Guidance for Industry 
Acute Bacterial Otitis Media:  
Developing Drugs for 
Treatment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
U.S. Department of Health and Human Services 
Food and Drug Administration 
Center for Drug Evaluation and Research (CDER) 
 
September 2012 
Clinical Antimicrobial  
   
Guidance for Industry 
Acute Bacterial Otitis Media:  
Developing Drugs for 
Treatment 
 
 
 
Additional copies are available from: 
 
Office of Communications, Division of Drug Information 
Center for Drug Evaluation and Research 
Food and Drug Administration 
10903 New Hampshire Ave., Bldg. 51, rm. 2201 
Silver Spring, MD  20993-0002 
Tel: 301-796-3400; Fax: 301-847-8714; E-mail: druginfo@fda.hhs.gov 
http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
U.S. Department of Health and Human Services 
Food and Drug Administration 
Center for Drug Evaluation and Research (CDER) 
 
September 2012 
Clinical Antimicrobial 
 
   
TABLE OF CONTENTS 
 
I.  INTRODUCTION............................................................................................................. 1 
II.  BACKGROUND ............................................................................................................... 2 
III.  DEVELOPMENT PROGRAM ....................................................................................... 2 
A.  General Considerations .................................................................................................................2 
1. Early Phase Clinical Development Considerations .........................................................................2 
a.  Nonclinical studies ....................................................................................................................2 
b.  Animal models ..........................................................................................................................2 
c.  Efficacy outcome measure development ...................................................................................3 
2. Drug Development Population .........................................................................................................3 
3. Efficacy Considerations ...................................................................................................................4 
4. Safety Considerations .......................................................................................................................4 
B.  Specific Efficacy Trial Considerations .........................................................................................5 
1. Trial Design ......................................................................................................................................5 
a.  Active-controlled clinical trials .................................................................................................5 
b.  Placebo-controlled clinical trials ...............................................................................................5 
2. Clinical Trial Population .................................................................................................................6 
3. Entry Criteria ...................................................................................................................................6 
a.  Patient history and characteristics .............................................................................................6 
b.  Symptoms and observable signs ...............................................................................................6 
c.  Clinical signs .............................................................................................................................7 
d.  Baseline tympanocentesis .........................................................................................................7 
e.  Exclusion criteria .......................................................................................................................7 
4. Randomization, Stratification, and Blinding ....................................................................................8 
5. Dose Selection ..................................................................................................................................8 
6. Choice of Comparators ....................................................................................................................9 
7. Concomitant Medications .................................................................................................................9 
8. Efficacy Endpoints ............................................................................................................................9 
9. Trial Procedures and Timing of Assessments ................................................................................ 10 
a.  Entry visit ................................................................................................................................ 10 
b.  On-therapy visits ..................................................................................................................... 12 
c.  Early follow-up visit ................................................................................................................ 12 
d.  Late follow-up assessment ...................................................................................................... 12 
10.  Statistical Considerations .......................................................................................................... 13 
a.  Analysis populations ............................................................................................................... 13 
b.  Sample size ............................................................................................................................. 13 
c.  Missing data ............................................................................................................................ 14 
d.  Interim analyses and data monitoring committee ................................................................... 14 
e.  Other analyses of interest and secondary endpoints ................................................................ 14 
11.  Ethical Considerations .............................................................................................................. 15 
REFERENCES ............................................................................................................................ 16 
 
 
  Contains Nonbinding Recommendations 
1
Guidance for Industry  
Acute Bacterial Otitis Media: 
Developing Drugs for Treatment 
 
 
 
 
This guidance represents the Food and Drug Administrations (FDAs) current thinking on this topic.  It 
does not create or confer any rights for or on any person and does not operate to bind FDA or the public.  
You can use an alternative approach if the approach satisfies the requirements of the applicable statutes 
and regulations.  If you want to discuss an alternative approach, contact the FDA staff responsible for 
implementing this guidance.  If you cannot identify the appropriate FDA staff, call the appropriate 
number listed on the title page of this guidance.  
 
 
 
 
I.  INTRODUCTION 
 
The purpose of this guidance is to assist sponsors in the clinical development of drugs for the 
treatment of acute bacterial otitis media (ABOM).  This guidance defines ABOM as the recent 
or acute onset of inflammation of the middle ear caused by a bacterial pathogen.  Specifically, 
this guidance addresses the FDAs current thinking regarding the overall development program 
and clinical trial designs for drugs to support an indication for treatment of ABOM.2   
 
This guidance does not contain discussion of the general issues of clinical trial design or 
statistical analysis.  Those topics are addressed in the ICH guidances for industry E9 Statistical 
Principles for Clinical Trials and E10 Choice of Control Group and Related Issues in Clinical 
Trials.3  This guidance focuses on specific drug development and trial design issues that are 
unique to the study of ABOM.   
 
