What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day divided in 2 doses) is the first-line treatment for acute otitis media, with treatment duration of 10 days for children under 2 years and 5-7 days for older children and adults. 1

Diagnosis Criteria

Accurate diagnosis is essential before initiating treatment. Acute otitis media (AOM) requires:

1. History of acute onset of signs and symptoms
2. Presence of middle ear effusion
3. Signs of middle ear inflammation 2

Diagnostic findings on otoscopy include:

• Bulging or fullness of the tympanic membrane
• Limited or absent mobility of the tympanic membrane
• Distinct erythema of the tympanic membrane 1

Treatment Algorithm

First Step: Pain Management

• Begin with adequate pain management using acetaminophen or ibuprofen 1
• Address pain regardless of whether antibiotics are prescribed 2

Antibiotic Decision Making

Immediate Antibiotic Therapy Recommended For:

• Children under 6 months of age
• Children 6-23 months with severe symptoms
• Children with bilateral AOM regardless of severity
• Patients with severe symptoms (moderate to severe otalgia or fever ≥39°C) 1

Observation Option (48-72 hours without antibiotics) Appropriate For:

• Otherwise healthy children 6 months to 2 years with non-severe illness and uncertain diagnosis
• Children 2 years or older without severe symptoms 2

First-Line Antibiotic Therapy

• Amoxicillin at 80-90 mg/kg/day divided in two doses 2, 1
  • This high dose is effective against most S. pneumoniae strains, including those with intermediate penicillin resistance 1

Alternative Antibiotics for Specific Situations:

For Non-Type I (non-severe) Penicillin Allergy:

• Cefdinir, cefpodoxime, or cefuroxime 2, 1

For Type I (severe) Penicillin Allergy:

• Azithromycin, clarithromycin, or trimethoprim-sulfamethoxazole 1
  • Note: These have limited effectiveness against common otitis media pathogens (20-25% failure rate) 1

For Treatment Failure After 48-72 Hours:

• Amoxicillin-clavulanate 1, 3
• Consider ceftriaxone for severe cases 1

For Recurrent AOM or Recent Amoxicillin Use:

• Amoxicillin-clavulanate 1, 4

Special Considerations

Treatment Duration

• Children under 2 years: 10-day course 2
• Children 2-5 years with mild/moderate AOM: 7-day course 2
• Children 6 years and older: 5-10 day course 2, 1

Follow-up

• Reassess if symptoms worsen or fail to respond within 48-72 hours 1
• Clinical improvement should be noted within 48-72 hours of starting antibiotics 1

Important Caveats

• Persistent middle ear effusion is common after successful treatment (60-70% at 2 weeks, 40% at 1 month) and does not indicate treatment failure if symptoms have resolved 2, 1
• Middle ear effusion without clinical symptoms is defined as otitis media with effusion (OME) and does not require antibiotics 2
• For patients with multiple treatment failures, consider tympanocentesis for culture and susceptibility testing 2

Prevention and Surgical Options

• Consider tympanostomy tubes for children with ≥3 episodes in 6 months or ≥4 episodes in 12 months 1
• Surgical intervention with tympanostomy tubes is recommended for bilateral OME lasting >3 months with significant hearing loss or developmental impact 1

Bacterial Pathogens

The main pathogens in AOM are:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis 1, 3

Risk factors for resistant pathogens include recent antibiotic treatment, children in daycare, winter infections, and age less than two years 5.