What is the recommended treatment for otitis media (middle ear infection)?

Treatment of Otitis Media

Amoxicillin is the first-line treatment for acute otitis media (AOM), with high-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) recommended for children and amoxicillin-clavulanate for adults or treatment failures. 1, 2

Diagnosis of Acute Otitis Media

Proper diagnosis is essential before initiating treatment:

• Definitive diagnosis requires:

  • Moderate to severe bulging of the tympanic membrane OR new onset of otorrhea not due to otitis externa 2
  • Mild bulging of the tympanic membrane AND recent onset of ear pain (less than 48 hours) or intense erythema 2

• Not AOM: Isolated redness of the tympanic membrane with normal landmarks does not constitute AOM and does not require antibiotics 1

Treatment Algorithm for Acute Otitis Media

Initial Management:

1. Pain management is essential regardless of antibiotic use 1

   • Topical analgesics can reduce ear pain within 10-30 minutes 1

2. Antibiotic therapy decisions based on age and severity:

   • Children <6 months: Always prescribe antibiotics 2

   • Children 6-23 months:

     • Bilateral AOM: Prescribe antibiotics 2
     • Unilateral AOM without severe symptoms: Consider observation or antibiotics based on joint decision-making with parents 2

   • Children ≥24 months without severe symptoms: Consider observation or antibiotics based on joint decision-making with parents 2

   • Any age with severe symptoms (moderate to severe otalgia, otalgia >48 hours, or temperature ≥39°C): Always prescribe antibiotics 2

3. Observation approach (when appropriate):

   • Symptomatic relief only
   • Begin antibiotics if symptoms worsen or don't improve within 48-72 hours 2
   • Ensure follow-up mechanism is in place 2

Antibiotic Selection:

1. First-line therapy:

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

2. Second-line therapy (for treatment failures, recent amoxicillin use within 30 days, concurrent purulent conjunctivitis, or history of recurrent AOM unresponsive to amoxicillin):

   • Amoxicillin-clavulanate 2, 1
   • Cephalosporins: cefuroxime axetil, cefpodoxime proxetil, cefdinir 1
   • Intramuscular ceftriaxone (50 mg/kg) for severe cases or expected noncompliance 2

3. For penicillin allergies:

   • Cephalosporins (if no severe/recent penicillin allergy history) 1
   • Respiratory fluoroquinolones in adults only 1
   • Avoid macrolides like azithromycin due to inadequate coverage for common AOM pathogens 1

Treatment Failure Management:

1. Reassess within 48-72 hours if symptoms worsen or fail to improve 2, 1

2. For persistent symptoms with unimproved otologic findings:

   • If initially treated with amoxicillin, switch to amoxicillin-clavulanate 2
   • If initially treated with amoxicillin-clavulanate or oral cephalosporins, consider intramuscular ceftriaxone 2
   • For multiple antibiotic failures, consider tympanocentesis for culture and susceptibility testing 2

3. When tympanocentesis is unavailable:

   • Consider clindamycin (with or without coverage for H. influenzae and M. catarrhalis) 2
   • For multidrug-resistant cases, consultation with specialists may be needed 2

Special Considerations

• Otorrhea with tympanostomy tubes: Use topical antibiotic drops (e.g., ciprofloxacin) as first-line treatment 1

• Follow-up: Not routinely needed after clinical improvement unless the patient is young, had severe symptoms, or has recurrent AOM 2

• Middle ear effusion: Common after AOM resolution (60-70% at 2 weeks, 40% at 1 month, 10-25% at 3 months) and doesn't require antibiotics 2

Common Pitfalls to Avoid

1. Inadequate pain management: Always address pain regardless of antibiotic use 1

2. Using antibiotics with inadequate coverage against common pathogens (e.g., macrolides, doxycycline) 1, 3

3. Premature change of antibiotics: Symptoms may worsen slightly during first 24 hours before improving 1

4. Treating isolated redness of tympanic membrane with normal landmarks as AOM 1

5. Failing to differentiate between AOM and otitis media with effusion (OME), which doesn't require antibiotics 2