FDAs guidance documents, including this guidance, do not establish legally enforceable 
responsibilities.  Instead, guidances describe the Agencys current thinking on a topic and should 
be viewed only as recommendations, unless specific regulatory or statutory requirements are 
cited.  The use of the word should in Agency guidances means that something is suggested or 
recommended, but not required. 
 
                                                 
1 This guidance has been prepared by the Division of Anti-Infective Products in the Center for Drug Evaluation and 
Research (CDER) at the Food and Drug Administration.  
 
2 For the purposes of this guidance, all references to drugs include both human drugs and therapeutic biological 
products unless otherwise specified.  
 
3 We update guidances periodically.  To make sure you have the most recent version of a guidance, check the FDA 
Drugs guidance Web page at 
http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm. 
1  Contains Nonbinding Recommendations 
 
II.  BACKGROUND 
 
There have been a number of public discussions regarding clinical trial designs for the study of 
ABOM.4  These discussions have primarily focused on the appropriateness of endpoints and trial 
designs for ABOM and other important trial design issues such as the following: 
 
  Inclusion criteria 
  Application of appropriate diagnostic criteria   
  Use of appropriate definitions of clinical outcomes 
  Timing of outcome assessments 
  Use of concomitant medications 
  Role of microbiological data 
  Noninferiority and superiority trial designs 
 
 
III.  DEVELOPMENT PROGRAM 
 
A.  General Considerations 
 
1.  Early Phase Clinical Development Considerations  
 
a.  Nonclinical studies 
 
New drugs being studied for ABOM should have nonclinical data documenting activity against 
the most commonly implicated pathogens for ABOM (i.e., Streptococcus pneumoniae, 
Haemophilus influenzae, and Moraxella catarrhalis).   
 
b.  Animal models 
 
Animal models may be useful in demonstrating potential activity in the treatment of ABOM (or 
in comparing the in vivo activity of different antimicrobials).  Pharmacokinetic (PK) and 
pharmacodynamic data from animal studies may be helpful in the design of subsequent clinical 
trials, including the selection of doses that will be evaluated in those trials.  However, animal 
studies cannot be considered a substitute for clinical trials.  Because clinical trials are ethical and 
feasible in patients with ABOM, approval cannot be obtained under subpart I.5   
 
                                                 
4 ABOM clinical trial design was the subject of the July 11, 2002, meeting of the Anti-Infective Drugs Advisory 
Committee (meeting transcripts are available at www.fda.gov/ohrms/dockets/ac/02/transcripts/3875T2.doc).  We 
also convened a 2011 public workshop titled Design of Clinical Trials for Systemic Antibacterial Drugs for the 
Treatment of Acute Otitis Media.  Transcripts of the workshop proceedings are available at 
http://www.fda.gov/Drugs/NewsEvents/ucm262641.htm. 
 
5 See 21 CFR 314.600, subpart I, Approval of New Drugs When Human Efficacy Studies Are Not Ethical or 
Feasible. 
2  Contains Nonbinding Recommendations 
c.  Efficacy outcome measure development 
 
There should be well-defined and reliable methods of diagnosing ABOM and of assessing 
patient responses in ABOM trials.  Sponsors should anticipate the need for appropriate 
instruments to evaluate responses (e.g., well-developed patient-reported outcome (PRO) or 
caregiver-reported outcome instrument, or clinician-reported outcome instruments) early in the 
clinical development process.  The development of new instruments should begin in advance of 
phase 3 clinical trials so that the instrument can be ready for incorporation into the phase 3 
protocols.  For example, after content validity is established (a critical step during instrument 
development that evaluates the extent to which the instrument measures the concepts of interest), 
other types of validity, reliability, and responsiveness of the instrument can be evaluated during 
phase 2 trials.  Evaluation of the responses using the instrument in phase 2 could be used to 
inform sample size calculations for phase 3 trials. 
 
PRO instruments can be used to measure patient symptoms and self-reported signs; for young 
children and individuals who cannot respond reliably for themselves, a caregiver-reported 
outcome instrument can be used to measure patient signs as observed by the caregiver 
(observable signs).6  Both types of instruments may be appropriate for use in a single trial 
depending on the patient population enrolled.  For more information regarding the development 
of PRO measures or caregiver outcome measures, see the guidance for industry Patient-Reported 
Outcome Measures:  Use in Medical Product Development to Support Labeling Claims and the 
draft guidance for industry Qualification Process for Drug Development Tools.7  
 
Documentation of clinical signs of ABOM as observed by the clinician is useful for outcome 
assessments (e.g., a clinician-reported outcome instrument).  Sponsors should describe the 
characteristics of patients with a diagnosis of ABOM and describe objective assessments of the 
patients responses to therapy.  It is important to distinguish patients with otitis media caused by 
viral pathogens or allergic conditions from patients with ABOM.  
 
