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

Indications for prescribing antibiotics in acute otitis media (AOM) include:

• People who are systemically very unwell or have symptoms and signs of a more serious illness or condition, including red flag symptoms suggesting complications such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, or facial nerve paralysis should be offered immediate antibiotics and admitted for specialist assessment if needed.
• Children younger than 3 months of age with a temperature of 38°C or more should be admitted for immediate paediatric assessment and offered antibiotics.
• Children aged 3–6 months with a temperature of 39°C or more should be considered for admission and antibiotic treatment based on clinical judgement.
• People who do not require admission but are systemically unwell or at high risk of complications should be offered immediate antibiotic prescription.
• Children and young people under 18 years with bilateral infection or those with otorrhoea (ear discharge) may be more likely to benefit from antibiotics; however, the potential adverse effects and rarity of complications should be considered.
• Antibiotics should be prescribed if symptoms do not improve within 3 days or worsen significantly or rapidly at any time, especially if no prior antibiotic treatment has been given.
• A back-up antibiotic prescription may be considered for those not needing immediate antibiotics, with advice to use it if symptoms fail to improve within 3 days or worsen.

When antibiotics are indicated, a 5–7 day course of amoxicillin is first-line; alternatives include clarithromycin or erythromycin for penicillin-allergic patients, with co-amoxiclav reserved for worsening symptoms after initial treatment.

Analgesic and anaesthetic ear drops are recommended for children and young people under 18 when antibiotics are not immediately prescribed and there is no eardrum perforation or otorrhoea.

Routine antibiotic prescribing is not recommended for most cases as symptoms often improve within 3 days without antibiotics, and complications are rare.

Patients should be advised to seek medical help if symptoms worsen rapidly or significantly, or if they become systemically very unwell.