What is the best antibiotic for acute otitis media (middle ear infection)?

Best Antibiotic for Middle Ear Infection (Acute Otitis Media)

Amoxicillin is the first-line antibiotic treatment for acute otitis media (middle ear infection) when a decision to treat with antibiotics has been made. 1, 2

First-Line Treatment

• High-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 5-7 days 2
• This recommendation is supported by the American Academy of Pediatrics and the American Academy of Family Physicians guidelines 1, 2
• Amoxicillin remains effective against the most common bacterial pathogens in AOM, particularly Streptococcus pneumoniae

When to Use Alternative Antibiotics

Use an antibiotic with additional β-lactamase coverage when:

1. The child has received amoxicillin in the past 30 days
2. The child has concurrent purulent conjunctivitis
3. The child has a history of recurrent AOM unresponsive to amoxicillin
4. The child is allergic to penicillin 1, 2

Alternative Antibiotic Options

For patients meeting the above criteria, consider:

• Amoxicillin-clavulanate (provides additional coverage against β-lactamase producing organisms)
• Cefuroxime axetil, cefprozil, or cefpodoxime proxetil (for penicillin-allergic patients not allergic to cephalosporins)
• Clindamycin (30-40 mg/kg/day in 3 divided doses) for penicillin-allergic patients 2
• Ceftriaxone (50 mg/kg IM or IV daily for 3 days) for severe cases or when compliance is a concern 2, 3

Microbiology Considerations

The three most common bacterial pathogens in AOM are:

1. Streptococcus pneumoniae
2. Haemophilus influenzae (often β-lactamase producing)
3. Moraxella catarrhalis 1

The prevalence of these pathogens has evolved since the introduction of pneumococcal conjugate vaccines, with H. influenzae becoming more prominent in some regions 1.

Treatment Duration

• Minimum treatment duration should be 5-7 days
• Treatment should continue for at least 48-72 hours beyond symptom resolution 2

Follow-up and Treatment Failure

• Reassess the patient if symptoms worsen or fail to respond within 48-72 hours of starting antibiotics 1
• For treatment failures with amoxicillin, switch to an antibiotic with β-lactamase coverage 1, 4

Important Considerations

• Pain management is essential and should be addressed immediately with acetaminophen or ibuprofen at age-appropriate doses 2
• Ensure pneumococcal and influenza vaccinations are up-to-date to reduce risk of recurrent AOM 2
• Avoid unnecessary use of decongestants or antihistamines, which are ineffective for otitis media 2

Common Pitfalls to Avoid

• Misdiagnosing otitis media with effusion (OME) as acute otitis media (AOM), leading to unnecessary antibiotic use
• Inadequate pain management, focusing only on antibiotic therapy
• Using antibiotics for viral infections or self-limiting cases that could resolve without antibiotics

The evidence strongly supports amoxicillin as the first-line treatment for uncomplicated AOM, with alternative antibiotics reserved for specific clinical scenarios where resistance or treatment failure is likely.