What is the treatment for acute otitis media?

Treatment for Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg per day in 2 divided doses) is the 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 crucial and requires:

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

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

Step 1: Pain Management

• Address pain regardless of antibiotic use, especially during the first 24 hours 1
• Use appropriate analgesics (acetaminophen or ibuprofen) based on age and weight

Step 2: Antibiotic Decision

Based on age, severity, and diagnostic certainty:

For Most Patients:

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

Special Circumstances:

• For patients who have taken amoxicillin in previous 30 days: High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1
• For patients with concurrent conjunctivitis: High-dose amoxicillin-clavulanate 1
• For patients requiring coverage for M. catarrhalis: High-dose amoxicillin-clavulanate 1

For Penicillin-Allergic Patients:

• Cefdinir (14 mg/kg/day in 1-2 doses)
• Cefuroxime (30 mg/kg/day in 2 divided doses)
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 1

Step 3: Duration of Therapy

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

Step 4: Treatment Failure Management

If no improvement after 48-72 hours:

1. Reassess to confirm diagnosis and exclude other causes
2. For initial observation: Begin antibacterial therapy
3. For initial amoxicillin: Switch to amoxicillin-clavulanate
4. For initial amoxicillin-clavulanate: Consider ceftriaxone (50 mg IM or IV for 3 days) 1

Bacterial Pathogens and Resistance Considerations

The most common pathogens in AOM are:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis 1, 2

High-dose amoxicillin is effective because:

• It achieves middle ear fluid levels that exceed the minimum inhibitory concentration of intermediately resistant S. pneumoniae
• It has demonstrated improved bacteriologic and clinical efficacy compared to regular-dose amoxicillin 1

Common Pitfalls to Avoid

1. Misdiagnosis: Distinguishing acute otitis media from otitis media with effusion is critical to avoid unnecessary antibiotic use 2

2. Inadequate dosing: Using standard-dose instead of high-dose amoxicillin may lead to treatment failure with resistant organisms 3

3. Inappropriate follow-up: Once clinical improvement occurs, routine follow-up is not necessary for all children but may be considered for young children with severe symptoms or recurrent AOM 1

4. Overlooking persistent middle ear effusion: 60-70% of children will have middle ear effusion 2 weeks after successful antibiotic treatment, decreasing to 40% at 1 month and 10-25% at 3 months. This is normal and does not require additional antibiotics 1

5. Unnecessary antibiotic switches: Some worsening may occur in the first 24 hours of therapy, but patients should stabilize within this period and begin improving during the second 24 hours 1

High-dose amoxicillin remains the most appropriate first-line therapy for AOM, with amoxicillin-clavulanate as the second-line agent when treatment fails or when specific risk factors are present.