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.