Otitis media (acute): antimicrobial prescribing

? When no antibiotic given, advise:

Self-care
• antibiotic is not needed

• Offer regular doses • seeking medical help if symptoms worsen • Offer regular doses of paracetamol
of paracetamol or rapidly or significantly, do not start to or ibuprofen to manage pain,
ibuprofen for pain improve after 3 days or the child or with the right dose for age or
young person becomes very unwell weight at the right time and
Otorrhoea (discharge
No • Consider no antibiotic maximum doses for severe pain
or a back-up antibiotic • Evidence suggests that
after ear drum prescription With a back-up antibiotic prescription,
perforation) in any child decongestants or antihistamines
advise: do not help symptoms
or young person
• antibiotic is not
or needed immediately

Under 2 years with

? • use prescription if no improvement
in 3 days or symptoms worsen
infection in both ears?
• seeking medical help if symptoms worsen
• Offer regular doses Evidence on antibiotics
Yes of paracetamol or
rapidly or significantly, or the child or
young person becomes very unwell
ibuprofen for pain
Acute otitis media

• Antibiotics make little difference

• Consider no antibiotic, With an immediate antibiotic prescription,
to the number of children
a back-up antibiotic advise:
whose symptoms improve
prescription or an • Antibiotics make little difference
immediate antibiotic • seeking medical help if symptoms worsen to the number of children with
Advise: rapidly or significantly, or the child or recurrent infections, short-term
• acute otitis media lasts young person becomes very unwell hearing loss or perforated ear drum
about 3 days but can • Complications (such as mastoiditis)
last up to 1 week are rare with or without antibiotics
• manage symptoms with • Possible adverse effects include
self-care Reassess at any time if symptoms worsen rapidly or significantly, taking account of: diarrhoea and nausea
• other possible diagnoses
• any symptoms or signs suggesting a more serious illness or condition
• previous antibiotic use, which may lead to resistant organisms
Groups who may be
more likely to benefit
If the child or young
from antibiotics
person:
is systemically very • Children and young people with acute
unwell, or otitis media and otorrhoea (discharge
• Offer an immediate Refer to hospital if: following ear drum perforation)
has symptoms and signs antibiotic prescription • severe systemic infection, or • Children under 2 years with
of a more serious illness • complications like mastoiditis acute otitis media in both ears
or condition, or
has high risk of
complications March 2018
Otitis media (acute): antimicrobial prescribing
Choice of antibiotic: children and young people under 18 years

Antibiotic1 Dosage and course length2

First choice

Amoxicillin 1 to 11 months: 125 mg three times a day for 5 to 7 days

1 to 4 years: 250 mg three times a day for 5 to 7 days
5 to 17 years: 500 mg three times a day for 5 to 7 days
Alternative first choices for penicillin allergy or intolerance3

Clarithromycin 1 month to 11 years:

Under 8 kg: 7.5 mg/kg twice a day for 5 to 7 days
8 to 11 kg: 62.5 mg twice a day for 5 to 7 days
12 to 19 kg: 125 mg twice a day for 5 to 7 days
20 to 29 kg: 187.5 mg twice a day for 5 to 7 days
30 to 40 kg: 250 mg twice a day for 5 to 7 days
or
12 to 17 years: 250 mg to 500 mg twice a day for 5 to 7 days
Erythromycin 1 month to 1 year: 125 mg four times a day or 250 mg twice a day for 5 to 7 days
2 to 7 years: 250 mg four times a day or 500 mg twice a day for 5 to 7 days
8 to 17 years: 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 to 7 days
Second choice (worsening symptoms on first choice taken for at least 2 to 3 days)

Co-amoxiclav 1 to 11 months: 0.25 ml/kg of 125/31 suspension three times a day for 5 to 7 days
1 to 5 years: 5 ml of 125/31 suspension three times a day or 0.25 ml/kg of 125/31 suspension three times a day for 5 to 7 days
6 to 11 years: 5 ml of 250/62 suspension three times a day or 0.15 ml/kg of 250/62 suspension three times a day for 5 to 7 days
12 to 17 years: 250/125 mg three times a day or 500/125 mg three times a day for 5 to 7 days
Alternative second choice for penicillin allergy or intolerance

Consult local microbiologist

1
See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment.
2
The age bands apply to children of average size and, in practice, the prescriber will use age bands in conjunction with other factors such as the severity of
2
the condition and the child’s size in relation to the average size of children of the same age. Doses given are by mouth using immediate-release medicines,
2
unless otherwise stated.
3
Erythromycin is preferred in young women who are pregnant.

When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account,
alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory
to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the
© NICE 2018. All rights reserved. Subject to Notice of rights. circumstances of the individual, in consultation with them and their families and carers or guardian.