What antibiotic is recommended for treating an ear infection, specifically acute otitis media (AOM)?

Antibiotic Treatment for Acute Otitis Media

First-line treatment for acute otitis media (AOM) is high-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 5-7 days. 1

First-Line Treatment Options

• High-dose amoxicillin: 80-90 mg/kg/day divided twice daily for 5-7 days

  • Preferred first-line therapy due to safety and efficacy against most causative pathogens
  • Targets common AOM pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

• Amoxicillin-clavulanate: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate

  • Indicated when patient has received amoxicillin in the past 30 days
  • Recommended for patients with concurrent conjunctivitis
  • Provides coverage against beta-lactamase producing organisms 1
  • Clinical trials show comparable efficacy between twice daily and three times daily dosing 2

Alternative Treatment Options for Penicillin Allergy

For patients with penicillin allergy, several alternatives are available:

• Cephalosporins (if no cross-reactivity with penicillins):

  • Cefdinir: 300 mg twice daily for 5-7 days
  • Cefuroxime: 500 mg twice daily for 5-7 days
  • Cefpodoxime: 200 mg twice daily for 5-7 days 1

• Clindamycin: 30-40 mg/kg/day in 3 divided doses 1

• Respiratory fluoroquinolones (for adults with severe penicillin allergy):

  • Levofloxacin: 10 mg/kg twice daily for children 6 months and older (up to 500 mg per dose) for 5-7 days
  • Reserved for severe allergies, recurrent/persistent otitis media, confirmed multidrug-resistant pathogens, or treatment failures 1

• Azithromycin: For pediatric patients with AOM, 30 mg/kg as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on day 1 followed by 5 mg/kg/day on days 2-5 3

Treatment Approach Algorithm

1. Confirm diagnosis of AOM by identifying:

   • Moderate to severe bulging of tympanic membrane OR
   • New onset otorrhea OR
   • Mild bulging with recent onset ear pain or intense erythema
   • Accompanying symptoms: pain, irritability, or fever

2. Initiate pain management:

   • Acetaminophen or ibuprofen for symptom relief

3. Select appropriate antibiotic:

   • Standard case: High-dose amoxicillin
   • Recent amoxicillin use (within 30 days) or concurrent conjunctivitis: Amoxicillin-clavulanate
   • Penicillin allergy: Select appropriate alternative based on allergy severity and patient factors

4. Monitor treatment response:

   • If no improvement after 72 hours, reevaluate and consider switching antibiotics
   • Follow up within 48-72 hours if symptoms persist or worsen

Important Clinical Considerations

• The American Academy of Pediatrics recommends high-dose amoxicillin over standard-dose due to increasing prevalence of drug-resistant bacteria, although research has shown similar efficacy in low-risk populations 4

• Diarrhea is a common side effect of amoxicillin-clavulanate, with clinical trials showing 14-15% incidence with twice daily dosing 2

• For patients with tympanostomy tubes and visible drainage, topical antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) are preferred over oral antibiotics 1

• Consider probiotic supplements to reduce gastrointestinal side effects of antibiotics 1

• Be vigilant for rare complications such as mastoiditis, which may require more aggressive intervention 1

• Consider referral if recurrent episodes (3+ in 6 months or 4+ in 12 months) occur 1