What is the first line treatment for ear infections, specifically acute otitis media (AOM) and otitis externa?

First-Line Treatment for Ear Infections

For acute otitis media (AOM), high-dose amoxicillin (80-90 mg/kg/day divided into two doses) is the first-line treatment, while for otitis externa, topical ofloxacin drops are the first-line therapy. 1, 2

Acute Otitis Media (AOM)

First-Line Treatment

• Amoxicillin 80-90 mg/kg/day divided into two doses for 10 days (for children <2 years) or 5-7 days (for children ≥2 years with mild/moderate disease) 1
• This high-dose regimen is effective against most Streptococcus pneumoniae strains, including those with intermediate penicillin resistance 1

Treatment Algorithm

1. First episode of AOM: Amoxicillin (if no amoxicillin use in past 30 days)
2. Recurrent AOM or recent amoxicillin use (within 30 days): Amoxicillin-clavulanate
3. Treatment failure with amoxicillin-clavulanate: Consider ceftriaxone or specialist consultation 1

Alternative Antibiotics for Penicillin Allergy

• Non-Type I (non-severe) allergy: Cefdinir
• Type I (severe) allergy: Azithromycin, clarithromycin, or trimethoprim-sulfamethoxazole (TMP-SMX) 1

Important Considerations

• Pain management with acetaminophen or ibuprofen should be provided regardless of antibiotic prescription 1
• Observation without antibiotics for 48-72 hours may be appropriate for otherwise healthy children ≥2 years with mild symptoms 1
• 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

Otitis Externa

First-Line Treatment

• Topical ofloxacin drops 2:
  • Children 6 months to 13 years: Five drops (0.25 mL) once daily for seven days
  • Patients ≥13 years: Ten drops (0.5 mL) once daily for seven days

Administration Technique

1. Warm the solution by holding the bottle in hand for 1-2 minutes
2. Patient should lie with affected ear upward
3. Instill drops into ear canal
4. Maintain position for 5 minutes to facilitate penetration 2

Special Considerations

Recurrent AOM

• 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

Treatment Failures

• If symptoms worsen or fail to improve within 48-72 hours, reassessment is needed 1
• For persistent severe symptoms after initial amoxicillin treatment, change to amoxicillin-clavulanate 3
• For failures with multiple antibiotics, consider tympanocentesis for bacterial diagnosis and susceptibility testing 3

Common Pathogens

• Main bacterial pathogens in AOM: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• Beta-lactamase-producing H. influenzae is the predominant pathogen in children failing high-dose amoxicillin therapy 4

Chronic Suppurative Otitis Media

• For patients ≥12 years with perforated tympanic membranes: Ten drops (0.5 mL) of ofloxacin instilled into the affected ear twice daily for fourteen days 2

By following these evidence-based recommendations, clinicians can effectively manage ear infections while minimizing complications and reducing the risk of antibiotic resistance.