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Wise Use of Antibiotics

August 2022

Delayed Antibiotics for Acute Otitis Media...A Success Story



Author: Holly Austin, MD | Children's Mercy Urgent Care | Clinical Assistant Professor of Pediatrics, UMKC School of Medicine | Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine


Column Editor: Rana El Feghaly, MD, MSCI | Director, Clinical Services | Director, Outpatient Antibiotic Stewardship Program | Associate Professor of Pediatrics, UMKC School of Medicine


Watchful waiting (WW) has been recommended for many cases of acute otitis media (AOM) for over a decade. The American Academy of Pediatrics’ 2013 clinical practice guideline refined criteria for delaying antibiotics for a diagnosis of AOM.1 Children who meet these criteria are those between 6 and 24 months with unilateral otitis media and mild symptoms, and those over 24 months with unilateral or bilateral disease and mild symptoms. Mild symptoms are defined as no otalgia or otalgia for less than 48 hours that is not severe (adequately controlled with over-the-counter (OTC) pain medication) and fever below 39 C (102.2 F). Children under 6 months, children with otorrhea, tympanostomy tubes, immune deficiencies, frequent recurrent/chronic OM and/or anatomic abnormalities of the head and neck are excluded from recommendations for WW.

As pediatric providers, we are aware of the significant time and financial stresses many of the families we serve are under. With conventional WW, parents are asked to return to the office for reassessment of their child if not improving after two to three days. As such, even knowing that 70% or more of AOM will resolve in otherwise healthy children without antibiotics,2 I still struggle with WW. I struggle with diagnosing AOM and NOT providing antibiotic treatment. Even knowing that a significant number of children will have adverse effects from antibiotic treatment, ranging from mild diarrhea and rashes to life-threatening anaphylaxis or Clostridioides difficile infections, I still struggle. I suspect some of you might also struggle with this concept of WW. This struggle may explain why, despite the guidelines, most patients with AOM are given an immediate antibiotic prescription.3,4 Here is where safety-net antibiotic prescriptions (SNAPs) can be helpful.

In October 2021, the urgent care clinics at Children’s Mercy undertook a quality improvement project to incorporate SNAPs for eligible cases of AOM. As a pediatrician, I find it much more palatable to recommend delayed antibiotic use for AOM when I can empower the family to start treatment in a few days, under very specific guidelines given at discharge, by providing a SNAP. These guidelines include patients having persistent ear pain beyond 48 hours, severe ear pain not relieved with OTC pain meds, development of ear drainage, and fevers over 39 C. If any one of these conditions develops, the family is asked to fill and administer the antibiotic prescription. My cynical side assumes families will fill the SNAP as soon as they leave the urgent care rather than adhering to the WW advice, but at least one study looking at this showed only 20%-50% of parents eventually fill the SNAP. In other words, 50%-80% of children whose parents accept WW and SNAP avoid exposure to antibiotics for their AOM.5

I know many of you have used this concept of SNAP in your practices through the years when you have confidence in the family’s ability to follow your guidance for which the prescription is provided. I did as well during my 20-plus years in office practice. I surmised offering SNAP in urgent care, without an ongoing relationship with the family, might be more difficult and result in very few families opting for WW and SNAP. I have been surprised by the positive reception of most families to the idea of WW and SNAP. Many parents are relieved to find their child has an ear infection but may not need antibiotics to heal. They appreciate knowing that the majority of children will recover from AOM on their own.2 Emphasizing pain control with OTC analgesics and other comfort measures, and knowing they have a “just in case” prescription has been associated with high levels of satisfaction with the urgent care visit. Families do not want to medicate their child needlessly, and providers do not want to subject their patients to the pitfalls of antibiotic therapy unless absolutely necessary. SNAP has been an effective way to practice antibiotic stewardship and provide our families with high-quality, up-to-date medical care.

Let me share with you some of the data from our urgent care project over this past year. Prior to the quality improvement project, only about 10% of our patients with AOM who were eligible for WW and/or SNAP were introduced to the concept. Over the past nine months this percentage has risen to between 50% and 60% of eligible patients being offered a SNAP. We continue to educate and support providers to increase this percentage over the coming months. Parental acceptance of WW and provision of a SNAP was around 60% as well. Notably, an increase in return visits for unresolved AOM has not occurred.

Introducing the concept of WW for patients with AOM who meet eligibility requirements and providing a SNAP are well received by the majority of parents. It is another way we, as pediatric providers, can enhance the health of our patients and protect them and the communities we serve from the adverse effects of unnecessary antibiotics.

I hope this article helps address challenges and concerns with using WW and SNAP in your offices and increases acceptance of the concept by your patients and families.

Below are some resources that may help you in your practice:

Children’s Mercy Care Process Model

Outpatient Antimicrobial Handbook

Children’s Mercy Antimicrobial Stewardship website



  1. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-999.
  2. Rovers MM, Glaszious P, Appelman CL, et al. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics. 2007;119:579-585.
  3. Marom T, Shefer G, Tshori S, Mingelgrin S, Pitaro J. Antibiotic prescription policy for acute otitis media: do we follow the guidelines? J Antimicrob Chemother. 2021;76(10):2717-2724.
  4. Smolinski NE, Antonelli PJ, Winterstein AG. Watchful waiting for acute otitis media. Pediatrics. 2022;150(1):e2021055613.
  5. MacGeorge EL, Smith RA, Caldes EP, Hackman NM. Toward reduction in antibiotic use for pediatric otitis media: predicting parental compliance with “watchful waiting” advice. J Health Commun. 2017;22(11):867-875.