First-Line Treatment for Acute Otitis Media
High-dose amoxicillin (80-90 mg/kg/day divided into two doses) is the first-line treatment for acute otitis media when antibiotics are indicated, unless the patient has received amoxicillin in the past 30 days, has concurrent purulent conjunctivitis, or has a penicillin allergy. 1
Diagnosis of Acute Otitis Media
Accurate diagnosis is essential before initiating treatment. AOM is diagnosed based on:
- Moderate to severe bulging of the tympanic membrane
- Limited or absent mobility of the tympanic membrane
- Distinct erythema of the tympanic membrane
- New-onset otorrhea not caused by otitis externa
- Symptoms including ear pain, fever, irritability, and sometimes vomiting or lethargy
Treatment Algorithm
Step 1: Pain Management
Pain management should be addressed regardless of whether antibiotics are prescribed:
- Acetaminophen or ibuprofen for pain relief
- Continue analgesics as needed throughout the course of illness 2
Step 2: Antibiotic Decision
Based on patient characteristics:
Severe AOM (moderate to severe otalgia, otalgia for ≥48 hours, or temperature ≥39°C/102.2°F):
- Prescribe antibiotics immediately
Non-severe AOM:
- Children <6 months: Prescribe antibiotics
- Children 6-23 months with bilateral AOM: Prescribe antibiotics
- Children 6-23 months with unilateral AOM: Consider observation with close follow-up
- Children ≥2 years: Observation may be appropriate if symptoms are mild 1
Step 3: Antibiotic Selection
| Clinical Scenario | Recommended Treatment |
|---|---|
| First episode (no amoxicillin in past 30 days) | Amoxicillin 80-90 mg/kg/day divided into 2 doses |
| Recent amoxicillin use (within 30 days) | Amoxicillin-clavulanate |
| Concurrent purulent conjunctivitis | Amoxicillin-clavulanate |
| Non-Type I penicillin allergy | Cefdinir, cefpodoxime, or cefuroxime |
| Type I (severe) penicillin allergy | Azithromycin, clarithromycin, or TMP-SMX |
| Treatment failure with amoxicillin-clavulanate | Consider ceftriaxone or specialist consultation |
Step 4: Treatment Duration
- Children <2 years: 10 days
- Children ≥2 years with mild/moderate disease: 5-7 days 1
Important Considerations
Observation Approach
When using observation:
- Ensure a mechanism for follow-up within 48-72 hours
- Consider providing a "safety-net" or "wait-and-see" prescription that parents can fill if symptoms worsen or don't improve within 48-72 hours 2
Treatment Failures
- Reassess if symptoms worsen or fail to improve within 48-72 hours
- Clinical improvement should be noted within 48-72 hours of starting appropriate antibiotics
- For treatment failures with initial amoxicillin, switch to amoxicillin-clavulanate 1
Antibiotic Limitations
- Macrolides (azithromycin, clarithromycin) and TMP-SMX have limited effectiveness against common otitis media pathogens, with potential bacterial failure rates of 20-25% 1
- Ceftriaxone can be considered for treatment failures, but note that in clinical studies, a single dose of ceftriaxone showed lower clinical cure rates compared to 10 days of oral therapy 3
Follow-up and Prevention
- 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
- Consider tympanostomy tubes for children with ≥3 episodes in 6 months or ≥4 episodes in 12 months 1
- Preventive measures include pneumococcal vaccination, limiting pacifier use after 6 months, breastfeeding for at least 6 months, and avoiding supine bottle feeding 1