What is the recommended treatment for bilateral acute otitis media?

From the Guidelines

The recommended treatment for bilateral acute otitis media typically involves antibiotics, with amoxicillin as the first-line therapy at a dose of 80-90 mg/kg/day divided twice daily for 10 days, as supported by the most recent and highest quality study 1.

Key Considerations

• Bilateral infections generally warrant antibiotic treatment due to lower spontaneous resolution rates and higher risk of complications such as hearing loss or speech delays if inadequately treated.
• For patients with penicillin allergy, alternatives include azithromycin (10 mg/kg on day 1, then 5 mg/kg for 4 more days) or clarithromycin (15 mg/kg/day divided twice daily for 10 days) 1.
• In cases of treatment failure or severe infection, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) may be used, as recommended by the Expert Committee 1.

Pain Management and Follow-up

• Pain management is essential and can include acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) 1.
• Follow-up within 2-3 weeks is recommended to ensure resolution of the infection, as suggested by the American Academy of Pediatrics 1.

Rationale

• The choice of antibiotic should be based on the anticipated clinical response and the microbiologic flora likely to be present, with amoxicillin being the preferred first-line treatment due to its efficacy, safety, and narrow microbiologic spectrum 1.
• The most recent study 1 supports the use of amoxicillin as the first-line therapy, with amoxicillin-clavulanic acid as a second-choice option, emphasizing the importance of evidence-based treatment for bilateral acute otitis media.

From the FDA Drug Label

ACUTE BACTERIAL OTITIS MEDIA Caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase producing strains) or Moraxella catarrhalis (including beta-lactamase producing strains). 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.

The recommended treatment for bilateral acute otitis media is:

• Azithromycin: 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 2
• Ceftriaxone: may be used as an alternative, but the exact dosage is not specified for bilateral acute otitis media, however, it is indicated for the treatment of acute bacterial otitis media caused by susceptible organisms 3

From the Research

Treatment Options for Bilateral Acute Otitis Media

• The recommended treatment for bilateral acute otitis media includes high-dose amoxicillin (80 to 90 mg/kg/d divided twice daily) as the first line of treatment 4.
• For patients who do not respond to amoxicillin, alternative options include high-dose amoxicillin/clavulanate (90/6.4 mg/kg/d), cefdinir, cefprozil, cefpodoxime, cefuroxime, or ceftriaxone 4, 5.
• Amoxicillin/clavulanate has been shown to be effective in eradicating bacterial pathogens, including Streptococcus pneumoniae and Haemophilus influenzae, in patients with acute otitis media 6, 7.
• The use of amoxicillin/clavulanate is supported by its favorable pharmacokinetic/pharmacodynamic profile and its ability to cover beta-lactamase-producing pathogens 8.

Considerations for Treatment

• The choice of antibiotic should be based on the severity of the infection, the patient's age and weight, and the presence of any underlying medical conditions 5.
• The use of tympanocentesis may be beneficial in identifying the causative pathogen and guiding treatment decisions 5, 6.
• The pneumococcal conjugate vaccine has been shown to be effective in preventing recurrent acute otitis media and should be administered to all children less than 2 years old and those at risk for recurrent AOM 5.