Short-Acting Antibiotics for 5 Days Might Be Less Effective than Longer Course Antibiotic Treatments for Children with AOM
Acute otitis media (AOM) is the most common reason children are prescribed antibiotics in the United States. While the optimal treatment duration is unclear, previous studies, including a Cochrane review from 2000, have suggested that short courses of treatment (< 7 days) may be as effective as longer courses. A recent update of that Cochrane review provides evidence that treatment with short-acting antibiotics for 5 days is associated with significantly higher rates of treatment failure than longer course treatments (level 2 [mid-level] evidence). The review examined 49 moderate-quality randomized trials comparing short vs. long course antibiotic regimens in 12,000 children (aged 1 month to 18 years) with a clinical diagnosis of acute otitis media. The primary outcome was treatment failure within 1 month, defined as absence of clinical resolution, relapse, or recurrence of AOM following initiation of therapy. In an analysis of 16 trials of short-acting antibiotics (e.g. amoxicillin), treatment for 5 days was associated with increased risk of treatment failure (OR 1.34, 95% CI 1.15-1.55) compared to 8-10 days of treatment. This corresponds to an NNH of 11-41, assuming treatment failure in 16% of children receiving longer treatment. This result might be due to differences in efficacy for children with and without a history of ear infections. Five-day treatment had a higher failure rate in analysis of 6 trials that included children with a history of recurrent AOM, but not in 4 trials that excluded these patients. For oral azithromycin, treatment for 3-5 days was associated with increased treatment failure at 8-19 days' follow-up compared to longer treatments (OR 1.27, 95% CI 1.04-1.55), but there was no significant difference by 20-30 days' follow-up. The risks of gastrointestinal adverse effects were significantly reduced with short course treatments for both short-acting antibiotics and azithromycin. The authors suggest that clinicians must weigh the relative benefits and harms of longer treatment durations (Cochrane Database Syst Rev 2010 Sep 08;(9):CD001095).
Guidelines from the American Academy of Pediatrics recommend antibiotics for 10 days in children < 6 years old and children with severe disease and for 5-7 days in children ≥ 6 years old with mild to moderate disease (Pediatrics. 2004 May;113(5):1451).
For more information, see the Acute otitis media (AOM) topic in DynaMed.
