How often does acute otitis media resolve without antibiotic therapy?

Resolution Rate of Acute Otitis Media Without Antibiotics

Approximately two-thirds (60-70%) of acute otitis media cases in children resolve without antibiotic therapy, with only about one-third of initially observed children eventually requiring rescue antibiotics. 1, 2

Resolution Rates by Age and Severity

• Children under 2 years of age:

  • Lower spontaneous resolution rates
  • Approximately 50% experience clinical success when given placebo in studies using stringent diagnostic criteria 1
  • Immediate antibiotic therapy is recommended for this age group 1, 2

• Children over 2 years of age:

  • Higher spontaneous resolution rates
  • Observation is reasonable except in cases with marked symptoms (high fever, intense earache) 1, 2
  • In watchful waiting studies, approximately 66% completed without requiring antibiotics 1

Factors Affecting Resolution Without Antibiotics

More Likely to Resolve Without Antibiotics:

• Mild symptoms
• Children ≥2 years of age
• Unilateral AOM
• Absence of otorrhea
• Absence of high fever (≥39°C)

Less Likely to Resolve Without Antibiotics:

• Severe symptoms (high fever, intense otalgia)
• Children <2 years of age
• Bilateral AOM
• Presence of otorrhea
• Tympanic membrane perforation

Watchful Waiting Approach

The American Academy of Pediatrics recommends a watchful waiting approach for:

• Low-risk children ≥2 years with mild symptoms
• With clear follow-up instructions
• Rescue antibiotics prescribed for use if symptoms persist or worsen after 48-72 hours 2

Important Clinical Considerations

• Follow-up timing: Reassessment within 48-72 hours if symptoms are not improving 2
• Pain management: Immediate pain control with acetaminophen or ibuprofen is essential during observation period 2
• Complications: Withholding antibiotics in properly selected children with adequate follow-up does not increase suppurative complications 1
• Antibiotic resistance: Observation strategy can help reduce antibiotic resistance by potentially reducing antibiotic use by 65% in eligible children 1

Caveat

While observation is appropriate for many cases, it's important to recognize that antibiotics do provide faster symptom resolution (particularly in children <2 years) and lower failure rates at 12 days, though by 30 days there is no difference in failure or recurrence rates between immediate antibiotic and watchful waiting groups 1.

When otoscopic improvement (resolution of tympanic membrane bulging, intense erythema) is required for a positive outcome, the number needed to treat with antibiotics is 3-4, compared to 8-16 when only symptom improvement is considered 1.