Treatment Duration for Acute Otitis Media
For acute otitis media (AOM), a 10-day course of amoxicillin is recommended for children younger than 2 years and for children with severe symptoms, while a 7-day course is sufficient for children 2-5 years of age with mild to moderate AOM. 1
Age-Based Treatment Duration Algorithm
Children Younger Than 2 Years
- Duration: 10 days of antibiotic therapy
- Rationale: Several studies favor standard 10-day therapy over shorter courses for this age group
- Dosage: Amoxicillin 80-90 mg/kg/day 1
Children 2-5 Years of Age with Mild/Moderate AOM
- Duration: 7 days of antibiotic therapy
- Rationale: A 7-day course appears equally effective as 10 days in this age group 1
- Dosage: Amoxicillin 80-90 mg/kg/day 1
Children 6 Years and Older with Mild/Moderate AOM
- Duration: 10 days of antibiotic therapy
- Rationale: Standard recommendation for this age group 1
- Dosage: Amoxicillin 80-90 mg/kg/day 1
First-Line Antibiotic Selection
Amoxicillin remains the first-line antibiotic of choice for AOM when:
- The child has not received amoxicillin in the past 30 days
- The child does not have concurrent purulent conjunctivitis
- The child is not allergic to penicillin 1
Dosing Considerations
- Standard dose: 80-90 mg/kg/day divided into 2-3 doses 1, 2
- Treatment should continue for a minimum of 48-72 hours beyond the time the patient becomes asymptomatic 2
Special Considerations
When to Use Alternative Antibiotics
Use antibiotics with additional β-lactamase coverage when:
- Child has received amoxicillin in the past 30 days
- Child has concurrent purulent conjunctivitis
- Child has a history of recurrent AOM unresponsive to amoxicillin 1
Follow-up Assessment
- Reassess the patient if symptoms worsen or fail to respond to initial antibiotic treatment within 48-72 hours 1
- Routine 10-14 day reevaluation visit is not scientifically supported for all children with AOM 1
Recent Evidence on Treatment Duration
Recent research suggests that 10-day regimens may be unnecessarily long in many cases. A 2024 systematic review and network meta-analysis found that:
- 7-day regimens of amoxicillin were noninferior to 10-day regimens in clinical responses for children over 2 years
- 5-day regimens were inferior to 10-day regimens
- Children ≤2 years still benefit from the full 10-day course 3
Common Pitfalls to Avoid
Undertreating young children: Children under 2 years require the full 10-day course to prevent treatment failure
Overprescribing antibiotics: For children over 2 years with mild symptoms, a 7-day course is typically sufficient
Ignoring persistent symptoms: If symptoms worsen or don't improve within 48-72 hours, reassessment is necessary to determine if a change in therapy is needed
Failing to recognize middle ear effusion: Persistent middle ear effusion (MEE) is common after AOM treatment (60-70% at 2 weeks, 40% at 1 month) and should not be confused with treatment failure 1
Inappropriate follow-up: Follow-up should be based on clinical course rather than routine visits for all patients 1
By following these evidence-based guidelines for treatment duration, clinicians can effectively manage AOM while minimizing unnecessary antibiotic exposure and the risk of developing antimicrobial resistance.