Background: Acute otitis media (AOM) is among the most common infectious diseases in children andremains a leading indication for antibiotic prescriptions worldwide. Despite evidence-based clinicalguidelines advocating selective antibiotic use and watchful waiting in uncomplicated cases, inappropriateprescribing continues to contribute to antimicrobial resistance and unnecessary healthcare costs. Thisstudy evaluated antibiotic prescription patterns and adherence to clinical practice guidelines in patientsdiagnosed with AOM at a tertiary care hospital. Methods: A hospital-based cross-sectional observationalstudy was conducted from January to June 2024 in the Departments of Otorhinolaryngology and Pediatricsof a tertiary care teaching hospital. A total of 150 patients diagnosed with AOM were enrolled usingconvenience sampling. Demographic characteristics, clinical presentation, antibiotic prescriptions,treatment duration, and prescribing practices were recorded using a structured data collection form.Prescriptions were assessed for appropriateness according to the American Academy of Pediatrics andNational Institute for Health and Care Excellence guidelines. Data were analyzed using SPSS version 25.0,with descriptive statistics and Chi-square tests applied where appropriate. A p-value <0.05 was consideredstatistically significant. Results: Of the 150 patients, 60.0% were male and 70.0% were younger than fiveyears. Antibiotics were prescribed to 128 (85.3%) patients, while only 22 (14.7%) were managed using thewatchful waiting approach. Amoxicillin was the most frequently prescribed antibiotic (39.8%), followed byamoxicillin-clavulanate (29.7%), cephalosporins (20.3%), and macrolides (10.2%). Overall guidelineadherence was observed in 54.7% of prescriptions. Broad-spectrum antibiotics were prescribed withoutappropriate indication in 50.0% of cases, and inappropriate treatment duration was identified in 35.2% ofprescriptions. Fever (p=0.03) and bilateral disease (p=0.04) were significantly associated with inappropriateprescribing. Conclusion: Antibiotic prescribing for acute otitis media remained high, with only moderateadherence to evidence-based guidelines. Frequent use of broad-spectrum antibiotics and inappropriatetreatment duration highlight the need for strengthened antimicrobial stewardship programs, regular prescription audits, physician education, and greater implementation of guideline-directed management tooptimize antibiotic use and combat antimicrobial resistance.