What is the recommended antibiotic (abx) treatment for otitis media?

From the Guidelines

The recommended first-line antibiotic treatment for acute otitis media is amoxicillin at a dose of 80-90 mg/kg/day divided twice daily. This recommendation is based on the most recent and highest quality study available, which prioritizes the use of amoxicillin due to its effectiveness against common AOM bacterial pathogens, safety, low cost, acceptable taste, and narrow microbiologic spectrum 1.

Key Considerations

• For patients with penicillin allergy, alternatives include amoxicillin-clavulanic acid as a second choice, as recommended by the Expert Committee 1.
• The use of cefuroxime and ceftriaxone is not recommended as first-line treatment for severe otitis media, in order to reduce unnecessary antibiotic use and favor oral options over intravenous and intramuscular treatments 1.
• Pain management with acetaminophen or ibuprofen should also be provided to alleviate symptoms.

Treatment Approach

• The approach targets the most common pathogens in otitis media, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
• Treatment should be initiated promptly to prevent complications such as mastoiditis, hearing loss, or tympanic membrane perforation.

Evidence-Based Recommendations

• The recommendations are based on the latest guidelines and studies, including the WHO's Essential Medicines and Aware: Recommendations on First- and Second-Choice Antibiotics for Empiric Treatment of Clinical Infections 1.
• The use of amoxicillin as first-line treatment is supported by trial evidence and existing guidelines, making it a reasonable and effective choice for the treatment of acute otitis media.

From the FDA Drug Label

One US/Canadian clinical trial was conducted which compared 45/6. 4 mg/kg/day (divided every 12 hours) of amoxicillin and clavulanate potassium for 10 days versus 40/10 mg/kg/day (divided every 8 hours) of amoxicillin and clavulanate potassium for 10 days in the treatment of acute otitis media. The clinical efficacy rates at the end of therapy visit (defined as 2-4 days after the completion of therapy) and at the follow-up visit (defined as 22-28 days post-completion of therapy) were comparable for the 2 treatment groups, with the following cure rates obtained for the evaluable patients: At end of therapy, 87% (n = 265) and 82% (n = 260) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively. At follow-up, 67% (n = 249) and 69% (n = 243) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively.

The recommended antibiotic treatment for otitis media is amoxicillin-clavulanate. The dosage can be either 45 mg/kg/day every 12 hours or 40 mg/kg/day every 8 hours for 10 days, with comparable cure rates for both regimens 2. Diarrhea was reported as an adverse event, with a lower incidence in the every 12 hours regimen (14%) compared to the every 8 hours regimen (34%) 2.

From the Research

Otitis Media ABX Treatment

• The recommended antibiotic treatment for otitis media is amoxicillin as the first-line agent to treat uncomplicated acute otitis media (AOM) 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 3.
• High dose (70 to 90 mg/kg/day) amoxicillin is recommended as first line therapy of acute otitis media (AOM) in geographic areas where drug-resistant Streptococcus pneumoniae is prevalent 4.
• Amoxicillin remains the standard antibiotic for acute otitis media in children, but its use is justified in certain situations only 5.
• For patients who are allergic to penicillin, a macrolide such as erythromycin, or cotrimoxazole, appear to be acceptable first-line alternatives 5.
• Delaying the decision about antibacterial treatment by 72 hours in children with acute otitis media does no harm, and if the decision is delayed, three quarters of children avoid antibacterial therapy altogether 5.
• Patients get no extra benefit from extending treatment beyond 5 to 7 days, and prolonged treatment, and the use of low doses are risk factors for subsequent carriage of resistant bacteria 5.
• For routine empirical treatment of uncomplicated acute otitis media, amoxicillin is the drug of choice, and persistence of signs and symptoms of infection during antimicrobial therapy calls for a change to an antibiotic effective against beta-lactamase-producing bacteria 6.
• High-dose versus standard-dose amoxicillin for acute otitis media showed that high-dose amoxicillin had neither benefit nor detriment compared with standard-dose for AOM in children at low risk for infection with antibiotic-resistant bacteria 7.