2.  Drug Development Population 
 
The drug development population should include patients with ABOM, defined as the recent or 
acute onset of inflammation of the middle ear caused by a bacterial pathogen.   
 
                                                 
6 It is important to note how the terms sign and symptom are used in this guidance in the context of PRO and 
caregiver-reported outcome instruments.  PRO instruments can capture both signs and symptoms reported by the 
patient.  A caregiver-reported outcome instrument by definition is not a PRO, but may be the best option for 
capturing patient outcomes for younger children who may not be able to directly articulate their subjective state.  In 
a caregiver-reported outcome instrument, pain intensity measurement as experienced by a young child can be 
inferred and reported by a caregiver based on the childs behavior, in which case it is measured as a sign rather than 
as a true symptom.  As used in this guidance, the terms sign and symptom include in most contexts the subjective 
state of the patient, but symptoms can be reported only by the patient.  Therefore, where a caregiver-reported 
outcome instrument is used, the information captured may be limited to observable signs. 
 
7 When final, this guidance will represent the FDAs current thinking on this topic.   
3  Contains Nonbinding Recommendations 
3.  Efficacy Considerations  
 
The goal of ABOM clinical trials should be to demonstrate an effect of antibacterial therapy on 
the clinical course of ABOM caused by H. influenzae, S. pneumoniae, M. catarrhalis, or other 
additional bacterial pathogens, provided that data are sufficient to substantiate the clinical 
relevance of the particular bacterial pathogen as a pathogen in ABOM.  During drug 
development, sponsors should discuss with the FDA the methods they may use to provide data 
on relevant bacterial pathogens that cause ABOM.  For example, microbiological data may be 
obtained by one or more of the following methods:  (1) baseline tympanocentesis in all patients 
enrolled in a phase 3 trial (see section III.B.3.d., Baseline tympanocentesis); (2) baseline 
tympanocentesis in a subset of patients in the phase 3 trial; (3) baseline tympanocentesis in 
patients enrolled in a phase 2 trial; or (4) microbiological data obtained during clinical 
development of the investigational drug for treatment of another infectious disease in which the 
bacterial pathogens are identical or similar to bacterial pathogens that are known to cause 
ABOM.  An advantage of microbiologic confirmation by tympanocentesis is the potential to 
perform analyses of treatment responses by individual pathogens.   
 
The number of clinical trials that should be conducted in support of an ABOM indication 
depends on the overall development plan for the drug under consideration.  A single trial for an 
ABOM indication may be appropriate if there are data from other clinical trials demonstrating 
effectiveness in other respiratory tract diseases and there is additional supportive information, 
such as PK trials demonstrating concentration of the antibacterial drug in the middle ear fluid at a 
level expected to be active against the common pathogens causing ABOM.8 
 
The disease course and treatment for ABOM is of a short-term duration and the clinical outcome 
is readily measured.  Currently, there are no surrogate markers accepted by the FDA as 
substituting for clinical outcomes in ABOM trials.  Sponsors who wish to propose a surrogate 
marker for clinical outcome of ABOM should discuss this with the FDA early in the drug 
development process.  
 
4.  Safety Considerations  
 
There should be sufficient evidence of drug safety from ongoing or completed clinical trials of 
other respiratory infections in adults before ABOM trials are initiated in children, even if ABOM 
for a pediatric population is the sole indication being pursued by a sponsor.  Antibacterial drugs 
with clinically significant toxicity identified in earlier trials are not considered appropriate for 
study of this indication. 
 
Drug safety information should be collected from studies of pediatric patients who receive the 
drug administered at the dose and duration proposed for use.  Although it may be possible to 
derive some safety information from trials of the new drug in adults when exposure is similar to 
or greater than what is anticipated for treatment of ABOM in children, there also should be 
sufficient evidence of safety derived from trials in children.  The total number of pediatric 
patients and the distribution by age group (given that ABOM occurs more commonly among 
                                                 
8 See the guidance for industry Providing Clinical Evidence of Effectiveness for Human Drug and Biological 
Products. 
4  Contains Nonbinding Recommendations 
children younger than approximately 5 years of age) that are needed to support an ABOM 
indication should be discussed with the FDA early in the drug development process. 
 
Safety evaluations and assessments should consider the patient populations that are likely to be 
treated for ABOM.  Protocols for ABOM should specify the age-appropriate methods to be used 
to obtain safety data during clinical trials.  Clinical trials should be designed in a manner that 
facilitates the collection of information to characterize the safety of the experimental drug.  Age- 
and sex-appropriate normal laboratory values should be included with clinical measurements 
when reporting laboratory data.  Additional safety evaluations may be appropriate because of the 
nonclinical and clinical profile of the specific drug under study.  Longer term assessment of 
adverse events after discontinuation or completion of the antimicrobial drug should be 
considered depending on the specific drug being studied and the potential for long-term or 
delayed adverse effects based on, for example, observations from nonclinical toxicology studies, 
safety data from other clinical trials, or postmarketing safety data, if available.  
 
