Background and Aim Over-prescription of antibiotics in otitis media has been a major factor in the evolution and spread of resistant strains of bacteria. This has led to many organisations in many countries producing guidelines somewhat restrictive of clinical freedom to prescribe antibiotics in acute otitis media. We sought evidence on whether these had sufficiently controlled the problem as perceived in the 1990s.

Methods We searched for review and major primary evidence of two main types: (1a) clinical opinion/awareness surveys; (1b) activity databases on prescriptions and consultations; (2) specific studies on carriage and prevalence of resistant strains where changed clinical behaviour could be confidently invoked as cause of reduced resistance.

Results There was congruent but limited and not strong or highly-controlled evidence from both sources for beneficial effects. The argument is still most directly supported by microbiological studies in small numbers of individuals or on only moderately controlled comparisons internationally and/or over time.

Conclusions (1) The introduction of guidelines favouring rational prescribing has probably had beneficial effects, but it is difficult to claim consequent massive reductions in resistance or to be sure that there have been no consequent harms. (2) Some countries with healthcare systems and beliefs lacking strong feedback mechanisms or sanctions are still performing poorly. (3) The implementation of universal preventive programmes targeting OM would reduce resistance both directly and indirectly via herd immunity, and would offer stronger support for conservative and rational prescribing via lowered perceived risk.