Current management of children with acute otitis media: a feasibility survey for a pragmatic study

  • Respati Wulansari Ranakusuma CEEBM Unit CMH-FMUI
  • Amanda R. McCullough Bond University, Queensland, Australia
  • Elaine M. Beller Insititute of Evidence-Based Healthcare, Bond University, Queensland, Australia
  • Christopher B. Del Mar Institute for Evidence-Based Healthcare, Bond University, Queensland, Australia
  • Eka Dian Safitri CEEBM Unit CMH-FMUI
  • Yupitri Pitoyo
  • Widyaningsih Widyaningsih
Keywords: otitis media, acute disease, anti-bacterial agents, health services, survey and questionnaires


Background Acute otitis media (AOM) is a common self-limiting infection where antibiotics confer limited benefit. Other treatments, such as anti-inflammatory agents have been proposed as an alternative to antibiotics, but no high-quality clinical trials have tested this.

Objective To identify current AOM management practices among Indonesian clinicians. We also required this information for our proposed corticosteroids clinical trial for AOM.

Methods This cross-sectional study surveyed a convenience sample of general practitioners (GPs), pediatricians, and Ear-Nose-Throat (ENT) specialists in Jakarta, Depok, and Bekasi. We addressed their current AOM management practices and willingness to participate in a future trial on corticosteroids.

Results We distributed 2,694 questionnaires through conferences, primary care/hospital visits, and by mail-list group. Of 492 questionnaires received (response rate 18%), 352 were from eligible clinicians. Most clinicians diagnosed AOM by using an otoscope (64-91%). Tympanometry was used by a quarter of ENT specialists. Amoxicillin-clavulanate was the most common antibiotic for AOM, prescribed by pediatricians and ENT specialists, whilst most GPs prescribed amoxicillin. Clinical scenarios indicated most ENT specialists (88%) would prescribe antibiotics and most pediatricians (54%) would choose expectant observation by withholding antibiotics for mild AOM. Almost half of clinicians would consider using corticosteroids in a trial.

Conclusion Most clinicians would prescribe antibiotics for mild AOM. However, slightly over half of pediatricians would solely choose expectant observation. Adequate numbers of potential participating clinicians, who would consider using corticosteroids, make our proposed corticosteroids trial for AOM feasible. We found gaps between clinical practice and evidence requiring further investigation to improve AOM management in Indonesia.