B.  Specific Efficacy Trial Considerations 
 
1.  Trial Design 
 
The type of clinical trial design will depend on the type of patients enrolled in the trial (e.g., age 
and disease presentation).   
 
a.  Active-controlled clinical trials 
 
Children for whom treatment with an antibacterial drug is recommended by treatment guidelines 
from professional societies (e.g., children between 6 months and 23 months of age with severe 
ABOM)9 should be enrolled in active-controlled clinical trials.  An active-controlled trial can be 
designed for a finding of superiority or noninferiority.  Sponsors planning an active-controlled 
noninferiority trial should discuss with the FDA the scientific data needed to support selection of 
a noninferiority margin.10  
 
b.  Placebo-controlled clinical trials 
 
Children for whom either observation (watchful waiting) or treatment with an antibacterial drug 
is recommended by treatment guidelines from professional societies (e.g., children 24 months of 
age or older without severe ABOM) can be enrolled in placebo-controlled trials.  Placebo-
controlled trials should include an early assessment at approximately 48 hours that documents 
clinical signs of ABOM as observed by the clinician with defined objective characteristics of 
patients with no improvement or progression of disease.  Such patients should be offered rescue 
antibacterial drug therapy. 
 
                                                 
9 See the most recent treatment guidelines by professional societies (e.g., Subcommittee on Management of Acute 
Otitis Media, 2004). 
 
10 See the draft guidance for industry Non-Inferiority Clinical Trials.  When final, this guidance will represent the 
FDAs current thinking on this topic. 
5  Contains Nonbinding Recommendations 
2.  Clinical Trial Population 
 
Clinical trials should enroll male and female children with ABOM. 
 
3.  Entry Criteria  
 
The minimum subset of specific signs and symptoms needed for enrollment should be defined in 
the protocol as part of the inclusion criteria for the trial.  The inclusion criteria should be selected 
to yield a strong likelihood that a patient has disease attributable to a bacterial pathogen.  A 
protocol also can specify different criteria for the diagnosis of ABOM for different age groups if 
this improves the overall positive predictive validity for bacterial disease.  A combination of 
signs and symptoms, including fever with yellow or red bulging tympanic membrane, irritability, 
and ear tugging, has been associated with a tympanocentesis culture demonstrating the presence 
of a bacterial pathogen (Rodriguez and Schwartz 1999; Leibovitz, Satran, et al. 2003).  The 
following information may be used in the selection of appropriate inclusion criteria. 
 
a.  Patient history and characteristics 
 
The following patient demographic characteristics should be used to provide a better chance of 
selecting patients likely to have bacterial disease:  
 
  Younger ages (e.g., younger than approximately 5 years) 
 
  Biphasic illness:  acute onset (24 to 48 hours) of ABOM symptoms preceded by 
predisposing infections, such as rhinitis, pharyngitis, and tonsillitis 
 
b.  Symptoms and observable signs 
 
Infants and younger children often present with nonlocalizing observable signs of otitis media; 
older children may be more likely to articulate symptoms referable to the ear. 
 
Signs that may be observed in infants and younger children include the following: 
 
  Head rolling 
  Ear tugging 
  Ear rubbing 
  Fussiness or irritability 
  Inconsolability 
  Decreased appetite 
  Sleep disturbance 
 
Symptoms that may be measured in older children with ABOM include the following: 
 
  Ear pain or earache 
  Ear fullness 
  Decreased hearing 
6  Contains Nonbinding Recommendations 
 
c.  Clinical signs 
 
The following bullet points provide a general framework for defining clinical signs for the 
protocol and for deciding whether to include them as part of the entry criteria. 
 
  Clinicians with experience in otoscopy should be able to identify patients who have 
ABOM.  Otoscopic findings considered consistent with ABOM include: 
 
  Bulging or fullness of the tympanic membrane (convexity of the plane of the 
-
eardrum), with loss of anatomic landmarks on visualization  
 
  Opacification of the tympanic membrane regardless of color 
-
 
  Erythema of the tympanic membrane  
-
 
  Abnormal tympanic membrane mobility on biphasic pneumatic otoscopy; a tympanic 
-
membrane in the neutral position or retracted is not sufficient evidence of ABOM 
because these findings are not specific enough to distinguish the disease from otitis 
media with effusion 
 
  Photography or videography can be performed and evaluated centrally for findings 
consistent with ABOM 
 
