What is the recommended treatment for a middle ear infection?

Treatment of Middle Ear Infection (Acute Otitis Media)

Amoxicillin at a dose of 80-90 mg/kg/day divided twice daily for 5-7 days is the recommended first-line treatment for acute otitis media, particularly in children under 2 years of age. 1

Diagnosis and Assessment

Accurate diagnosis of acute otitis media (AOM) requires:

• Acute onset of signs and symptoms
• Presence of middle ear effusion
• Evidence of middle ear inflammation
• Symptoms such as ear pain, irritability, or fever

Key physical examination findings include:

• Bulging of the tympanic membrane
• Limited or absent mobility of the tympanic membrane
• Air-fluid level behind the tympanic membrane
• Otorrhea (ear drainage)
• Distinct erythema of the tympanic membrane

Treatment Algorithm

First-Line Treatment

• For children under 2 years: Immediate antibiotic therapy with high-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 5-7 days 1, 2
• For children 2 years or older with mild symptoms: Consider watchful waiting for 48-72 hours with adequate pain management 3
• For adults: Amoxicillin remains the first-line treatment due to its superior penetration into middle ear fluid 2

Pain Management

• Address pain immediately with acetaminophen or ibuprofen at age-appropriate doses
• Topical analgesics may provide additional relief

When to Use Alternative Antibiotics

• For patients allergic to penicillin: Consider clindamycin (30-40 mg/kg/day in 3 divided doses) 1
• For treatment failures after 48-72 hours: Switch to amoxicillin-clavulanate 3
• When β-lactamase-producing bacteria are suspected or confirmed: Use amoxicillin-clavulanate at a dose of 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanic acid 2

Special Considerations

For Ear Infections with Tympanostomy Tubes

For patients with tympanostomy tubes who develop ear infections with drainage:

1. Topical antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) are the preferred treatment 4
2. Apply drops in the ear canal twice daily for up to 10 days
3. "Pump" the flap of skin in front of the ear canal after placing drops to help them enter the ear tube

Bacterial Pathogens

The most common bacterial pathogens in AOM are:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

These pathogens require coverage with appropriate antibiotics, with amoxicillin being effective against most strains 4, 3.

Treatment Failures and Recurrent Infections

If symptoms persist despite 48-72 hours of antibiotic therapy:

1. Reexamine the patient
2. Consider switching to a second-line agent such as amoxicillin-clavulanate 3
3. Consider tympanocentesis for culture and susceptibility testing in severe or recurrent cases 4

For recurrent AOM:

• Consider chemoprophylaxis with antibiotics, which has shown 60-90% efficacy in preventing new episodes 4
• Ensure pneumococcal and influenza vaccinations are up-to-date 1

Otitis Media with Effusion (OME)

OME is defined as middle ear effusion without acute symptoms:

• Watchful waiting for up to 3 months is appropriate 1
• Antibiotics, decongestants, or nasal steroids are not recommended as they do not hasten clearance of middle ear fluid 3
• Consider referral to an otolaryngologist if effusion persists beyond 3 months with documented hearing loss 1

Common Pitfalls to Avoid

1. Misdiagnosing OME as AOM, leading to unnecessary antibiotic use
2. Inadequate pain management, focusing only on antibiotic therapy
3. Using standard-dose amoxicillin for AOM when high-dose is needed, especially with resistant S. pneumoniae
4. Using decongestants or antihistamines, which are ineffective for otitis media
5. Failing to reassess treatment failures within 48-72 hours

Remember that approximately one-third of children with AOM caused by bacterial pathogens improve without antibiotics, but since it's impossible to identify these patients without tympanocentesis, antibiotic therapy is recommended for all cases of AOM, particularly in children under 2 years of age 4, 2.