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Overview
Offer self care and regular pain relief
to all patients
Offer self care and regular pain reli...
Patient presenting with
signs and symptoms of acute otitis media
Patient presenting with...
NHSE PATHWAYS
NHSE PATHWAYS
Consider the risk of deterioration, red flags or serious illness
Consider the risk of deterioration, red flags or serious illness
Does the patient have acute onset of symptoms including:
  • In older children — earache
  • In younger children — holding, tugging, or rubbing of the ear
  • In younger children: non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea
Does the patient have acute onset of symptoms including:...
YES
YES
NO
NO
NICE CKS
NICE CKS
NHSE PGDs
NHSE PGDs View PGD in right panelView PGD in right panel
Digital PGD
 Digital PGD
Gateway Point
Gateway Point
YES
YES
Offer amoxicillin (if no allergy) for 5 days
(subject to inclusion/exclusion criteria in PGD)
plus self care
Offer amoxicillin (if no allergy) for 5 da...
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...
If pregnant (aged 16-17 years)
 If pregnant (aged 16-17 years)
Offer clarithromycin for 5 days (subject to inclusion/exclusion criteria in PGD) plus self care
Offer clarithromycin for 5 days (subj...
Offer erythromycin for 5 days (subject to inclusion/exclusion criteria in PGD) plus self care
Offer erythromycin for 5 days (subjec...
Acute Otitis Media (For children aged 1 to 17 years)
Acute Otitis Media Context: UK Pharmacy First Scheme Acu...
Acute otitis media mainly affects children, can last for around 1 week and over 80% of children recover spontaneously without antibiotics 2-3 days from presentation
Acute otitis media mainly affects children, can last for around 1 week and over 80% of children recover spontaneously without antibiotics 2-3 days...
Suspected acute complications:
  • 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
Suspected acute complications:...
Signpost patient to A&E or call 999
in a life threatening emergency
Signpost patient to A&E or call 999...
Gateway Point
Gateway Point
Exclude: recurrent acute otitis media (3 or more episodes in 6 months or four or more episodes in 12 months), pregnant individuals under 16 years
Exclude: recurrent acute otitis media (3 or more episodes in 6 months or four or more episodes in 12 months), pregnant individuals...
Does the patient meet ANY of the following criteria:
  • Patient is systemically very unwell
  • Patient has signs of a more serious illness
  • Patient is 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)
Does the patient meet ANY of the following criteria:...
Acute otitis media more likely
Acute otitis media more lik...
Ear infections
Ear infections
NHS
NHS
YES
YES
Does the patient need an otoscopic examination?
Does the patient need an otoscopic examination?
  • A distinctly red, yellow, or cloudy tympanic membrane
  • Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane
  • Perforation of the tympanic membrane and/or sticky discharge in the external auditory canal
A distinctly red, yellow, or cloudy tympanic membrane Moderate to severe bulging of the tympanic membrane, with loss of normal land...
Consider alternative diagnosis
and proceed appropriately
Consider alternative diagnosis...
NO
NO
Acute otitis media less likely
Acute otitis media less lik...
Onward referral
  • General practice
  • Other provider as appropriate
Onward referral...
YES
YES
Does the child/young person have otorrhoea (discharge after eardrum perforation) or eardrum perforation (suspected or confirmed)
Does the child/young person have otorrhoea (discharge after eardrum...
NO
NO
Is the child under 2 years AND with infection in both ears?
Is the child under 2 years AND with infection in both ears?
NO
NO
In patients with mild symptoms
offer self-care and pain relief
In patients with mild symptoms...
In patients with moderate and severe symptoms, without eardrum perforation - consider offering 
phenazone 40 mg/g with lidocaine 10 mg/g ear drops for up to 7 days
(subject to inclusion/exclusion criteria in PGD) plus self care
In patients with moderate and severe sy...
Ask patient to return to Community Pharmacy if no improvement within 3-5 days for pharmacist reassessment 
Ask patient to return to Community Phar...
NO
NO
YES
YES
YES
YES
Shared decision making approach
and clinician global impression 
Shared decision making approach...
Does the patient meet ANY of the following criteria:
  • Severe symptoms based on clinician global impression
  • Symptoms for >3 days
Does the patient meet ANY of the follo...
NO
NO
YES
YES

Content sourced and adapted from NHS Pharmacy First – Clinical Pathways and Patient Group Directions (PGDs) on the NHS England website, licensed under the Open Government Licence v3.0.

Content sourced and adapted from NHS Pharmacy First – Clinical Pathways and Patient Group Directions (PGDs) on the NHS England website, licensed under the Open Government Licence v3.0.
FOR ALL PATIENTS:
  • 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 2-3 days
  • Share self-care and safety-netting, and evidence on antibiotics using NICE guidelines
FOR ALL PATIENTS:...
Onward referral
  • General practice
  • Other provider as appropriate
Onward referral...Text is not SVG - cannot display