Acute otitis media in children: amoxicillin remains the standard antibiotic, but justified in certain situations only.

(1) The best-assessed antibacterial agents in otitis are penicillin V and amoxicillin. No other antibacterial agents are any more effective in clinical trials. (2) In France, amoxicillin seems the best choice because it is still active against pneumococci with diminished sensitivity to penicillin. Also, amoxicillin causes very few serious adverse effects. (3) There is no firm evidence that clavulanic acid makes amoxicillin any more effective. In fact the combination of amoxicillin + clavulanic acid causes more gastrointestinal adverse effects (including potentially severe diarrhoea) than any other antibacterial agent. (4) For patients who are allergic to penicillin, a macrolide such as erythromycin, or cotrimoxazole, appear to be acceptable first-line alternatives. (5) According to a reliable randomised trial, delaying the decision about antibacterial treatment by 72 hours in children with acute otitis media does no harm. If the decision is delayed, three quarters of children avoid antibacterial therapy altogether. (6) Patients get no extra benefit from extending treatment beyond 5 to 7 days. (7) Prolonged treatment, and the use of low doses are risk factors for subsequent carriage of resistant bacteria. (8) There are no comparative trials of antibacterial agents in children at high risk of severe or complicated disease including infants under 3 months old, children with immunosuppression, and those with high fever.