How can I differentiate between viral and bacterial otitis media in a primary care setting?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 14 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

The provided UK guidelines do not offer specific clinical signs or symptoms to differentiate between viral and bacterial otitis media at initial presentation in a primary care setting .

However, if a person's symptoms of acute otitis media (AOM) fail to improve or worsen after 2 to 3 days of antibiotic treatment, it is recommended to reassess them and consider that the symptoms could be due to a viral infection or antibiotic resistance . NICE guidance also advises reviewing treatment if symptoms do not improve within 7 days or worsen at any time .

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