58
In developing countries where there could be a high rate of serious acute complications, such as mastoiditis, and where short-term and long-term complications of untreated
AOM can lead to death or severe disability, antibiotic use is beneicial.
Risks In a Cochrane review, use of antibiotics resulted in a 37 95 CI 0.05 to 0.67
relative increase in risk of adverse events: 16 110 out of 690 of children treated with antibiotics versus 11 83 out of 711 of children treated with placebo experienced
vomiting, diarrhoea, or rash. Others have reported antibiotics to cause adverse efects in 4 to 10 of children [Coker, 2010].
8.2.3 Acceptability and feasibility
Until there is more direct evidence speciically addressing the efectiveness of anti- biotics in children with AOM in developing countries, and the safety of withhold-
ing them, it would not be safe to withhold antibiotics. here is a high incidence of possible complications; the ‘watch and wait’ approach of not giving antibiotics and
observation is limited in developing countries by poor systems for follow-up, poor access to health facilities, and resource limitations.
Implementation of this recommendation exists based on the fact that it is feasible to distribute oral amoxicillin in resource-limited settings as it is available in tablet
and suspension form in all countries. Oral amoxicillin is the recommended treatment for non-severe pneumonia, and should therefore be widely accessible.
8.3 Antibiotic treatment for Chronic Suppurative Otitis Media CSOM
a Children with chronic suppurative otitis media CSOM should, in addition to aural toilet by dry wicking, be treated with instillation of drops containing quinolones
such as ciproloxacin, norloxacin, oloxacin three times daily for two weeks.
Strong recommendation, low quality evidence
b Children who fail to respond to treatment should be referred for further evaluation for other causes of CSOM, especially tuberculosis.
Strong recommendation, expert opinion
Remarks he duration of treatment was not clear from studies and depended on clinical
circumstances, therefore the panel could not make a deinitive recommendation on the duration of treatment. It was noted that the price of ciproloxacin varies
widely across diferent countries, and in some settings it may not be the cheapest luoroquinolone and therefore necessitates the recommendation of any of the other
available alternative luoroquinolones.
8.3.1 Evidence and summary of findings
Two systematic reviews of antibiotic therapy for CSOM in children were identiied: one compared topical versus systemic antibiotics and the other compared the efec-
59
tiveness of various topical antibiotics. here is low-moderate quality evidence that topical quinolones are better than topical non-quinolones at reducing discharge at
2–3 weeks, but there was no signiicant diference in discharge at 1 week
see GRADE A7.20
. here was moderate quality evidence that improvement in hearing thresholds is
better with topical quinolone when compared to topical antiseptics or no treatment. he review of topical antibiotics included 14 trials 1724 ears. Study quality was low-
moderate and deinitions of CSOM varied, with some studies including children with otitis externa and mastoid cavity infections. here is moderate quality evidence
that topical quinolone antibiotics were better than no treatment in preventing the persistence of discharge at 1 week RR 0.83, 95 CI 0.76 to 0.89
see GRADE table A7.21
. One study in Malawi [Macfadyn, 2005] compared hearing thresholds for children treated with ciproloxacin versus boric acid and showed a diference in mean
59 improvement of 2.17db 95 CI 0.09 to 4.24 at 2 weeks, and 3.43 95 CI 1.34 to 5.52 at 4 weeks in favour of ciproloxacin.
he review of systemic versus topical antibiotics included 8 trials 474 participants. he deinition of CSOM varied between studies. Study quality ranged from very low
to moderate, with most studies having inadequate allocation concealment and no blinding. here was moderate quality evidence for higher rates of treatment failure
with systemic antibiotics compared to topical quinolone antibiotics. here was no signiicant diference in treatment failure between systemic non-quinolone and
topical non-quinolones antibiotics very low quality evidence, or systemic antibiotics and topical antiseptics moderate quality evidence
see GRADE table 22
. 8.3.2
Benefits and risks
Benefits Topical quinolone antibiotics reduce persistent discharge, hearing thresholds
improve. Risks
Local discomfort, opportunistic fungal infection. [WHO 2010].
8.3.3 Acceptability and feasibility
