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Acute otitis media (AOM) is a common reason for childhood primary care visits and antibiotic prescription in the United Kingdom.1 2 Many randomised controlled trials (RCTs) have shown that symptoms settle within a few days, irrespective of antibiotic use,3 with one systematic review reporting that ear pain takes eight days to resolve fully in 90% of children.4 However observational data and an individual patient data meta-analysis showed that, among children with AOM, those with ear discharge have a worse prognosis5 and a more prolonged duration of ear pain or fever than those without ear discharge.6 Current guidance from the UK National Institute for Health and Care Excellence recommends that general practitioners consider immediately prescribing oral antibiotics for children presenting with AOM and ear discharge.7 However, oral antibiotics commonly have side effects such as diarrhoea, vomiting, and rashes3 and increase the risk of antimicrobial resistance.8 For children with AOM and ear discharge, topical antibiotics are a possible alternative because they put less selective resistance pressure on bacteria and eardrum perforation allows direct entry of the antibiotic into the middle ear, without exposing children to systemic side effects.9 However the risk of ototoxicity is debated.10 11

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