What is the management of otitis (inflammation of the middle ear) media?

From the Guidelines

Management of otitis media involves a combination of pain relief, antibiotics, and watchful waiting depending on the severity and type, with the goal of minimizing morbidity, mortality, and improving quality of life. For acute otitis media, start with pain management using acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) 1. In children older than 2 years with mild symptoms, a watchful waiting approach for 48-72 hours is reasonable, as recommended by the clinical practice guideline on tympanostomy tubes in children (update) 1. If symptoms persist or are severe, prescribe amoxicillin as first-line therapy (80-90 mg/kg/day divided twice daily for 5-10 days), with alternatives including azithromycin (10 mg/kg on day 1, then 5 mg/kg daily for 4 days) or clarithromycin (15 mg/kg/day divided twice daily for 10 days) for patients with penicillin allergy 1. For recurrent or persistent cases, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) may be needed, and chronic otitis media with effusion often resolves spontaneously within 3 months, but persistent cases affecting hearing may require referral for tympanostomy tube placement, as noted in the executive summary of clinical practice guideline on tympanostomy tubes in children (update) 1. Prevention strategies include pneumococcal and influenza vaccination, breastfeeding, avoiding secondhand smoke exposure, and limiting pacifier use in older infants, which can help reduce the risk of otitis media and its complications, as discussed in the article on otitis media 1. The use of adenoidectomy in conjunction with tympanostomy tube insertion is also a consideration, particularly in children over 4 years old, as it may reduce the prevalence of middle ear effusion and improve hearing outcomes, as indicated in the clinical practice guideline on tympanostomy tubes in children (update) 1. Overall, the management of otitis media requires a comprehensive approach that takes into account the severity and type of the condition, as well as the individual needs and risk factors of the patient, with the goal of minimizing morbidity, mortality, and improving quality of life 1.

Some key points to consider in the management of otitis media include:

• The importance of accurate diagnosis and distinction between acute otitis media and otitis media with effusion 1
• The use of watchful waiting as an option for mild cases of acute otitis media in children over 2 years old 1
• The role of antibiotics in the treatment of acute otitis media, including the use of amoxicillin as first-line therapy and alternatives for patients with penicillin allergy 1
• The consideration of tympanostomy tube placement for persistent cases of otitis media with effusion that affect hearing 1
• The importance of prevention strategies, including pneumococcal and influenza vaccination, breastfeeding, avoiding secondhand smoke exposure, and limiting pacifier use in older infants 1
• The potential benefits and risks of adenoidectomy in conjunction with tympanostomy tube insertion, particularly in children over 4 years old 1.

By considering these factors and taking a comprehensive approach to the management of otitis media, healthcare providers can help minimize morbidity, mortality, and improve quality of life for patients with this condition.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

For the 366 patients who were evaluated for clinical efficacy at the Day 12 visit, the clinical success rate (i.e., cure plus improvement) was 83% for azithromycin and 88% for the control agent.

In the safety analysis of the above study, the incidence of treatment-related adverse events, primarily gastrointestinal, in all patients treated was 10.6% with azithromycin and 20.0% with the control agent.

Management of Otitis Media:

• The recommended dose of azithromycin for pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days.
• Clinical success rates for azithromycin in the treatment of acute otitis media were 83% at Day 12 and 74% at Day 24 to 28.
• Common side effects of azithromycin include diarrhea, vomiting, and abdominal pain.
• The incidence of treatment-related adverse events was 10.6% with azithromycin and 20.0% with the control agent 2.

From the Research

Management of Otitis Media

• The management of otitis media involves the use of antibiotics, with amoxicillin being a common first-line treatment 3, 4, 5.
• The dosage of amoxicillin recommended is 90 mg/kg/day, divided into two or three doses 3, 5.
• For patients who do not respond to amoxicillin, second-line therapy options include high-dose amoxicillin/clavulanate, ceftriaxone, and other cephalosporins 3, 4.
• The use of topical fluoroquinolone agents, with or without a corticosteroid, is recommended for the treatment of acute otitis media with tympanostomy tubes 6.
• Azithromycin has been shown to be effective in the treatment of acute otitis media, with a decreased risk of failure overall compared to amoxicillin 7.

Antibiotic Resistance and Treatment

• The increasing prevalence of drug-resistant Streptococcus pneumoniae and beta-lactamase-producing organisms presents a clinical challenge for practitioners in the selection of empiric antimicrobial therapy 3.
• The use of pharmacokinetic/pharmacodynamic principles should be considered in addition to minimum inhibitory concentrations in selecting antibiotics for otitis media 3.
• The pneumococcal conjugate vaccine has been shown to be effective in preventing recurrent otitis media and should be administered to all children less than 2 years old and those at risk for recurrent otitis media 3.

Treatment Duration and Compliance

• A five-day duration of therapy is advised for the treatment of acute otitis media 5.
• Key factors for enhancing compliance include the taste of suspension, dosing frequency, and duration of therapy 4.
• A 48-72 hour period of "watchful waiting" is recommended before initiating antibiotic therapy in healthy children, during which symptoms are treated while monitoring the patient clinically to see if symptoms resolve 5.