Antibiotics

Under the Pharmacy First clinical pathway there are two main groups eligible for pharmacist antibiotic provision:

• Patients under 18 years who have otorrhoea (discharge after eardrum perforation) or eardrum perforation (suspected or confirmed)
• Children under two years of age with infection in both ears diagnosed via otoscopy with severe symptoms and symptoms that have lasted for three or more days. 

In children under two years with bilateral AOM whose symptoms are not so severe, or who do not appear particularly unwell, watchful waiting for three to five days, and possible use of phenazone with lidocaine, is advised. 

Amoxicillin is the recommended first-line antibiotic. Clarithromycin can be offered if there is a history of penicillin allergy stated by the patient/carer or recorded on the NHS national care record. Erythromycin is an option in pregnancy, or suspected pregnancy, in the context of penicillin allergy.

Despite being used by GPs in up to 60 per cent of cases of AOM, antibiotics have limited benefits. A Cochrane review showed that without antibiotic treatment, symptoms improved within 24 hours in 60 per cent of children and settled spontaneously within three days in 80 per cent. Antibiotics did not significantly reduce pain at 24 hours compared with placebo – nor did they significantly reduce pain at two to three days, but the absolute difference was small. Eighty-eight per cent of children had no pain in the antibiotic group compared with 84 per cent in the placebo group (NNT 24).

Some children may benefit from antibiotics more than others and subgroup analyses showed that children under two years with bilateral AOM had a NNT of four for earlier symptom resolution. Children with acute otitis media and otorrhoea had a NNT of three for earlier symptom resolution.

Common complications of acute otitis media are recurrence of infection, hearing loss (which is usually temporary) and perforated eardrum. Antibiotics were found to make little difference in preventing any of these. Acute complications of AOM, such as mastoiditis, meningitis, intra-cranial abscess, sinus thrombosis and facial nerve paralysis, are all very rare. There is limited evidence that some of these can be avoided by antibiotics but many patients would need to be treated to prevent one case.

Any benefits of antibiotics must be weighed against the possible harms: the Cochrane review found that for every 14 children treated with antibiotics, one child experienced an adverse event (such as vomiting, diarrhoea or rash) that would not have occurred if antibiotics had not been given.

Working with GPs on antimicrobial stewardship

Where pharmacists are authorised to assess AOM and supply antibiotics, there is the opportunity to reduce unnecessary use and reinforce good stewardship. Pharmacists managing AOM may wish to talk their strategy through with local GPs – the interventions GPs advise for symptomatic relief are important to know. Agreeing a common approach ensures that patients are not confused by variations in practice and will enhance consistency and continuity of care.