What is the recommended treatment for acute otitis media (AOM)?

From the Guidelines

The recommended treatment for acute otitis media (AOM) is amoxicillin, not cephalexin, as the first-line antibiotic, usually prescribed at 80-90 mg/kg/day for children or 500-875 mg twice daily for adults, for a 5-10 day course depending on severity and age 1. For patients with penicillin allergy, alternatives include azithromycin or trimethoprim-sulfamethoxazole. Pain management with acetaminophen or ibuprofen is important for symptom relief. Watchful waiting without immediate antibiotics may be appropriate for mild cases in children over 2 years without severe symptoms. Patients should maintain adequate hydration and may use warm compresses on the affected ear for comfort. Antibiotics are effective because they target the common bacterial pathogens in AOM (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) that cause middle ear inflammation following upper respiratory infections when bacteria ascend through the Eustachian tube 1. The choice of antibacterial agent after initial failure of observation or first-line antibacterial therapy should be based on the likely pathogen(s) present or the physician's clinical experience 1. Initial observation, defined as initial management of AOM limited to symptomatic relief, with commencement of antibiotic therapy only if the child’s condition worsens at any time or does not show clinical improvement within 48 to 72 hours of diagnosis, is also a viable option 1. Key considerations in the management of AOM include:

• The use of amoxicillin as the first-line antibiotic
• The importance of pain management and supportive care
• The potential for watchful waiting in mild cases
• The need for follow-up and reassessment if symptoms persist or worsen.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Acute Otitis Media (AOM)

• The recommended first-line treatment for uncomplicated AOM is amoxicillin 2, 3.
• For clinical treatment failures after 3 days of amoxicillin, recommended antimicrobial agents include oral amoxicillin/clavulanate, cefuroxime axetil, cefprozil, cefpodoxime proxetil, and intramuscular (i.m.) ceftriaxone 2.
• Cephalexin is not specifically mentioned as a recommended treatment option for AOM in the provided studies.
• However, other oral cephalosporins such as cefuroxime-axetil, cefprozil, cefdinir, and cefpodoxime-proxetil have been discussed as potential treatment options for AOM due to their in vitro activity against the pathogens and their middle-ear concentrations, pharmacokinetics, and pharmacodynamics (PK/PD) 4.

Considerations for Antibiotic Resistance

• The increasing resistance of Streptococcus pneumoniae to penicillin and amoxicillin, as well as the production of beta-lactamases by Haemophilus influenzae and Moraxella catarrhalis, presents a clinical challenge for practitioners in the selection of empiric antimicrobial therapy 3, 5.
• The selection of an antibiotic should consider in vitro activity, particularly against drug-resistant Streptococcus pneumoniae, pharmacokinetics, adverse events, palatability of the suspension, and cost 2.

Alternative Treatment Options

• The newer macrolides, azithromycin and clarithromycin, provide reasonable in vitro coverage against penicillin-resistant S. pneumoniae and beta-lactamase-producing H. influenzae, and achieve notably higher, sustained concentrations in middle ear fluid than do beta-lactam antibiotics 5.
• Cefaclor has been compared to amoxicillin in the treatment of AOM, with similar results in terms of resolution of signs and symptoms 6.