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June, 2021

Clinical practice guidelines for acute otitis media in children: A systematic review and appraisal of European national guidelines1


Acute otitis media (AOM) is one of the most common infections in childhood; approximately 60% of children have had at least one episode by 4 years of age. It is also one of the most frequently cited reasons for antibiotic prescription in children less than 3 years of age, accounting for 14% of all antibiotic prescriptions in children in the UK. 

The aim of this systematic review was to describe European guidelines for AOM in children to assess their methodological quality, to describe their evidence-based Strength of Recommendations (SoR) and to assess whether they incorporate consideration of antibiotic stewardship.


  • A three-pronged approach included (1) a systematic database search; (2) a website search of European national societies and (3) expert consultation.
  • Guidelines were included if they were pertaining to the management of simple AOM and were national guidelines or endorsed by the national medical society from a European Union (EU) or European Free Trade Area (EFTA) country.
  • The American Association of Paediatrics (AAP) and the WHO guidelines were also included for comparison as they are widely recognised and used internationally.
  • Guidelines were scored on methodological quality, LoE, SoR and ABS.


Key findings

National guidelines were obtained from 17 of 32 European countries (53%). Of these:
  • 15 of 17 (88%) European guidelines outlined the signs and symptoms for diagnosing AOM with considerable similarities between the guidelines
  • 15 of 17 (88%) European guidelines advised examination tools including standard otoscopy. Pneumatic otoscopy (9/15; 60%) and tympanometry (7/15; 50%) were also recommended
  • 15 of 17 (88%) of the European guidelines recommended a watchful waiting approach where clinicians were encouraged to prescribe antibiotics if symptoms persisted for 1–3 days or in case of any clinical deterioration
  • 14 of 17 (82%) European guidelines recommended oral amoxicillin as an option for first-line treatment
  • In case of treatment failure, per oral/intravenous amoxicillin + clavulanic acid (11/15; 73%) and intravenous/intramuscular ceftriaxone (8/15; 53%) were the most commonly recommended antibiotics. In case of penicillin allergy, guidelines advised either oral clarithromycin (8/16; 50%) or oral trimethoprim–sulfamethoxazole (6/16; 38%)
  • Less than half referred to country-specified AMR patterns, and 4 (24%) included both country-specific AMR data and specified resistance levels to amoxicillin/amoxicillin + clavulanic acid to guide local choices.



  • National guidelines for the management of AOM play a vital role in antibiotic stewardship.
  • Guidelines for managing AOM were similar across European countries.
  • The authors found that guideline quality was mostly weak, and it often did not refer to country-specific antibiotic resistance patterns.
  • Coordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance.

LoE: level of evidence. 



  1. Suzuki HG, Dewez JE, Nijman RG, et al. Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines. BMJ Open 2020;10(5):e035343.

    Article originally published May, 2020

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