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Three Part Question

In [a systemically well child with otitis media] are [oral antibiotics better than placebo] at [decreasing time to recovery and reducing the incidence of secondary complications]?

Clinical Scenario

A 2 year old child is brought into the emergency department with a general malaise and irritability for the last 24 hours. Examination of the right ear reveals a diffusely red bulging ear drum. A diagnosis of acute otitis media is made. You wonder whether there is any evidence that oral antibiotics would decrease the time to recovery and prevent secondary complications.

Search Strategy

Medline 1966-11/00 using the OVID interface.
[(exp otitis media OR otitis media.mp OR acute otitis media.mp OR acute red ear.mp) AND (exp antibiotics OR antibiotic$.mp OR exp amoxycillin OR amoxycillin.mp OR exp amoxicillin-potassium clavulanate combination OR augmentin.mp OR co-amoxyclav.mp OR exp erythromycin OR exp erythromycin estolate OR erythromycin.mp OR exp penicillins OR penicillin.mp OR non-antibiotic treatment.mp OR placebo.mp)] AND maximally sensitive RCT filter LIMIT to human AND english.

Search Outcome

865 papers were found of which 10 were relevant and had been meta-analysed by the Cochrane review group which was last updated on 28/04/2000. No further relevant papers have been published since. A meta-analysis done in 1994 was also selected.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rosenfeld RM et al, 1994 USA	33 trials including 5400 children with acute otitis media Antibiotics vs no antibiotics	Meta-analysis	Complete clinical resolution of signs (primary control)	Compared with placebo or no drug, antimicrobial therapy increased primary control by 13.7% (8.2% to 19.2%) (NNT=7)	Outcome not patient orientated
Glasziou PP et al, 2000 UK	7 trials with patient related outcomes. Total inclusion of 2,202 children with acute otitis media. Antibiotics vs no antibiotics	Systematic review	Hearing between 1 and 3 months	No significant difference	Only one episode of mastoiditis in all the trials
			Pain between 2 and 7 days	28% (CI 15%-38%) relative reduction with antibiotics (NNT=17)
			Pain at 24 hours	No difference

Comment(s)

Most cases of otitis media will spontaneously resolve.

Editor Comment

A recent Cochrane review on this subject has been published in August 2004. This BET will be re-examined in light of this and updated shortly.

Clinical Bottom Line

There is benefit from the use of antibiotics in otitis media.

References

1. Rosenfeld RM, Vertrees JE, Carr J et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials J Pediatr 1994;124(3):355-67.
2. Glasziou PP, Del Mar CB, Hayem M. Antibiotics for acute otitis media in children (Cochrane Review) In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software.