What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg per day in 2 divided doses) is the recommended first-line treatment for acute otitis media in most patients due to its effectiveness against common bacterial pathogens, safety, low cost, acceptable taste, and narrow microbiologic spectrum. 1

Diagnosis of Acute Otitis Media

Accurate diagnosis is essential and requires:

• History of acute onset of signs and symptoms
• Presence of middle ear effusion
• Signs of middle ear inflammation 1

Specific diagnostic criteria include:

• Bulging of the tympanic membrane
• Limited or absent mobility of the tympanic membrane
• Air-fluid level behind the tympanic membrane
• Otorrhea
• Distinct erythema of the tympanic membrane 1

Treatment Algorithm

First-line Treatment

• High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) 1

Alternative First-line Treatment (in specific situations)

• High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) should be used in:
  • Children who have taken amoxicillin in the previous 30 days
  • Patients with concurrent conjunctivitis
  • Cases where coverage for Moraxella catarrhalis is desired 1

For Penicillin-Allergic Patients

• Cefdinir (14 mg/kg/day in 1 or 2 doses)
• Cefuroxime (30 mg/kg/day in 2 divided doses)
• Cefpodoxime (10 mg/kg/day in 2 divided doses)
• Ceftriaxone (50 mg IM or IV per day for 1 or 3 days) 1

Treatment Failure (48-72 hours after initial treatment)

If no improvement after 48-72 hours:

• If initially treated with observation: Begin antibacterial therapy
• If initially treated with amoxicillin: Switch to amoxicillin-clavulanate
• If initially treated with amoxicillin-clavulanate: Consider ceftriaxone (50 mg IM or IV for 3 days) 1

Second Treatment Failure

• Consider clindamycin (30-40 mg/kg/day in 3 divided doses) with or without a third-generation cephalosporin
• Consider tympanocentesis/drainage if skilled in the procedure or refer to otolaryngologist 1

Duration of Therapy

• Children <2 years and those with severe symptoms: 10-day course
• Children 2-5 years with mild/moderate AOM: 7-day course
• Children ≥6 years with mild/moderate AOM: 10-day course 1

Pain Management

Pain management is essential, especially during the first 24 hours, regardless of whether antibiotics are prescribed 1

Special Considerations

Observation Option

In certain cases, observation without immediate antibiotics for 48-72 hours may be appropriate:

• Children ≥6 months to 2 years with non-severe illness and uncertain diagnosis
• Children ≥2 years without severe symptoms or with uncertain diagnosis 1

Cross-reactivity with Cephalosporins

The risk of cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported. Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin due to their distinct chemical structures 1

Follow-up

• Routine 10-14 day reevaluation is not necessary for all children
• Persistent middle ear effusion (MEE) is common after successful treatment (60-70% at 2 weeks, 40% at 1 month, 10-25% at 3 months)
• MEE without clinical symptoms is defined as otitis media with effusion (OME) and does not require antibiotics 1

Common Pitfalls

1. Overdiagnosis: Differentiating AOM from otitis media with effusion is crucial to avoid unnecessary antibiotic use
2. Inadequate dosing: Using standard-dose instead of high-dose amoxicillin may lead to treatment failure against intermediately resistant pneumococci
3. Failure to reassess: Not reevaluating patients who fail to improve within 48-72 hours
4. Inappropriate antibiotic selection: Not considering recent antibiotic use or local resistance patterns

By following this evidence-based approach to diagnosis and treatment, clinicians can effectively manage acute otitis media while minimizing complications and reducing unnecessary antibiotic use.