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

From the Guidelines

The treatment for otitis media typically involves antibiotics, pain management, and supportive care, with amoxicillin being the first-line antibiotic, and tympanostomy tubes or adenoidectomy considered for recurrent infections or complications, as recommended by the most recent guidelines 1.

Key Considerations

• The goal of treatment is to eliminate the bacterial infection, reduce inflammation and fluid buildup in the middle ear, and alleviate symptoms such as ear pain and fever.
• Accurate diagnosis of otitis media is crucial to reduce over-diagnosis, overtreatment, and antibiotic resistance, as emphasized in recent literature and guidelines 1.
• Watchful waiting may be appropriate for mild cases in children over 2 years without severe symptoms, but antibiotics should be prescribed for children with severe, persistent, or recurrent infections.

Treatment Options

• Antibiotics: amoxicillin is the first-line antibiotic, usually prescribed at 80-90 mg/kg/day divided into two doses for children or 500 mg three times daily for adults, for 5-10 days depending on severity.
• Pain relief: acetaminophen or ibuprofen can be used to manage ear pain and fever.
• Supportive care: patients should complete the full antibiotic course even if symptoms improve, stay hydrated, and avoid getting water in the ears.
• Additional treatments: tympanostomy tubes or adenoidectomy may be considered for recurrent infections or complications, such as chronic otitis media with effusion or recurrent acute otitis media.

Recent Guidelines

• The 2022 clinical practice guideline on tympanostomy tubes in children recommends the use of tympanostomy tubes for children with chronic otitis media with effusion, recurrent acute otitis media, or both, and emphasizes the importance of balancing the risks and benefits of tube insertion 1.
• The guideline also recommends the use of topical antibiotic therapy for acute tube otorrhea and highlights the potential benefits of tympanostomy tubes in improving quality of life for children with chronic otitis media with effusion or recurrent acute otitis media.

From the FDA Drug Label

From the perspective of evaluating pediatric clinical trials, Days 11 to 14 were considered on-therapy evaluations because of the extended half-life of azithromycin. In a double-blind, controlled clinical study of acute otitis media performed in the United States, azithromycin (10 mg/kg on Day 1 followed by 5 mg/kg on Days 2 to 5) was compared to amoxicillin/clavulanate potassium (4:1). 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. One U.S./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 to 4 days after the completion of therapy) and at the follow-up visit (defined as 22 to 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.

The treatment for otitis media (inflammation of the middle ear) includes:

• Amoxicillin-clavulanate (45/6.4 mg/kg/day every 12 hours or 40/10 mg/kg/day every 8 hours for 10 days) 2
• Azithromycin (10 mg/kg on Day 1 followed by 5 mg/kg on Days 2 to 5) 3 Key points:
• The clinical efficacy rates of amoxicillin-clavulanate and azithromycin are comparable.
• The incidence of diarrhea is lower in patients who received amoxicillin-clavulanate every 12 hours compared to every 8 hours.
• Azithromycin has a lower incidence of treatment-related adverse events, primarily gastrointestinal, compared to amoxicillin/clavulanate potassium.

From the Research

Treatment Options for Otitis Media

The treatment for otitis media (inflammation of the middle ear) has several options, including:

• Relieving pain and controlling fever with salicylates or paracetamol 4
• Using antibiotic therapy, with amoxicillin being the first line treatment for suppurative AOM 4, 5, 6, 7
• Using a combination of amoxicillin and clavulanate for persistent or recurrent AOM 5, 7
• Considering alternative antibiotics such as cefdinir, cefprozil, cefpodoxime, cefuroxime, or ceftriaxone for treatment of AOM 5
• Using a delayed prescribing strategy, where antibiotic therapy is delayed for 48-72 hours after diagnosis, and only initiated if symptoms persist or worsen 6
• Treating pain and watching for improvement, with the option to initiate antibiotic therapy if necessary 6

Specific Treatment Regimens

Specific treatment regimens for otitis media include:

• High-dose amoxicillin (80-100 mg/kg/day) for treatment of bacterial otitis media 5, 6
• Amoxicillin/clavulanate (90/6.4 mg/kg/day) for persistent or recurrent AOM 5
• Azithromycin and acetylcysteine for treatment of chronic otitis media with effusion, with some studies suggesting a combination of these drugs may be useful in treatment 8

Additional Considerations

Additional considerations for treatment of otitis media include:

• The use of strict diagnostic criteria to direct antibiotic treatment to only those patients likely to benefit 6
• The careful use of antibiotic therapy to minimize the development of antibiotic resistance 6
• The potential benefits of vaccinating against influenza and pneumococcus to reduce the incidence of AOM 6