review). Cochrane Database Syst Rev. 2013 Dec; 13(12):1-61. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004975.pub3/epdf.
  15. Kozyrskyj A, Klassen TP, Moffatt M, Harvey K. Short-course antibiotics for acute otitis media (Review). Cochrane Database Syst Rev. 2010 Sep; 8(9):1-151. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001095.pub2/epdf .
    British Columbia Medical Association (2010) Otitis media: acute otitis media (AOM) & otitis media with effusion (OME).British Columbia Health Services. http://www.bcguidelines.ca/
    Lieberthal, A., Carroll, A., Chonmaitree, T. et al. (2013) The diagnosis and management of acute otitis media.Pediatrics131(3), e964-e999.
    CKS topic on Otitis media with effusion.
    COMPASS (2009) COMPASS therapeutic notes on the management of acute otitis media.Central Services Agency, Northern Ireland.
    Venekamp, R., Sanders, S., Glasziou, P. et al. (2013) Antibiotics for acute otitis media in children (Cochrane Review).The Cochrane Library. Issue 1. John Wiley & Sons, Ltd. www.thecochranelibrary.com

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