Is azithromycin or amoxicillin-clavulanate preferred for the treatment of children with persistent or recurrent otitis media?

According to this POEM – there is no difference between Azithomycin and Amox-Clav in the treatment of otitis media.

Bottom line
For every 10 children with persistent or recurrent otitis media who get high-dose azithromycin for 3 days instead of high-dose amoxicillin-clavulanate for 10 days, there is one additional clinical cure at 1 month and 1 less episode of diarrhea. There is no difference, however, in clinical success at 2 weeks. (LOE = 1b)

But where's the placebo group?  The study referenced above

A reminder that Chris Cates' EBM website has excellent resources on otitis media. 

It's odd – because I do recall seeing many cases of recurent otitis when I was in residency – and even when I was at the Albany Medical Center residency program – where I was on the faculty.  But in my current practice, my  colleagues and I are so conservative with antibiotics that we rarely treat kids who present initially.  We're seeing fewer cases overall – and fewer cases of resistant otitis and VERY few cases of recurrent otitis.  I can't think of the last kid I referred to ENT. 

Questions for the literature:

  • Do delayed prescriptions reduce antibiotic prescriptions?  Yes
  • Is there a way to clinically predict which organism is causing an episode of otitis? YES (cool!) (viruses?)
  • Why does AOM cause persistent OME?
  • Are there well established international guidelines?  No