guidelines

otitis media (acute)

detailed summary of nice ng91: watchful waiting criteria, antibiotic indications (amoxicillin), and perforation care.

last reviewed: 2026-02-13
based on: NICE NG91 (published 28 Mar 2018)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Default: Watchful waiting. 60% resolve in 24h. Analgesia (Paracetamol/Ibuprofen) is the mainstay.
  • Treat Immediately If: Systemically unwell, Otorrhoea (discharge/perforation), or Age <2 years with bilateral infection.
  • Safety Net: "Return if discharge begins or no improvement in 3 days."

Treatment Logic

  • No Antibiotics: Most children >2 years with unilateral infection and no fever/vomiting.
  • Delayed Prescription: Offer if symptoms are mild but parent is anxious or history of recurrence.
  • Immediate Prescription:
    • Systemically unwell (fever/vomiting).
    • Discharge (perforation).
    • Age < 2 years with bilateral infection.

Antibiotic Choice (5-7 days)

  • First Line: Amoxicillin
    • Adult/Child >40kg: 500mg tds.
    • Child: Age-banded (e.g., 250mg tds 1-5y).
  • Penicillin Allergy:
    • Clarithromycin: Age-banded doses bd.
    • Erythromycin: Age-banded doses qds.
  • Recurrent/Treatment Failure: Co-amoxiclav is second line (usually specialist advice if persistent).

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.