Treatment of Otitis Media in Adults
For adults with acute otitis media (AOM), amoxicillin-clavulanate is the recommended first-line antibiotic treatment, with macrolides, pristinamycin, or doxycycline as alternatives for those with penicillin allergies. 1
Diagnostic Considerations
Before initiating treatment, it's important to distinguish between:
- Acute otitis media (AOM): Characterized by purulent or mucopurulent middle ear fluid, typically bacterial in origin
- Otitis media with effusion (OME): Presence of middle ear fluid without acute symptoms, which generally does not require antibiotics
First-Line Treatment
Antibiotic Therapy
- First choice: Amoxicillin-clavulanate 1
- Dosage: Standard adult dosing (875 mg amoxicillin/125 mg clavulanate twice daily)
- Duration: 7-10 days
Alternative Options for Penicillin-Allergic Patients
- First-generation cephalosporins (if no history of severe allergic reaction to penicillin)
- Macrolides (e.g., azithromycin)
- Pristinamycin
- Doxycycline 1
Note: Cotrimoxazole is not recommended due to inconsistent activity against pneumococci and poor benefit/risk ratio 1
Treatment Failure
If symptoms persist after 48-72 hours of initial antibiotic treatment:
- Reassess the diagnosis
- Consider second-line antibiotics:
- Cefuroxime-axetil
- Cefpodoxime-proxetil
- Fluoroquinolones active against pneumococci (e.g., levofloxacin, moxifloxacin) 1
Pain Management
- Analgesics: Acetaminophen or NSAIDs for immediate pain relief
- Topical analgesics: May provide relief 10-30 minutes after administration 1
Special Considerations
Bacterial Pathogens
The most common bacterial pathogens in adult AOM are similar to those in children:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis 2
Otitis Media with Effusion
- Antibiotics are not indicated for OME except in cases of AOM that continue beyond 3 months
- Consider referral to an ENT specialist for persistent cases with hearing loss 1
Common Pitfalls to Avoid
Misdiagnosis: Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotic therapy 1
Inappropriate antibiotic selection: Fluoroquinolones inactive on pneumococci (ofloxacin, ciprofloxacin) and cefixime are not recommended for AOM treatment 1
Inadequate duration: Complete the full course of antibiotics even if symptoms improve before completion
Confusing otitis media with otitis externa: Otitis externa typically requires topical treatment with fluoroquinolone ear drops rather than systemic antibiotics 3
While AOM is less common in adults than in children, the treatment approach follows similar principles. Prompt antibiotic therapy with appropriate agents is essential to prevent complications and reduce symptom duration.