What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/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, and narrow microbiologic spectrum. 1

Diagnosis Criteria

Before initiating treatment, ensure accurate diagnosis of acute otitis media (AOM), which requires:

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

Specifically look for:

• 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 for:
  • Children <2 years: 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

Alternative First-line Treatment (Special Circumstances)

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) for:
  • Children who have taken amoxicillin in the previous 30 days
  • Children with concurrent conjunctivitis
  • When coverage for M. catarrhalis is desired 1

For Penicillin Allergy (non-Type I hypersensitivity)

• 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 1

For Type I Penicillin Allergy

• Azithromycin: 10 mg/kg on day 1, followed by 5 mg/kg on days 2-5 2
• Clarithromycin (alternative)

Treatment Failure (48-72 hours after initial therapy)

1. Reassess to confirm AOM diagnosis and exclude other causes
2. If initially treated with observation, begin antibacterial therapy
3. If initially treated with amoxicillin, switch to:
   • Amoxicillin-clavulanate: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate
   • Ceftriaxone: 50 mg IM or IV for 3 days 1

Severe Treatment Failure

For patients failing second-line therapy:

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

Pain Management

Pain management should be addressed regardless of whether antibiotics are prescribed:

• Acetaminophen or ibuprofen for pain relief
• Topical benzocaine drops may provide temporary relief 1

Observation Option

In certain cases, observation without immediate antibiotics may be considered:

• Children ≥2 years with non-severe symptoms or uncertain diagnosis
• Children 6 months to 2 years with non-severe illness and uncertain diagnosis
• Must ensure follow-up within 48-72 hours 1

Follow-up Considerations

• Routine follow-up visits are not necessary for all children with AOM
• Reassessment is recommended for:
  • Young children with severe symptoms
  • Children with recurrent AOM
  • When specifically requested by parents 1

Common Pitfalls to Avoid

1. Misdiagnosis: Differentiating AOM from otitis media with effusion (OME) is crucial. OME is defined as middle ear effusion without clinical symptoms and does not require antibiotics 1

2. Inappropriate antibiotic selection: Using broad-spectrum antibiotics as first-line treatment contributes to antibiotic resistance

3. Inadequate dosing: Underdosing amoxicillin (using standard rather than high-dose) may lead to treatment failure with resistant S. pneumoniae 3

4. Overlooking pain management: Pain control should be addressed regardless of antibiotic use 1

5. Overtreatment of persistent effusion: Persistent middle ear effusion is common (60-70% at 2 weeks post-treatment) and does not require additional antibiotics 1

High-dose amoxicillin remains the cornerstone of AOM treatment due to its effectiveness against S. pneumoniae, including intermediately resistant strains. The higher dose ensures adequate middle ear fluid levels that exceed the minimum inhibitory concentration for longer periods, improving both bacteriologic and clinical efficacy 1.