  The results of tympanometry and/or electroacoustic reflectometry can be used to define 
entry criteria and help select patients to undergo tympanocentesis, if this procedure is 
planned in the clinical trial  
 
  Other clinical signs of ABOM may include the following: 
 
  Elevated body temperature (e.g., temperature greater than 38 degrees Celsius) 
-
  Elevation in peripheral white blood cell (WBC) count 
-
 
d.  Baseline tympanocentesis 
 
If tympanocentesis is included in a trial, sponsors should ensure that the individuals at these 
centers have sufficient experience and training to perform tympanocentesis.  When 
tympanocentesis is performed, Gram stain of the aspirate material with examination for WBC 
count also should be performed, with culture as well as antimicrobial susceptibility testing of all 
bacterial isolates.  
 
e.  Exclusion criteria 
 
The following patients should be excluded from trials for the treatment of ABOM: 
 
  Patients with otitis externa   
7  Contains Nonbinding Recommendations 
 
  Patients with tympanostomy tubes at the time of trial entry11 
 
  Immunocompromised patients or patients with other medical conditions that may affect 
interpretation of the effect of investigational drugs 
 
  Patients on any medications that may affect the interpretation of trial outcome (e.g., 
inhaled steroids) 
 
  Patients with craniofacial abnormalities 
 
  Patients with concomitant infections other than ABOM that may influence the assessment 
of drug efficacy and safety 
 
  Patients who are allergic to any of the investigational drugs 
 
  Patients with erythema of the tympanic membrane without other evidence of otitis 
media12 
 
For noninferiority trials, patients who have received antimicrobial therapy for the current episode 
of ABOM may bias the results toward a finding of noninferiority.  Thus, we recommend 
exclusion of patients who received prior antibacterial drug therapy from noninferiority trials.  For 
superiority trials, receipt of prior antibacterial drugs for the current episode of ABOM can be 
permitted.  
 
4.  Randomization, Stratification, and Blinding 
 
Patients should be randomized for receipt of investigational drugs at enrollment.  All trials 
should be double-blinded for trial therapy and assessment of outcome.  
 
We recommend stratification by age because younger patients (i.e., younger than 2 years of age) 
may have lower cure rates than older patients.  Other possible stratification factors include 
unilateral versus bilateral disease, and the presence or absence of otorrhea.  
 
5.  Dose Selection 
 
The pharmacokinetics of the drug in children, including any changes in pharmacokinetics with 
age, should be established before initiating efficacy trials in children.13  Initial dose selection 
                                                 
11 Patients with an acute, recent tympanic membrane perforation related to the present episode of ABOM can be 
enrolled if other entry criteria are met.  
 
12 Although nonspecific as an isolated finding, the absence of diffuse erythema has a relatively high negative 
predictive value for ABOM. 
 
13 For guidance on the PK information needed to select appropriate doses for the pediatric population, see the draft 
guidance for industry General Considerations for Pediatric Pharmacokinetic Studies for Drugs and Biological 
Products.  When final, this guidance will represent the FDAs current thinking on this topic.  
8  Contains Nonbinding Recommendations 
may be made based on a single-dose PK trial in children.  The single-dose trial may include dose 
adjustments to achieve the desired exposure that is anticipated to provide efficacy.  After 
sufficient data are available to select an appropriate dose and duration for the investigational 
drug, an efficacy trial can include a population PK approach to supplement the single-dose PK 
data.  PK data in combination with efficacy and safety data from phase 2 dose-ranging trials 
contribute to the selection of an appropriate dose and duration for phase 3 clinical development.  
Data from phase 2 trials with tympanocentesis demonstrating drug penetration into middle ear 
fluid can also inform dose selection for subsequent trials.  
 
6.  Choice of Comparators 
 
In an active-controlled trial, the control antibacterial drug should be FDA-approved for treatment 
of acute otitis media (AOM) or treatment of ABOM and recommended for treatment in 
guidelines published by professional societies.   
 
7.  Concomitant Medications  
 
The protocol should specify the use of effective analgesia for pain associated with ABOM.  We 
discourage the use of antihistamines or decongestants.  If other treatments are permitted in the 
trial, their use should be standardized across treatment groups.  Because concomitant 
medications may have an effect on outcome assessments and introduce confounding, the use of 
concomitant medications should be well-balanced between the treatment groups to ensure that 
the observed treatment effect is caused by the investigational drug. 
 
8.  Efficacy Endpoints 
 
The primary efficacy endpoint of the clinical trial should evaluate the effect of the antimicrobial 
drug on clinically important patient symptoms and functioning.  A parent- or caregiver-reported 
outcome instrument can be used as a primary efficacy endpoint if it is well-defined and reliable.  
It may be helpful to evaluate symptom improvement based on measurements at time points early 
in therapy, which may have greater sensitivity to treatment differences of an antibacterial drug.  
However, the amount of improvement determined to be clinically meaningful (and, therefore, 
appropriate for regulatory decisions) should be determined during clinical development and 
discussed with the FDA before trial initiation. 
 
