What is the 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 (AOM). 1

Diagnosis

Accurate diagnosis of AOM requires:

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

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
• Distinct erythema of the tympanic membrane 1

Treatment Algorithm

First-Line Treatment

• Amoxicillin (80-90 mg/kg/day divided into two doses) for children without penicillin allergy and no amoxicillin use in the past 30 days 1, 2
  • This high-dose regimen is effective against most strains of S. pneumoniae, the most common pathogen in AOM 3

Second-Line Treatment (for treatment failures or recurrent AOM)

• Amoxicillin-clavulanate for:
  • Treatment failure with amoxicillin after 48-72 hours
  • Recent amoxicillin use within past 30 days
  • Recurrent AOM 1, 4

For Penicillin-Allergic Patients

• Non-Type I (non-severe) allergy: Cefdinir, cefpodoxime, or cefuroxime 1
• Type I (severe) allergy: Azithromycin, clarithromycin, or trimethoprim-sulfamethoxazole (TMP-SMX) 1
  • Note: Macrolides have bacteriologic failure rates of 20-25% in Type I allergic patients 1

For Treatment Failures with Second-Line Therapy

• Consider ceftriaxone (parenteral therapy) or consultation with a specialist 1
• For multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered 5

Treatment Duration

• Children <2 years and those with severe symptoms: 10-day course
• Children 2-5 years with mild to moderate AOM: 7-day course
• Children ≥6 years with mild to moderate AOM: 10-day course 5

Watchful Waiting Option

Antibiotic therapy can be deferred with close follow-up in:

• Children 6-23 months with unilateral AOM without severe symptoms
• Children ≥24 months with bilateral or unilateral AOM without severe symptoms 1

However, antibiotics are indicated for:

• All children <6 months with confirmed AOM
• Children <2 years with bilateral AOM or unilateral AOM with severe symptoms 1

Special Considerations

Recurrent and Persistent AOM

Recurrent AOM (defined as ≥3 episodes in 6 months or ≥4 episodes in 12 months) may require:

• Tympanostomy tubes 1
• Consideration of antibiotic prophylaxis in select cases 6

Otitis Media with Effusion (OME)

• Defined as middle ear effusion without acute symptoms
• Antibiotics, decongestants, and nasal steroids are not recommended for OME 2
• Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist 2

Common Pathogens and Antibiotic Coverage

The main bacterial pathogens in AOM are:

1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Moraxella catarrhalis 1, 2

High-dose amoxicillin effectively covers S. pneumoniae but may fail against beta-lactamase-producing H. influenzae and M. catarrhalis, which is why amoxicillin-clavulanate is recommended for treatment failures 3.

Preventive Measures

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

Remember that adequate pain management is an essential component of AOM treatment, regardless of whether antibiotics are prescribed 2.