What is the recommended management for acute suppurative otitis media (ASOM)?

Management of Acute Suppurative Otitis Media

Amoxicillin at a dosage of 80-90 mg/kg/day divided into two doses is the first-line treatment for acute suppurative otitis media (ASOM), with antibiotics indicated for all children younger than 2 years with bulging or fullness of the tympanic membrane. 1, 2

Diagnosis

Accurate diagnosis of ASOM requires:

• History of acute onset of signs and symptoms
• Presence of middle ear effusion
• Signs of middle ear inflammation 1

Specific diagnostic findings include:

• Bulging or fullness of the tympanic membrane
• Limited or absent mobility of the tympanic membrane
• Air-fluid level behind the tympanic membrane
• Otorrhea (drainage from the ear)
• Distinct erythema of the tympanic membrane 1, 2

Treatment Algorithm

Initial Management

1. Pain Management

   • Provide pain relief with acetaminophen or ibuprofen regardless of whether antibiotics are prescribed 2
   • Pain management should be addressed within the first 24 hours of an episode 1

2. Antibiotic Decision

   • For children <2 years: Prescribe antibiotics immediately 1, 2
   • For children ≥2 years with severe symptoms (moderate to severe otalgia, otalgia ≥48 hours, or temperature ≥39°C/102.2°F): Prescribe antibiotics immediately 2
   • For children ≥2 years with mild symptoms: Observation for 48-72 hours is an option if follow-up can be ensured 1, 2

Antibiotic Selection

First-line therapy:

• 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, 2

Second-line therapy (if patient fails to respond within 48-72 hours, has received amoxicillin in past 30 days, or has concurrent purulent conjunctivitis):

• Amoxicillin-clavulanate (90 mg/kg/day based on amoxicillin component) 2, 3

For penicillin allergies:

• Non-Type I (non-severe) allergy: Cefdinir, cefpodoxime, or cefuroxime 1, 2
• Type I (severe) allergy: Azithromycin or clarithromycin 2
  • Note: Macrolides have limited effectiveness against common otitis media pathogens (20-25% failure rate) 2

Follow-up and Treatment Failure

• 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
• If the patient fails to respond to initial management within 48-72 hours:
  1. Confirm the diagnosis of ASOM
  2. If initially managed with observation, begin antibiotics
  3. If initially managed with amoxicillin, change to amoxicillin-clavulanate 1
  4. Consider ceftriaxone or specialist consultation for treatment failure with amoxicillin-clavulanate 2

Special Considerations

Recurrent ASOM

• Consider tympanostomy tubes for children with ≥3 episodes in 6 months or ≥4 episodes in 12 months 2

Persistent Middle Ear Effusion

• 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 2

Prevention

Preventive measures include:

• Pneumococcal vaccination
• Limiting pacifier use after 6 months of age
• Breastfeeding for at least 6 months
• Avoiding supine bottle feeding 2
• Reducing respiratory infections by altering daycare attendance patterns 1

Complications to Monitor

• Mastoiditis (rare but serious)
• Watch for worsening ear pain, new neurological symptoms, and facial weakness or asymmetry 2

Evidence Quality and Considerations

The recommendations for antibiotic therapy are supported by high-quality evidence from the American Academy of Pediatrics and American Academy of Family Physicians 1, 2. The higher dose of amoxicillin (80-90 mg/kg/day) is specifically recommended to overcome intermediate resistant strains of Streptococcus pneumoniae 4.

Research has shown that antibiotic treatment of ASOM is particularly beneficial in children younger than 2 years with bilateral disease, with a number needed to treat (NNT) of only 3 patients 1. This supports the recommendation for immediate antibiotic therapy in this age group rather than observation.