What is the treatment for otitis media?

Treatment of Otitis Media

Amoxicillin is the first-line treatment for uncomplicated acute otitis media, with high-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) recommended for children due to its effectiveness against common pathogens, excellent safety profile, and acceptable taste. 1

Diagnosis and Assessment

Accurate diagnosis is crucial before initiating treatment:

• Acute otitis media (AOM) is characterized by:
  • Acute onset of symptoms
  • Middle ear effusion
  • Physical evidence of middle ear inflammation (bulging tympanic membrane)
  • Symptoms such as pain, irritability, or fever 2
• Isolated redness of the tympanic membrane with normal landmarks is NOT AOM and does not require antibiotics 1
• Otitis media with effusion (OME) generally does not require antibiotics unless it persists beyond 3 months 1

Treatment Algorithm

Step 1: Pain Management

• Pain relief is paramount and should be addressed regardless of antibiotic use 3
• Topical analgesics may be more effective than placebo at reducing ear pain 10-30 minutes after administration 3

Step 2: Initial Management Decision

• For children <6 months with AOM: Immediate antibiotics 3
• For children 6 months-2 years:
  • Severe AOM (moderate to severe otalgia or fever ≥39°C): Immediate antibiotics
  • Non-severe bilateral AOM: Immediate antibiotics
  • Non-severe unilateral AOM: Observation option with symptomatic relief 3
• For children >2 years:
  • Non-severe AOM: Observation option with symptomatic relief
  • Severe symptoms: Immediate antibiotics 3

Step 3: Antibiotic Selection (if indicated)

First-line therapy:

• Children: High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) for 10 days 1, 3
• Adults: Amoxicillin or amoxicillin-clavulanate for 5-7 days 1

Use amoxicillin-clavulanate instead of amoxicillin as first-line in:

• Patients who received amoxicillin in the previous 30 days
• Patients with concurrent purulent conjunctivitis
• Cases requiring coverage for β-lactamase-producing H. influenzae and M. catarrhalis 1

For penicillin allergies:

• 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

Treatment failure:

• If symptoms worsen or fail to improve within 48-72 hours:
  • Reassess to confirm diagnosis
  • If initially managed with observation: Begin antibiotics
  • If initially treated with amoxicillin: Switch to amoxicillin-clavulanate
  • Consider ceftriaxone (50 mg IM or IV for 3 days) for severe cases 1, 3

Special Considerations

Recurrent Acute Otitis Media

• Reduction of risk factors (day care attendance, tobacco smoke exposure)
• Active immunoprophylaxis with pneumococcal conjugate vaccines and influenza vaccine
• Long-term prophylactic antibiotics are discouraged 3

Otitis Media with Effusion

• Watchful waiting initially
• Medical treatment is discouraged
• Surgical intervention (tympanostomy tubes) considered after 3 months with hearing loss or developmental concerns 3

Common Pitfalls to Avoid

1. Overdiagnosis: Isolated redness of the tympanic membrane is not sufficient for AOM diagnosis 1

2. Inadequate pain management: Failing to provide adequate analgesia is a common mistake 1

3. Inappropriate antibiotic selection: Macrolides (azithromycin) should not be used as first-line therapy due to inadequate coverage for common AOM pathogens 1

4. Insufficient dosing: Using standard-dose instead of high-dose amoxicillin may lead to treatment failure with resistant pneumococci 1

5. Premature change of antibiotics: Symptoms may worsen slightly during the first 24 hours of therapy before stabilizing; only change antibiotics if no improvement after 48-72 hours 3

The treatment of otitis media has evolved with increasing bacterial resistance patterns, but amoxicillin remains the cornerstone of therapy for most patients, with specific alternatives for treatment failures or special circumstances.