A primary efficacy endpoint can be a binary response of clinical success or failure where 
response criteria are prespecified and are based upon measurements obtained using well-defined 
and reliable outcome assessment tools.  The primary efficacy endpoint can be evaluated as the 
time to clinical success or evaluated at a fixed time point (e.g., a fixed time point early in the 
course of therapy).   
 
  Clinical success.  Clinical success can be documented when a patient exhibits 
improvement (or resolution) of disease-specific symptoms and observable signs present 
at enrollment (e.g., head rolling, ear tugging, ear rubbing), and the absence of new 
symptoms or observable signs attributable to ABOM. 
 
9  Contains Nonbinding Recommendations 
  Clinical failure.  Clinical failure can be documented as follows:  
 
  Development of complications of ABOM such as mastoiditis 
 
  Lack of improvement or worsening of disease-specific clinically meaningful 
symptoms or observable signs 
 
  The development of new symptoms or signs attributable to ABOM 
 
  Treatment with rescue nontrial antibacterial drugs for ABOM 
 
  Treatment with nontrial antibacterial drug for another infectious disease, and the 
antibacterial drug has activity in the treatment of ABOM 
 
Patients designated as clinical failures at an early time point should also be designated as 
clinical failures for all subsequent follow-up visits.  
 
9.  Trial Procedures and Timing of Assessments 
 
a.  Entry visit 
 
At entry, the investigator should evaluate the patient by performing an appropriate history and 
physical examination, as follows: 
 
  History and demographic characteristics 
 
  Date of visit  
 
  Age, sex, and weight 
 
  Underlying medical conditions, if any 
 
  Current medications, if any 
 
  History of allergies or allergic symptoms  
 
  Social environment (e.g., day care attendance), including smoke exposure 
 
  Number of distinct and well-documented episodes of AOM/ABOM in the previous 
12 months and how this information is obtained (i.e., chart review or recall of 
caregiver); dates, treatment regimens, and outcomes should be recorded   
 
  Symptoms and observable signs 
 
The presence of each symptom should be documented directly as reported by the patient 
using a PRO assessment.  If patients cannot report for themselves, symptom assessment 
10  Contains Nonbinding Recommendations 
is not possible.  A caregiver can provide information about observable signs that may 
indirectly assess symptoms using a caregiver-reported outcome assessment. 
 
  Clinical signs at clinic visit  
 
  Vital signs, including body temperature measurement. 
 
  Presence of unilateral or bilateral disease.   
 
  Otoscopic findings for each ear, including position of tympanic membranes, color, 
and mobility on pneumatic otoscopy.  The absence of tympanic membrane 
perforation for each ear should be documented. 
 
  Tympanometry and/or electroacoustic reflectometry for each affected ear. 
 
  Other laboratory tests as appropriate (e.g., peripheral WBC count). 
 
For trials where microbiological information is being obtained by baseline tympanocentesis, the 
middle ear fluid should be sent for culture and in vitro susceptibility testing of any bacteria 
isolated.  All isolates considered to be possible pathogens should be saved in the event that 
additional testing of the isolate is needed.  For microbiological assessment, the investigator 
should collect the following information: 
 
  Identification of the affected ear sampled (i.e., right or left).  
 
  A description of how the sample was obtained, processed, and transported to the 
laboratory. 
 
  Identification of the bacterial isolate. 
 
  In vitro susceptibility testing of the isolates to both the investigational and control drugs.  
This information should remain blinded while the patient is receiving investigational 
drug.  In vitro susceptibility testing should be performed by using standardized 
methods.14 
 
The investigator should remain blinded to the bacterial isolate and in vitro drug susceptibility 
testing unless the patient meets the criteria for clinical failure, at which time the results of the 
bacterial isolate and in vitro susceptibility testing should be made immediately available to 
the treating clinician. 
 
                                                 
14 Standard methods for in vitro susceptibility testing are developed by organizations such as the Clinical and 
Laboratory Standards Institute, Wayne, PA. 
11  Contains Nonbinding Recommendations 
b.  On-therapy visits 
 
Each patient should have daily on-therapy assessments of symptoms or observable signs, as well 
as safety assessments.  These assessments can be performed by the investigator during a visit to 
the investigators office or by a PRO instrument.  Regardless of how the assessment is conducted 
(e.g., interview, interactive voice response via telephone, PRO), the questioning of patients or 
caregivers should be performed in a reproducible and structured way so that any potential biases 
in the method of questioning do not affect trial outcome.  If assessments are done often (e.g., 
twice daily), the ability to detect differences between therapies for a time-to-resolution endpoint 
or a fixed time point early in therapy may be increased.  Therapy should be continued as 
described in the protocol regardless of whether symptoms and observable signs have resolved.  
 
