What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day) 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

Proper diagnosis of acute otitis media (AOM) requires all three of the following:

• History of acute onset of signs and symptoms
• Presence of middle ear effusion
• Signs of middle ear inflammation 2, 1

Key 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

Step 1: Pain Management

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

Step 2: Antibiotic Decision

1. Immediate antibiotic therapy is recommended for:

   • Children under 6 months of age
   • Children 6-23 months with severe symptoms
   • Children with bilateral AOM regardless of severity 1

2. Observation without antibiotics (48-72 hours) may be 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, 1

Step 3: Antibiotic Selection

First-line therapy:

• Amoxicillin at 80-90 mg/kg/day divided into two doses 2, 1
  • Duration: 10 days for children <2 years; 5-7 days for children ≥2 years 1

For patients with penicillin allergy:

• Non-Type I (non-severe) allergy: Cefdinir, cefpodoxime, or cefuroxime 2, 1
• Type I (severe) allergy: Azithromycin, clarithromycin, or trimethoprim-sulfamethoxazole 1
  • Note: Macrolides and TMP-SMX have limited effectiveness against common otitis media pathogens (20-25% failure rate) 1

For treatment failure or recurrent AOM:

• Amoxicillin-clavulanate if symptoms persist after 48-72 hours of amoxicillin 2, 1
• Consider ceftriaxone or specialist consultation for failures with amoxicillin-clavulanate 1

Special Considerations

Bacterial Pathogens

The main bacterial pathogens in AOM are:

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

Risk Factors for Resistant Pathogens

• Recent antibiotic treatment
• Children in daycare facilities
• Winter infections
• Age less than two years 4

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
• Persistent middle ear effusion is common after successful treatment (60-70% at 2 weeks, 40% at 1 month) and does not necessarily indicate treatment failure if symptoms have resolved 2, 1

Prevention and Recurrent AOM

• Consider pneumococcal vaccination if not already administered 1
• Tympanostomy tubes should be considered for children with ≥3 episodes in 6 months or ≥4 episodes in 12 months 1

Azithromycin for AOM

For pediatric patients with AOM who cannot tolerate first-line therapy, azithromycin can be used at:

• 30 mg/kg as a single dose, or
• 10 mg/kg once daily for 3 days, or
• 10 mg/kg on day 1 followed by 5 mg/kg/day on days 2-5 5

Clinical trials have shown azithromycin to be effective in treating AOM, with clinical success rates of 83-89% at short-term follow-up 5.