Otitis media, the most common reason for prescribing antibiotics in children, figures prominently in the problem of antibiotic resistance. Hendley reviews the modern management of otitis media in children and provides his personal clinical recommendations for rational use of antibiotics.

Middle ear infections typically occur during a viral upper-respiratory infection. The eustachian tube becomes inflamed and dysfunctional, allowing fluid to accumulate in the middle ear. This fluid becomes a ripe medium for further infection. The usual infectious culprits, which occur in about equal proportions, include the viruses, and Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Both middle ear inflammation and fluid accumulation are required for a diagnosis of acute otitis media. Retraction of the tympanic membrane signifies eustachian tube dysfunction and negative middle ear pressure but not bacterial infection. Bacterial otitis media produces a bulging tympanic membrane with purulent fluid behind it. The most common clinical presentation of acute otitis media is erythema of the eardrum without bulging, accompanied by other evidence of infection, such as fever, ear pain, and cold symptoms.

The usefulness of antibiotics in the treatment of ear infections has been widely investigated. A meta-analysis found that antibiotics improved resolution of otitis media at one week post-treatment by 13 percent (94 percent resolution for treatment versus 81 percent for placebo). Most analyses also have shown modest reductions in clinical symptoms after the first three to five days of antibiotic use compared with placebo.

Despite the well documented in vitro resistance to penicillin among the usual ear pathogens, no drug has been proved superior to amoxicillin for promoting resolution of bacterial ear infections. The author advocates a delayed antibiotic strategy to minimize unnecessary prescriptions for otitis media, such as is commonly practiced in the Netherlands (see accompanying table). In this approach, acetaminophen is used for fever and pain; antibiotics are withheld unless clinical symptoms fail to improve within two to three days from the onset of the ear infection. Clinical trials have shown that this tactic leads to use of an antibiotic prescription in only 31 percent of acute otitis media cases.

Prevention rather than treatment of this common condition would be ideal, but the author notes that limited means are available to accomplish this. Influenza vaccination decreases episodes of acute otitis media only when influenza is epidemic. Pneumococcal vaccination produces a small decrease in rates of otitis media.