Rescue antibacterial drug therapy should be administered to patients who are worsening on their 
assigned treatment arm; specific criteria to identify these patients should be included in the 
protocol and the patients should continue to have protocol-specified assessments.  It is important 
that investigators distinguish patients who are worsening (i.e., where rescue therapy is 
appropriate) from patients who are slow to improve but may still remain on assigned therapy and 
thereby achieve clinical success later.  Although assessments for clinical improvement or clinical 
failure should be included as part of the on-therapy visits, all patients enrolled in placebo-
controlled trials should have a protocol-defined assessment for clinical failure at approximately 
48 hours after clinical trial enrollment.   
 
c.  Early follow-up visit 
 
The early follow-up visit should occur after completion of investigational drug administration, at 
a time when the drug is expected to have cleared from the infection site.  For example, if an 
investigational drug with a short half-life is administered for 5 days, this visit can occur on day 7 
to 10 after therapy initiation.  At this visit the investigator should perform a focused medical 
history and physical examination, as well as appropriate laboratory measurements.  The 
investigator also should inquire about adverse events.   
 
d.  Late follow-up assessment 
 
The late follow-up assessment should occur 10 to 14 days after the completion of all 
investigational drug.  For patients with no adverse events noted at the early follow-up assessment 
and who are clinical successes (i.e., previous resolution of symptoms and signs), this assessment 
can be performed by a telephone contact or other interactive technology.  For patients with 
adverse events occurring at or after the early follow-up assessment, investigators should perform 
an assessment that includes a medical history, a physical examination, appropriate laboratory 
evaluations, identification of any new adverse events, and follow-up on unresolved adverse 
events.  Although adverse events that are serious and unexpected are required to be reported and 
followed until resolution (21 CFR 312.32(c)(1)(i)(A) and 21 CFR 312.32(d)(1) and (2)), we 
recommend that all adverse events be followed to resolution, even if time of trial has been 
completed. 
 
12  Contains Nonbinding Recommendations 
10.  Statistical Considerations 
 
The trials primary and secondary hypotheses and the analysis methods should be prespecified in 
the protocol.  Sponsors should provide a detailed statistical analysis plan with the protocol for the 
phase 3 trial. 
 
a.  Analysis populations 
 
The following definitions apply to various populations for analyses in ABOM clinical trials:  
 
  Safety population  All patients who received at least one dose of drug during the trial. 
 
  Intent-to-treat (ITT) population  All patients who are randomized. 
 
  Microbiologically confirmed intent-to-treat (micro-ITT) population  When 
tympanocentesis is performed on patients at baseline, this population is all patients who 
are randomized and who have a pathogen known to cause ABOM isolated at baseline.  
Patients should not be excluded from this population based upon events that occur after 
randomization (e.g., loss to follow-up).   
 
  Per-protocol populations (also referred to as the clinically evaluable or 
microbiologically evaluable populations)  The population of patients who meet the 
definition for the primary analysis population (ITT population or micro-ITT population) 
and who follow important components of the protocol as specified (e.g., administration of 
a specified minimum amount of investigational drug). 
 
The ITT population should be evaluated in efficacy analyses as well as the population of patients 
who follow important aspects of the protocol (i.e., the per-protocol population) to ensure 
consistency of results.  However, it is also important to note that the per-protocol population 
analyses are subgroup analyses because they exclude patients based upon events that occur after 
randomization.  Patients in such subgroup analyses may differ by important factors (both 
measured and unmeasured) other than the drug received; because of this, analyses based on the 
ITT population should be considered the primary analyses, with analyses based on a per-protocol 
population reviewed for consistency of results.  
 
b.  Sample size  
 
The appropriate sample size for a clinical trial should be based upon the number of patients 
needed to answer the research question posed by the trial.  The sample size is influenced by 
several factors including the prespecified type I and type II error rates, the expected success rate, 
and the noninferiority margin (for a noninferiority trial) or the amount by which the 
investigational drug is expected to be superior to the control (for a superiority trial).   
 
