What are the antibiotic indications for Otitis Media (Middle Ear Infection)?

From the Guidelines

Antibiotics are indicated for acute otitis media (AOM) and should be treated with amoxicillin as the first-line therapy. The dosage of amoxicillin should be 80 to 90 mg per kg per day, as recommended by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) 1. This option is based on extrapolation from microbiologic studies and expert opinion, with preponderance of benefit over risk.

Key Points to Consider

• The choice of a first-line treatment should be based on the anticipated clinical response and the microbiologic flora likely to be present.
• Amoxicillin is recommended as first-line therapy for AOM because it is generally effective when used in sufficient doses against susceptible and intermediate resistant pneumococci.
• If the patient is allergic to amoxicillin and the allergic reaction is not a type I hypersensitivity reaction, the physician can prescribe cefdinir, cefpodoxime, or cefuroxime 1.

Treatment Duration and Alternatives

• The optimal duration of therapy for patients with AOM is uncertain, but amoxicillin should be prescribed for a sufficient duration to ensure complete resolution of symptoms.
• For penicillin-allergic patients, alternatives include other antibiotics that are effective against the common bacterial pathogens in AOM, such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Clinical Considerations

• The decision to treat with antibacterial agents should be based on the severity of symptoms, the age of the patient, and the presence of any underlying medical conditions.
• Watchful waiting with pain management may be appropriate for some patients, but antibiotics are generally recommended for patients with severe symptoms or high-risk cases 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE Ciprofloxacin otic solution, 0.2% is a quinolone antimicrobial indicated for the treatment of acute otitis externa due to susceptible isolates of Pseudomonas aeruginosa or Staphylococcus aureus.

The FDA drug label does not answer the question.

From the Research

Otitus Media Antibiotic Indication

• The first-line antibiotic treatment for acute otitis media (AOM) is high-dose amoxicillin (80 to 90 mg/kg/d divided twice daily) 2, 3, 4, 5.
• For patients who have taken amoxicillin for AOM in the previous 30 days or have concomitant purulent conjunctivitis, amoxicillin/clavulanate is typically used 3.
• Cefdinir or azithromycin should be the first-line antibiotic in those with penicillin allergy based on risk of cephalosporin allergy 3.
• The choice of antibiotic should consider the local prevalence of drug-resistant Streptococcus pneumoniae and beta-lactamase-producing pathogens 4, 6.
• In areas with low prevalence of nonsusceptible S. pneumoniae, standard-dose amoxicillin may be sufficient for uncomplicated AOM 6.
• Amoxicillin-clavulanic acid is only recommended when there is a risk of infection by β-lactamase-producing bacteria 5.
• The recommended amoxicillin dosage is 90 mg/kg/day, divided into three doses, though two doses may be considered to improve compliance 5.
• A five-day duration of therapy is advised 5.

Special Considerations

• Tympanostomy tubes should be considered in children with three or more episodes of AOM within six months or four episodes within one year with one episode in the preceding six months 3.
• Pneumococcal and influenza vaccines and exclusive breastfeeding until at least six months of age can reduce the risk of AOM 3.
• Children who attend child care or have recently received an antibiotic may require treatment with high-dose amoxicillin 6.