Diagnostic accuracy and management of suspected acute otitis media: A multi-continental survey of primary care physicians using tympanic membrane images in clinical cases

BACKGROUND: Acute otitis media (AOM) is a leading cause of primary care visits and antibiotic prescriptions in children. Diagnostic uncertainty and variability in management contribute to misdiagnosis and inappropriate antibiotic use. OBJECTIVE: This study examines how primary care physicians across countries diagnose and manage suspected AOM through clinical cases. METHODS: International cross-sectional survey using structured clinical cases with validated tympanic membrane images. The survey was administered during professional meetings for primary care physicians in 12 countries (Argentina, Australia, Belgium, Germany, Ireland, Japan, Norway, South Africa, Spain, Sweden, United Kingdom, and the United States). RESULTS: A total of 1,365 primary care physicians participated. Across all responses to AOM cases, 60% were correctly diagnosed as AOM, while only 31% of responses involving a normal tympanic membrane were correctly identified. Antibiotic prescribing varied substantially across countries and between cases. Multivariable regression analyses showed that diagnostic accuracy was a significant predictor of antibiotic prescribing. Physicians who correctly identified a normal tympanic membrane were significantly less likely to prescribe antibiotics (p < 0.001). Notable differences in prescribing patterns were evident between countries. CONCLUSION: Diagnostic accuracy for suspected AOM was generally low among primary care physicians, with wide variation across countries. Antibiotics were frequently prescribed even in the absence of AOM. This underscores the need for improved diagnostic education to reduce unnecessary antibiotic use globally.