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Data were collected between January 2017 and February 2018.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Eligibility criteria<\/jats:title>\n                    <jats:p>National guidelines of European countries for the clinical management of AOM in children aged &lt;16 years.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data extraction and synthesis<\/jats:title>\n                    <jats:p>Data were extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. LoE and SoR were compared. Guidelines were assessed for principles of antibiotic stewardship.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>AOM guidelines were obtained from 17 or the 32 countries in the European Union or European Free Trade Area. The mean AGREE II score was \u226441% across most domains. Diagnosis of AOM was based on similar signs and symptoms. The most common indication for antibiotics was tympanic membrane perforation\/otorrhoea (14\/15; 93%). The majority (15\/17; 88%) recommended a watchful waiting approach to antibiotics. Amoxicillin was the most common first-line antibiotic (14\/17; 82%). Recommended treatment duration varied from 5 to 10 days. Seven countries advocated high-dose (75\u201390\u2009mg\/kg\/day) and five low-dose (30\u201360\u2009mg\/kg\/day) amoxicillin. Less than 60% of guidelines used a national or international scale system to rate level of evidence to support recommendations. Under half of the guidelines (7\/17; 41%) referred to country-specific microbiological and antibiotic resistance data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Guidelines for managing AOM were similar across European countries. Guideline quality was mostly weak, and it often did not refer to country-specific antibiotic resistance patterns. Coordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2019-035343","type":"journal-article","created":{"date-parts":[[2020,5,5]],"date-time":"2020-05-05T13:39:42Z","timestamp":1588685982000},"page":"e035343","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":101,"title":["Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines"],"prefix":"10.1136","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3134-0297","authenticated-orcid":false,"given":"Hijiri G","family":"Suzuki","sequence":"first","affiliation":[{"name":"Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0323-6217","authenticated-orcid":false,"given":"Juan Emmanuel","family":"Dewez","sequence":"additional","affiliation":[{"name":"Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9671-8161","authenticated-orcid":false,"given":"Ruud G","family":"Nijman","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0997-0850","authenticated-orcid":false,"given":"Shunmay","family":"Yeung","sequence":"additional","affiliation":[{"name":"Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,5,5]]},"reference":[{"key":"2025121514251689000_10.5.e035343.1","doi-asserted-by":"crossref","first-page":"16063","DOI":"10.1038\/nrdp.2016.63","article-title":"Otitis media","volume":"2","author":"Schilder","year":"2016","journal-title":"Nat Rev Dis Primers"},{"key":"2025121514251689000_10.5.e035343.2","doi-asserted-by":"crossref","DOI":"10.1186\/s13052-015-0144-4","article-title":"The impact of the Italian guidelines on antibiotic prescription practices for acute otitis media in a paediatric emergency setting","volume":"41","author":"Palma","year":"2015","journal-title":"Ital J Pediatr"},{"key":"2025121514251689000_10.5.e035343.3","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2017-0181","article-title":"Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era","volume":"140","author":"Kaur","year":"2017","journal-title":"Pediatrics"},{"key":"2025121514251689000_10.5.e035343.4","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2010.1651"},{"key":"2025121514251689000_10.5.e035343.5","doi-asserted-by":"publisher","DOI":"10.2165\/00128072-200305010-00001"},{"key":"2025121514251689000_10.5.e035343.6","doi-asserted-by":"publisher","DOI":"10.1093\/pubmed\/fdn072"},{"key":"2025121514251689000_10.5.e035343.7","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1016\/j.jmii.2013.04.001","article-title":"Clinical manifestations and microbiology of acute otitis media with spontaneous otorrhea in children","volume":"46","author":"Chen","year":"2013","journal-title":"J Microbiol Immunol Infect"},{"key":"2025121514251689000_10.5.e035343.8","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1097\/INF.0000000000000595","article-title":"Acute otorrhea in children with tympanostomy tubes: prevalence of bacteria and viruses in the post-pneumococcal conjugate vaccine era","volume":"34","author":"van Dongen","year":"2015","journal-title":"Pediatr Infect Dis J"},{"key":"2025121514251689000_10.5.e035343.9","doi-asserted-by":"publisher","DOI":"10.1097\/MOP.0000000000000184"},{"key":"2025121514251689000_10.5.e035343.10","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(06)69606-2"},{"key":"2025121514251689000_10.5.e035343.11","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijporl.2011.08.015"},{"key":"2025121514251689000_10.5.e035343.12","doi-asserted-by":"publisher","DOI":"10.1016\/S0022-3476(94)70356-6"},{"key":"2025121514251689000_10.5.e035343.13","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD000219.pub3."},{"key":"2025121514251689000_10.5.e035343.14","first-page":"685","article-title":"Antibiotic therapy for children with acute otitis media","volume":"63","author":"Sakulchit","year":"2017","journal-title":"Can Fam Physician"},{"key":"2025121514251689000_10.5.e035343.15","unstructured":"Centres for Disease Control and Prevention . 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