Intended for healthcare professionals

Practice Uncertainties

Are topical antibiotics an alternative to oral antibiotics for children with acute otitis media and ear discharge?

BMJ 2016; 352 doi: (Published 04 February 2016) Cite this as: BMJ 2016;352:i308
  1. Roderick P Venekamp, general practitioner and assistant professor12,
  2. Vibhore Prasad, general practitioner and clinical assistant professor3,
  3. Alastair D Hay, general practitioner, professor of primary care, and National Institute for Health Research professor4
  1. 1Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, 3508 GA Utrecht, Netherlands
  2. 2Department of Otorhinolaryngology, University Medical Centre Utrecht, Utrecht, Netherlands
  3. 3School of Medicine, University of Nottingham, Nottingham, UK
  4. 4Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
  1. Correspondence to: R P Venekamp R.P.Venekamp{at}
  • Accepted 17 December 2015

What you need to know

  • Consider prescribing oral antibiotics immediately for children presenting with acute otitis media and ear discharge caused by spontaneous perforation of the eardrum

  • Topical antibiotics are associated with fewer systemic side effects and a lower risk of antibiotic resistance than oral antibiotics, but there is no strong direct evidence to support their use in this condition

Acute otitis media (AOM) is a common reason for childhood primary care visits and antibiotic prescription in the United Kingdom.1 2 Many randomised controlled trials (RCTs) have shown that symptoms settle within a few days, irrespective of antibiotic use,3 with one systematic review reporting that ear pain takes eight days to resolve fully in 90% of children.4 However observational data and an individual patient data meta-analysis showed that, among children with AOM, those with ear discharge have a worse prognosis5 and a more prolonged duration of ear pain or fever than those without ear discharge.6 Current guidance from the UK National Institute for Health and Care Excellence recommends that general practitioners consider immediately prescribing oral antibiotics for children presenting with AOM and ear discharge.7

However, oral antibiotics commonly have side effects such as diarrhoea, vomiting, and rashes3 and increase the risk of antimicrobial resistance.8 For children with AOM and ear discharge, topical antibiotics are a possible alternative because they put less selective resistance pressure on bacteria and eardrum perforation allows direct entry of the antibiotic into the middle ear, without exposing children to systemic side effects.9 However the risk of ototoxicity is debated.10 11

What is the evidence of uncertainty?

To our knowledge, no RCTs or relevant systematic reviews of the effectiveness of topical antibiotics for children with AOM and ear discharge have been published.

Oral antibiotics

By contrast, individual patient data meta-analysis evidence shows that oral antibiotics are more effective than …

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