13  Contains Nonbinding Recommendations 
c.  Missing data 
 
There is no optimal way to deal with missing data from clinical trials.  Sponsors should make 
every attempt to limit loss of patients from the trial by incorporating strategies for adequate 
follow-up and these strategies should be specified in the protocol.  Patients who do not complete 
the trial may differ substantially from patients who remain in the trial in both measured and 
unmeasured ways, posing analytic problems.  The way missing data will be handled should be 
specified in the protocol.  Patients who stop trial drug and initiate rescue therapy generally would 
be counted as nonresponders or failures, but should be followed.  Sponsors should prespecify 
several sensitivity analyses to assess the robustness of the primary analysis, including analyses 
with multiple imputation methods and classification of all missing outcomes as failures.  
However, all of these methods depend on uncertain assumptions, and interpretation of trial 
results may be difficult if there is a high rate of missing data or the rates of missing data are 
different across treatment arms. 
 
d.  Interim analyses and data monitoring committee 
 
If interim effectiveness analyses for success or futility will be performed, they should be 
prespecified in the protocol and in the analysis plan along with a justification.  Details on the 
operating procedures also should be provided before trial initiation.  The purpose of the interim 
analysis should be stated along with the appropriate statistical adjustment to control the overall 
type I error rate.  It is important that an appropriate firewall be in place to guarantee that the 
interim analysis will not affect trial conduct and thereby compromise trial results.  This can be 
accomplished by creating an independent data monitoring committee (DMC) that monitors the 
protocol with prespecified operational procedures.  Such a committee also might be created if 
there were safety concerns about the drug or treatment approach.  If a DMC is used, a detailed 
charter with the composition of the committee members, conflicts of interest, decision rules, 
details on the measures taken to protect operational bias and the integrity of the trial, and 
standard operating procedures should be provided for review.15  
 
e.  Other analyses of interest and secondary endpoints 
 
Analyses of secondary and additional endpoints should be considered exploratory because a trial 
usually is not designed to address the questions raised by these analyses, because of multiple 
comparisons and/or concerns with subgroup analyses.  However, the conclusions of such 
analyses can be strengthened if hypotheses related to these endpoints are prespecified in the 
protocol, if adjustments for multiple comparisons (maintenance of type I error) are outlined in 
the protocol, and if the trial is appropriately powered to determine differences between groups 
related to these variables.  Analyses of secondary and additional endpoints can be most helpful 
for identifying areas for study in future trials. 
 
                                                 
15 For more detailed guidance, see the guidance for clinical trial sponsors Establishment and Operation of Clinical 
Trial Data Monitoring Committees. 
14  Contains Nonbinding Recommendations 
11.  Ethical Considerations 
 
There are concerns that institutional review boards (IRBs) or investigators may consider a 
placebo-controlled trial in ABOM to be unethical.  The general issue of the ethics of placebo-
controlled trials is addressed in ICH E10.  For such a trial to be approvable by a local IRB under 
21 CFR part 50, subpart D, the risk to children randomized to a comparator group that involves 
the withholding of antibacterial treatment (whether placebo or delayed therapy) must be no more 
than a minor increase over minimal risk (21 CFR 50.53).  In addition, clinical trials must be 
designed so that risks to patients are minimized (21 CFR 56.111).   
 
Given the specific concern of rare infectious complications that may be associated with 
nontreatment of ABOM (e.g., mastoiditis or meningitis), the design for a placebo-controlled trial 
should include an early clinical assessment for clinical failure at approximately 48 hours after 
enrollment.  A review of all previous placebo-controlled trials of ABOM have not shown a 
substantial risk to placebo-treated recipients that make future placebo-controlled trials unethical; 
overall risk from placebo treatment may be similar to that associated with antibacterial therapy 
because low-frequency severe events (e.g., pseudomembranous colitis or serious allergic 
reactions) have been observed with almost all antibacterial drugs.  If necessary, effective 
antimicrobial rescue treatment can be initiated at the time of a clinical failure, thus limiting the 
risk exposure of the children randomized to the placebo-controlled arm of the trial. 
 
If tympanocentesis is included in the trial design, it should be performed only by individuals with 
expertise in this procedure to ensure that the procedure poses no more than a minor increase over 
minimal risk to patients (21 CFR 50.53).  Making unblinded culture results available so that 
effective antimicrobial treatment can be initiated in response to a treatment failure may provide 
prospect of direct benefit to the enrolled children, and thus be acceptable under 21 CFR 50.52.  
In addition, targeted therapy based on culture results from repeat tympanocentesis performed to 
assess clinical failures may offer prospect of direct benefit. 
 
Finally, for an isolated single-dose PK trial in children, sufficient evidence of drug safety in 
adults would be needed so that the risk exposure for children is limited to no more than a minor 
increase over minimal risk (21 CFR 50.53).  If the PK data are used to adjust the dose of the 
investigational drug for individual patients, an IRB may consider this aspect of the trial as 
offering the prospect of direct benefit (21 CFR 50.52).  If additional PK data are collected in an 
efficacy trial, the PK component of the efficacy trial may be acceptable as a minor increase over 
minimal risk, based on a component analysis of risk (21 CFR 50.53). 
 
 
15  Contains Nonbinding Recommendations 
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16  Contains Nonbinding Recommendations 
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17  Contains Nonbinding Recommendations 
 
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