Treatment of Otitis Media
The first-line treatment for acute otitis media is high-dose amoxicillin (80-90 mg/kg/day divided in two doses) for 5-10 days, with pain management using acetaminophen or ibuprofen as an essential component regardless of antibiotic decision. 1
Diagnosis
Accurate diagnosis of acute otitis media (AOM) requires all of the following:
- History of acute onset of signs and symptoms
- Presence of middle ear effusion
- Signs of middle ear inflammation 2
Physical findings that predict AOM include:
- Bulging or fullness of the tympanic membrane
- Limited or absent mobility of the tympanic membrane
- Air-fluid level behind the tympanic membrane
- Otorrhea 2
Treatment Algorithm
1. Pain Management
- Always address pain first, regardless of antibiotic decision
- Options:
- Acetaminophen or ibuprofen for systemic pain relief
- Consider topical analgesics for additional relief 1
2. Antibiotic Decision
Based on age, symptom severity, and diagnostic certainty:
Immediate Antibiotic Therapy for:
- Children under 6 months of age
- Children 6-23 months with severe symptoms (moderate to severe otalgia, otalgia for ≥48 hours, or temperature ≥39°C)
- Children with bilateral AOM regardless of severity
- Children with tympanic membrane perforation 1
Observation Option (48-72 hours) for:
- Children 6-23 months with unilateral AOM without severe symptoms
- Children ≥24 months with bilateral or unilateral AOM without severe symptoms 1
3. Antibiotic Selection
| Clinical Scenario | Recommended Treatment |
|---|---|
| First episode/no recent amoxicillin | Amoxicillin 80-90 mg/kg/day divided twice daily |
| Recent amoxicillin use (within 30 days) | Amoxicillin-clavulanate |
| Treatment failure with amoxicillin | Amoxicillin-clavulanate |
| Penicillin allergy (non-type I) | Cefdinir, cefuroxime, or cefpodoxime |
| Penicillin allergy (type I) | Consider macrolide or consult specialist |
4. Duration of Therapy
- Children <2 years: 10 days
- Children ≥2 years with mild/moderate disease: 5-7 days 1
Pathogen Considerations
The main bacterial pathogens in AOM are:
- Streptococcus pneumoniae
- Haemophilus influenzae (often beta-lactamase producing)
- Moraxella catarrhalis 3
High-dose amoxicillin (80-90 mg/kg/day) is effective against most S. pneumoniae strains, including those with intermediate penicillin resistance 3. However, beta-lactamase-producing H. influenzae and M. catarrhalis may require amoxicillin-clavulanate for effective treatment 3.
Management of Treatment Failure
If symptoms persist or worsen after 48-72 hours of initial therapy:
- Reassess the diagnosis
- Switch to a second-line agent:
Recurrent and Persistent Otitis Media
For children with recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months):
- Consider referral for tympanocentesis tubes
- Evaluate for risk factors (daycare attendance, smoke exposure)
- Ensure pneumococcal and influenza vaccination 1
Common Pitfalls to Avoid
Overdiagnosis: Ensure accurate differentiation between AOM and otitis media with effusion (OME). OME does not require antibiotics 5.
Inadequate pain management: Always address pain regardless of antibiotic decision 1.
Inappropriate antibiotic selection: First-generation cephalosporins like cephalexin have poor coverage for H. influenzae and should not be used as first-line therapy 1.
Reliance on macrolides: Macrolides (e.g., azithromycin) have poor efficacy against S. pneumoniae due to increasing resistance and should not be first-line therapy 1.
Failure to recognize persistent middle ear effusion: Effusion commonly persists after successful treatment (60-70% at 2 weeks, 40% at 1 month) and does not necessarily indicate treatment failure if symptoms have resolved 1.
By following this evidence-based approach to diagnosing and treating otitis media, clinicians can optimize outcomes while minimizing unnecessary antibiotic use and its associated risks.