What is the recommended treatment for acute otitis media?

Treatment of Acute Otitis Media

Amoxicillin at a dosage of 80-90 mg/kg/day divided into two doses is the first-line treatment for acute otitis media. 1, 2

Diagnosis

Proper diagnosis is essential before initiating treatment and requires:

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

Diagnostic findings on otoscopy that predict AOM include:

• Bulging or fullness of the tympanic membrane
• Limited or absent mobility of the tympanic membrane
• Distinct erythema of the tympanic membrane 1, 2

Treatment Algorithm

Step 1: Pain Management

• Begin with adequate pain management using acetaminophen or ibuprofen 2
• Pain management should be addressed regardless of whether antibiotics are prescribed 1

Step 2: Determine Need for Immediate Antibiotics vs. Observation

Immediate antibiotic therapy is recommended for:

• Children under 6 months of age
• Children 6-23 months with severe symptoms or bilateral AOM
• Children with severe symptoms (moderate to severe otalgia or fever ≥39°C)
• Children with otorrhea (drainage from the ear)
• Children who are immunocompromised 2

Observation without antibiotics (48-72 hours) may be appropriate for:

• Otherwise healthy children ≥2 years with mild symptoms and non-severe illness
• Children with uncertain diagnosis 1, 2, 3

Step 3: Antibiotic Selection

For first-line therapy:

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

For patients with penicillin allergy:

• Non-Type I (non-severe) allergy: Cefdinir, cefpodoxime, or cefuroxime 1, 2
• Type I (severe) allergy: Azithromycin or clarithromycin 2, 4

For treatment failure after 48-72 hours:

• Amoxicillin-clavulanate (if initially treated with amoxicillin) 1, 2
• Consider ceftriaxone or specialist consultation for multiple treatment failures 2

Bacterial Pathogens

The main pathogens in AOM are:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis 2, 3, 5

Follow-up

• Reassess if symptoms worsen or fail to improve within 48-72 hours 1, 2
• Clinical improvement should be noted within 48-72 hours of starting appropriate antibiotics 2
• 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 1, 2

Important Considerations and Pitfalls

High-dose vs. Standard-dose Amoxicillin

The high-dose recommendation (80-90 mg/kg/day) is based on concerns about penicillin-resistant S. pneumoniae. Some communities with low prevalence of resistant strains may be able to use standard dosing (40-45 mg/kg/day), but high-dose is generally recommended as first-line therapy 6.

Treatment Duration

Single-dose amoxicillin therapy has been shown to be ineffective with significantly higher failure rates compared to standard 10-day therapy 7.

Dosing Frequency

Twice-daily amoxicillin dosing has been shown to be as effective as thrice-daily dosing, which can improve medication adherence 8.

Common Side Effects

When using amoxicillin, be aware of potential side effects:

• Diarrhea (most common)
• Abdominal pain
• Vomiting
• Rash 4

Prevention

Consider these preventive measures:

• Pneumococcal vaccination
• Reducing risk factors such as:
  • Limiting pacifier use after 6 months of age
  • Breastfeeding for at least 6 months
  • Avoiding supine bottle feeding 1, 2

For recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months), consider referral for evaluation for tympanostomy tubes 2.