What are the recommended antibiotics for treating ear infections, specifically acute otitis media (AOM)?

From the Guidelines

The first-line antibiotic treatment for acute otitis media (AOM) is amoxicillin at a dose of 80-90 mg/kg/day divided into two doses for 5-10 days, with the longer duration typically recommended for children under 2 years old or those with severe symptoms. This recommendation is based on the most recent and highest quality study available, which suggests that amoxicillin is effective against the most common bacterial pathogens in AOM, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1.

For patients with penicillin allergy, alternatives include cefdinir, cefpodoxime, or cefuroxime, as these medications have a low risk of cross-reactivity with penicillin 1. In cases of treatment failure after 48-72 hours, or for patients with recurrent infections, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) is recommended due to increased beta-lactamase producing bacteria 1.

Some key points to consider when treating AOM include:

• Pain management with acetaminophen or ibuprofen is also important during treatment
• Some mild cases in children over 2 years without severe symptoms may be managed with watchful waiting for 48-72 hours before starting antibiotics, as many ear infections are viral and resolve without antibiotics
• The choice of antibiotic should be based on the anticipated clinical response and the microbiologic flora likely to be present 1
• The optimal duration of therapy for patients with AOM is uncertain, but a 5-10 day course is typically recommended 1

It's worth noting that the evidence suggests that many patients who present with a history of penicillin allergy do not have an immunologic reaction to penicillin, and that the risk of cross-reactivity between penicillins and cephalosporins is lower than historically reported 1. However, caution should still be exercised when prescribing antibiotics to patients with a history of penicillin allergy.

From the FDA Drug Label

The combined clinical success rate (i.e., cure and improvement) at the Day 11 visit was 88% for azithromycin and 88% for the control agent. For the 521 patients who were evaluated at the Day 30 visit, the clinical success rate was 73% for azithromycin and 71% for the control agent

The following clinical success rates were obtained from the evaluable group: Day 11 Day 30 Pathogen Azithromycin Azithromycin S. pneumoniae 61/74 (82%) 40/56 (71%) H. influenzae 43/54 (80%) 30/47 (64%) M. catarrhalis 28/35 (80%) 19/26 (73%) S pyogenes 11/11 (100%) 7/7 (100%) Overall 177/217 (82%) 97/137 (73%)

The recommended antibiotics for treating ear infections, specifically acute otitis media (AOM), include:

• Azithromycin: given over 5 days (10 mg/kg on Day 1 followed by 5 mg/kg on Days 2 to 5) with a clinical success rate of 88% at Day 11 and 73% at Day 30
• Amoxicillin/clavulanate: with a clinical success rate of 88% at Day 11 and 71% at Day 30 2

Key points:

• Azithromycin and amoxicillin/clavulanate have similar clinical success rates for AOM
• The choice of antibiotic may depend on the specific pathogen and patient factors 2

From the Research

Recommended Antibiotics for Acute Otitis Media (AOM)

The following antibiotics are recommended for treating ear infections, specifically AOM:

• Amoxicillin at conventional or high doses (80-90 mg/kg/day) as a first-line therapy 3
• Amoxicillin/clavulanate as a second-line therapy, especially for patients with penicillin-resistant S. pneumoniae or beta-lactamase-producing pathogens 3, 4
• Ceftriaxone as a second-line therapy, particularly for severe cases or patients with suspected noncompliance 3, 4
• Other options, such as cefuroxime axetil, cefprozil, and cefpodoxime proxetil, may also be considered as second-line therapies 4

Bacteriologic Efficacy of Antibiotics

Studies have compared the bacteriologic efficacy of different antibiotics in treating AOM:

• Amoxicillin/clavulanate was found to be more effective than azithromycin in eradicating bacterial pathogens, including Haemophilus influenzae and Streptococcus pneumoniae, from middle ear fluid 5
• Amoxicillin/clavulanate was also more likely to resolve signs and symptoms of AOM, particularly in patients with H. influenzae infections 5
• Another study found that amoxicillin-clavulanate had high success rates for both S. pneumoniae and H. influenzae, although the difference between success rates was not statistically significant 6

Clinical Efficacy of Antibiotics

The clinical efficacy of antibiotics in treating AOM has also been studied:

• Amoxicillin/clavulanate was found to have superior clinical efficacy compared to azithromycin in children with AOM, with higher rates of complete resolution or improvement of signs and symptoms 5
• Another study found that the clinical response rates were better in patients treated with amoxicillin-clavulanate, although the difference was not statistically significant 6