Pharmacy First for acute otitis media

Pharmacy teams seeing patients asking about earache in their children or teenager can explain about the Pharmacy First service for AOM, which may mean the pharmacist can offer them treatment and advice that can help.

The Pharmacy First service for acute otitis media is only for children aged one to 17 years, although it excludes those who have had recurrent infections (three or more episodes in six months, or four or more episodes in 12 months), and pregnant individuals under 16 years of age.

The pharmacist will start the Pharmacy First consultation with patients presenting with signs and symptoms of acute otitis media in order to consider the risk of deterioration or serious illness from suspected acute complications such as:

• Meningitis (neck stiffness, photophobia, mottled skin)
• Mastoiditis (pain, soreness, swelling, tenderness behind the affected ear(s))
• Brain abscess (severe headache, confusion or irritability, muscle weakness)
• Sinus thrombosis (headache behind or around the eyes)
• Facial nerve paralysis.

Pharmacy teams can reassure patients that these complications are rare, but if the pharmacist does suspect them they will immediately signpost the patient to A&E or call 999.

If none of these risks are suspected, this is the gateway point for 

the Pharmacy First acute otitis media service and the pharmacist will next consider if the patient has acute onset of symptoms including:

• Earache – in older children
• Holding, tugging, or rubbing of the ear – in younger children
• And non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea – in younger children.

The pharmacist might also use an otoscope to look in the patient’s ear to find out if their eardrum (the tympanic membrane) looks red, yellow, or cloudy; if it is bulging; or if it appears to be perforated and/or has a sticky discharge in the external ear canal.

If not, it would appear that acute otitis media is less likely to be the cause of the ear pain, and the pharmacist will consider an alternative diagnosis and proceed appropriately with advice and any onward referrals. However, if the pharmacist thinks AOM is more likely, they will recommend self care and pain relief to all patients.

In addition, the pharmacist will also check if the patient meets ANY of the following criteria:

• The patient is systemically very unwell
• They have signs of a more serious illness
• They are at high risk of complications because of pre-existing comorbidity (this includes children with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children who were born prematurely).

If the answer is ‘yes’ to any of these, the pharmacist will make an onward referral of the patient to general practice or other providers as appropriate.

If no, the pharmacist will check if the child or young person has otorrhoea (discharge after eardrum perforation) or eardrum perforation (suspected or confirmed) – and if they do the pharmacist will offer them amoxicillin (if they are not allergic to it) for five days, with self care advice. Alternatively, the pharmacist could offer the patient clarithromycin for five days, with self care advice, if the child/young person has a penicillin allergy. Finally, if the child/young person is pregnant (and aged 16-17 years), the pharmacist will offer them erythromycin for five days, along with self care advice.

If the patient DOES NOT have otorrhoea or eardrum perforation (suspected or confirmed) and is under two years of age, the pharmacist will check to see if they have infection in BOTH ears and have severe symptoms and/or have had symptoms for more than three days. If the answer is ‘yes’ to either of these, the pharmacist will offer them amoxicillin (if they have no allergy) for five days, or clarithromycin for five days (if they have a penicillin allergy) with advice on self care. Once again, if the patient is aged 16-17 and is pregnant the pharmacist will offer erythromycin for five days, along with self care advice.

If they do not have severe symptoms, or symptoms that have lasted for more than three days – or in patients with moderate and severe symptoms without eardrum perforation – the pharmacist will consider offering them phenazone 40mg/g with lidocaine 10mg/g ear drops for up to seven days plus self care, and will also ask the patient to come back and see them again for reassessment if there has been no improvement within three to five days.

Whatever the outcome of the consultation, the pharmacist will advise all patients and their carers that if symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least two to three days, they should see their GP or other appropriate healthcare provider. In addition, the pharmacist will share self care and safety-netting, and evidence on antibiotics using NICE guidelines, with all patients.