What is the treatment for acute otitis media (AOM) in pediatric patients?

From the Guidelines

The treatment of acute otitis media (AOM) in pediatric patients typically begins with pain management using acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours), and antibiotics are often prescribed, with amoxicillin as the first-line treatment at 80-90 mg/kg/day divided twice daily for 5-10 days. For acute otitis media, the choice of antibiotic and duration of therapy depends on the severity of symptoms, age of the child, and whether the child has received antibiotics in the past 30 days or has concurrent conjunctivitis. According to the American Academy of Pediatrics 1, the diagnosis and management of AOM should be based on the use of pneumatic otoscopy and the consideration of the child's overall condition, including the presence of otorrhea, unilateral or bilateral AOM, and the child's age. The use of amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) is preferred if the child has received antibiotics in the past 30 days or has concurrent conjunctivitis, and alternatives such as cefdinir, cefuroxime, or azithromycin can be used for penicillin-allergic patients. In some cases of mild symptoms in children over 2 years, a watchful waiting approach for 48-72 hours may be appropriate before starting antibiotics, as suggested by the study by Hoberman et al 1. For recurrent otitis media, preventive strategies include pneumococcal vaccination, avoiding passive smoke exposure, and in some cases, tympanostomy tubes may be considered if the child experiences 3 episodes in 6 months or 4 episodes in 12 months. The management of pain, especially during the first 24 hours of an episode of AOM, should be addressed regardless of the use of antibiotics, and analgesics such as acetaminophen or ibuprofen can be used to relieve pain associated with AOM, as recommended by the American Academy of Pediatrics 1. Key points to consider in the treatment of AOM include:

• The use of pneumatic otoscopy to diagnose AOM
• The consideration of the child's overall condition, including the presence of otorrhea, unilateral or bilateral AOM, and the child's age
• The use of amoxicillin as the first-line treatment for AOM
• The consideration of alternative antibiotics for penicillin-allergic patients
• The use of a watchful waiting approach for mild symptoms in children over 2 years
• The importance of pain management, especially during the first 24 hours of an episode of AOM. The American Academy of Pediatrics recommends that clinicians use a validated symptom scale, such as the AOM-SOS, to assess the severity of symptoms and to monitor the child's response to treatment 1. In addition, the use of Web-based educational resources, such as the ePROM program, can help clinicians improve their skills in diagnosing and managing AOM 1. Overall, the treatment of AOM in pediatric patients requires a comprehensive approach that takes into account the child's overall condition, the severity of symptoms, and the potential risks and benefits of antibiotic therapy, as well as the importance of pain management and preventive strategies.

From the FDA Drug Label

Pediatric Patients Azithromycin for oral suspension can be taken with or without food. Acute Otitis Media The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

The treatment for acute otitis media (AOM) in pediatric patients is azithromycin for oral suspension at a dose of:

• 30 mg/kg as a single dose
• 10 mg/kg once daily for 3 days
• 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5 2

From the Research

Treatment Options for Acute Otitis Media (AOM) in Pediatric Patients

• The first-line treatment for uncomplicated AOM is amoxicillin 3, 4, 5
• For clinical treatment failures after 3 days of amoxicillin, recommended antimicrobial agents include:
  • Oral amoxicillin/clavulanate
  • Cefuroxime axetil
  • Cefprozil
  • Cefpodoxime proxetil
  • Intramuscular (i.m.) ceftriaxone 3
• I.m. ceftriaxone should be reserved for severe cases or patients in whom noncompliance is expected 3
• Cephalosporins, such as cefuroxime axetil, cefdinir, and cefpodoxime proxetil, offer an alternative to penicillins and have a broad spectrum of activity 4
• The preferred therapeutic agents for AOM caused by Streptococcus pneumoniae are amoxicillin and the amoxicillin-clavulanate combination, while oral cephalosporin is preferred for AOM due to Moraxella catarrhalis and Haemophilus influenzae 5

Antibiotic Resistance and Treatment Guidelines

• Antibiotic resistance to pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, is a growing concern 4
• The Centers for Disease Control and the American Academy of Pediatrics promote the judicious use of antibiotics in the treatment of AOM 4
• Treatment guidelines emphasize the importance of distinguishing AOM from otitis media with effusion, minimizing the use of antibiotics, and discerning between first- and second-line antibiotics in the treatment of simple uncomplicated AOM versus non-responsive/recurrent AOM 4

Comparison of Antibiotic Treatments

• A study comparing amoxicillin/clavulanate with azithromycin for the treatment of bacterial AOM in children found that amoxicillin/clavulanate was clinically and bacteriologically more effective 6
• Amoxicillin/clavulanate eradicated 96.0% of Streptococcus pneumoniae and 89.7% of Haemophilus influenzae, while azithromycin eradicated 80.4% of Streptococcus pneumoniae and 49.1% of Haemophilus influenzae 6