What are the indications for prescribing antibiotics in cases of otitis media?

Antibiotics are indicated in cases of acute otitis media (AOM) when the patient is systemically very unwell or has symptoms and signs of a more serious illness or condition, or is at high risk of complications. This includes people with otorrhoea or children under 2 years with bilateral infection, although the potential benefits must be weighed against the rarity of complications and possible adverse effects of antibiotics. Immediate antibiotic prescription is recommended for those who are systemically unwell or have red flag symptoms suggesting complications such as meningitis or mastoiditis. Children younger than 3 months with a temperature of 38ºC or more should be admitted for immediate paediatric assessment and given antibiotics. For children aged 3–6 months with a temperature of 39ºC or more, clinical judgement should be used to consider antibiotic treatment and possible admission. If antibiotics are not prescribed immediately, a back-up antibiotic prescription may be given with advice to use it if symptoms do not improve within 3 days or worsen rapidly. Antibiotics should also be prescribed if symptoms fail to improve within 3 days or worsen at any time after initial conservative management. The first-line antibiotic is a 5–7 day course of amoxicillin, with clarithromycin or erythromycin as alternatives for penicillin-allergic patients. Co-amoxiclav is reserved for worsening symptoms after initial antibiotic treatment. Routine antibiotic use is not recommended for most cases as symptoms often improve within 3 days without antibiotics, and analgesic and anaesthetic ear drops are advised for symptom relief in children without perforation or otorrhoea.