1. Pettigrew MM, Gent JF, Pyles RB, Miller AL, Nokso-Koivisto J, Chonmaitree T. Viral-bacterial interactions and risk of acute otitis media complicating upper respiratory tract infection. J Clin Microbiol. 2011;49:3750-5.
2. Chonmaitree T, Revai K, Grady JJ, Clos A, Patel JA, Nair S, et al. Viral upper respiratory tract infection and otitis media complication in young children. Clin Infect Dis. 2008;46:815-23.
3. Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964-99.
4. South Australian Child Health Clinical Network. South Australian Paediatric Practice Guidelines: acute otitis media in children. South Australia: SA Health; 2014. ISBN No.: 978-1-74243-551-0. p.1-10
5. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;8:CD000219.
6. Bakhit M, Hoffman T, Scott AM, Beller E, Rathbone J, Del Mar C. Resistance decay in individuals after antibiotic exposure in primary care: a systematic review and meta-analysis. BMC Med. 2018;16:126.
7. Kementrian Kesehatan Republik Indonesia. Panduan praktik klinis bagi dokter di fasilitas pelayanan kesehatan primer. Jakarta: Menteri Kesehatan Republik Indonesia; 2014. Peraturan Menteri Kesehatan Republik Nomor 5 Tahun 2014. . p.176-180
8. Kelompok Studi Otologi Perhimpunan Dokter Spesialis THT-KL Indonesia (PERHATI-KL). Guideline penyakit THT-KL di Indonesia. Jakarta: Perhimpunan Dokter Spesialis THT-KL Indonesia; 2007. p.55
9. Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet. 2006;368:1429-35.
10. Gillies M, Ranakusuma A, Hoffmann T, Thorning S, McGuire T, Glasziou P, et al. Common harms from amoxicillin: a systematic review and meta-analysis of randomized placebo-controlled trials for any indication. CMAJ. 2015;187:E21-31.
11. Juhn SK, Jung MK, Hoffman MD, Drew BR, Preciado DA, Sausen NJ, et al. The role of inflammatory mediators in the pathogenesis of otitis media and sequelae. Clin Exp Otorhinolaryngol. 2008;1:117-38.
12. Ranakusuma RW, Pitoyo Y, Safitri ED, Thorning S, Beller EM, Sastroasmoro S, et al. Systemic corticosteroids for acute otitis media in children. Cochrane Database Syst Rev. 2018;3:CD012289.
13. Ruohola A, Heikkinen T, Jero J, Puhakka T, Juvén T, Närkiö-Mäkelä M, et al. Oral prednisolone is an effective adjuvant therapy for acute otitis media with discharge through tympanostomy tubes. J Pediatr. 1999;134:459-63.
14. Büyükcam Y, Kara A, Bedir T, Gülhan B, Özdemir H, Sütçü M, et al. Pediatricians′ attitudes in management of acute otitis media and ear pain in Turkey. Int J Pediatr Otorhinolaryngol. 2018;107:14-20.
15. D’silva L, Parikh R, Nanivadekar A, Joglekar S. A questionnaire-based survey of Indian ENT surgeons to estimate clinic prevalence of acute otitis media, diagnostic practices, and management strategies. Indian J Otolaryngol Head Neck Surg. 2013;65(Suppl 3):S575–81.
16. Marom T, Bobrow M, Eviatar E, Oron Y, Ovnat Tamir S. Adherence to acute otitis media diagnosis and treatment guidelines among Israeli otolaryngologists. Int J Pediatr Otorhinolaryngol. 2017;95:63-8.
17. Neumark T, Ekblom M, Brudin L, Groth A, Eliasson I, Molstad S, et al. Spontaneously draining acute otitis media in children: an observational study of clinical findings, microbiology and clinical course. Scand J Infect Dis. 2011;43:891–8.
18. Gribben B, Salkeld LJ, Hoare S, Jones HF. The incidence of acute otitis media in New Zealand children under five years of age in the primary care setting. J Prim Health Care. 2012;4:205–12.
19. Hersh AL, Jackson MA, Hicks LA, Committee on Infectious Diseases. Principal of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013;132:1146-54.
20. Pirozzo S, Del Mar C. Chapter 27. Otitis media. In: Moyer VA, editor. Evidence based paediatrics and child health. London: BMJ Books; 2000. pp. 238-47.
21. Blomgren K, Pitkäranta A. Current challenges in diagnosis of acute otitis media. Int J Pediatr Otorhinolaryngol. 2005;69:295-9.
22. McCullough AR, Pollack AJ, Plejdrup Hansen M, Glasziou PP, Looke DF, et al. Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations. Med J Aust. 2017;207:65-9.
23. Sidell D, Shapiro NL, Bhattacharyya N. Demographic influences on antibiotic prescribing for pediatric acute otitis media. Otolaryngol Head Neck Surg. 2012;146:653-8.
24. New South Wales Ministry of Health. Infants and children, otitis media: Acute management of sore ear. Clinical Practice Guidelines. Sydney: NSW Ministry of Health; 2014. Document number GL2014_023. p.1-17. [cited 2019 June 27]. Available from:
25. Bonevski B, Magin P, Horton G, Foster M, Girgis A. Response rates in GP surveys - trialling two recruitment strategies. Aust Fam Physician. 2011;40:427-30.+
26. Pit SW, Vo T, Pyakurel S. The effectiveness of recruitment strategies on general practitioner’s survey response rates – a systematic review. BMC Med Res Methodol. 2014;14:76.
27. Creavin ST, Creavin AL, Mallen CD. Do GPs respond to postal questionnaire surveys? A comprehensive review of primary care literature. Fam Pract. 2011;28:461-7.
28. Crouch S, Robinson P, Pitts M. A comparison of general practitioner response rates to electronic and postal surveys in the setting of the National STI Prevention Program. Aust N Z J Public Health. 2011;35:187-9.
29. Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C, Wentz R, Kwan I, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev. 2009;3:MR000008.
How to Cite
Ranakusuma R, McCullough A, Beller E, Del Mar C, Safitri E, Pitoyo Y, Widyaningsih W. Current management of children with acute otitis media: a feasibility survey for a pragmatic study. PI [Internet]. 28Nov.2019 [cited 30Nov.2022];59(6):303-7. Available from:
Infection & Tropical Pediatrics
Received 2019-08-21
Accepted 2019-11-28
Published 2019-11-28