What is the recommended treatment for a patient diagnosed with Acute Otitis Media (AOM)?

SOAP Note for Acute Otitis Media (AOM)

Subjective

• Chief complaint: Ear pain
• Associated symptoms: May include fever, irritability, otorrhea, anorexia, vomiting, lethargy
• Duration of symptoms: Note onset and progression
• Previous episodes of AOM: Number and frequency of prior episodes
• Recent upper respiratory tract infection
• Recent antibiotic use (especially within past 30 days)
• Allergies to medications
• Vaccination status (pneumococcal and influenza)

Objective

• Vital signs: Temperature, heart rate, respiratory rate, blood pressure
• General appearance: Level of discomfort, irritability
• Ear examination:
  • Tympanic membrane appearance: Bulging, limited mobility, air-fluid level, erythema
  • Presence of otorrhea
• Associated findings: Check for concomitant purulent conjunctivitis

Assessment

• Acute Otitis Media (AOM)
• Severity: Mild/Moderate/Severe
• Unilateral vs. Bilateral
• Risk factors: Age <2 years, daycare attendance, lack of breastfeeding, exposure to tobacco smoke

Plan

For children under 2 years of age with AOM, immediate antibiotic therapy with high-dose amoxicillin (80-90 mg/kg/day divided twice daily for 10 days) is recommended as first-line treatment. 1

Treatment Algorithm:

1. Pain management:

   • Acetaminophen or ibuprofen at age-appropriate doses
   • Consider topical analgesics as complementary therapy

2. Antibiotic therapy:

   • First-line therapy:

     • High-dose amoxicillin: 80-90 mg/kg/day divided twice daily
     • Duration: 10 days for children <2 years; 5-7 days for children ≥2 years 2, 1

   • Second-line therapy (if amoxicillin used in past 30 days, treatment failure, or concomitant purulent conjunctivitis):

     • Amoxicillin-clavulanate: 90 mg/kg/day based on amoxicillin component 2, 1
     • Cefuroxime-axetil or cefpodoxime-proxetil for H. influenzae infections 2

   • For penicillin allergy:

     • Non-type I allergy: Cefdinir, cefpodoxime, or cefuroxime 1
     • Type I allergy: Azithromycin (10 mg/kg on day 1, then 5 mg/kg on days 2-5) 3
     • Alternative: Erythromycin-sulfafurazole 2

   • For treatment failure:

     • Defined as worsening condition, symptoms persisting >48 hours after starting antibiotics, or recurrence within 4 days of completing treatment 2, 1
     • Switch to amoxicillin-clavulanate if not already prescribed
     • Consider ceftriaxone for severe cases (50 mg/kg IM, not to exceed 1 gram) 2, 4
     • Consider referral for tympanocentesis and culture-directed therapy for multiple failures 1

3. Observation approach:

   • May be appropriate for children ≥2 years with mild symptoms 1
   • Provide clear follow-up instructions
   • Prescribe rescue antibiotics if symptoms persist or worsen after 48-72 hours

4. Follow-up:

   • Reassess in 48-72 hours if symptoms persist or worsen
   • Distinguish between treatment failure and otitis media with effusion (OME)
   • OME (fluid without acute symptoms) does not require antibiotics 1

5. Prevention strategies:

   • Ensure pneumococcal and influenza vaccinations are up-to-date
   • Promote breastfeeding for at least 6 months
   • Reduce exposure to tobacco smoke
   • Consider limiting daycare attendance if recurrent episodes

6. Referral considerations:

   • ENT referral for:
     • Recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 1 year)
     • Complications (mastoiditis, persistent hearing loss)
     • Language development delay
     • Difficulty visualizing tympanic membrane

Clinical Pearls:

• Redness of the tympanic membrane alone with normal landmarks is not sufficient for AOM diagnosis 2
• Otitis media with effusion (OME) should not be treated with antibiotics unless it persists beyond 3 months 2
• 60-70% of children will have middle ear effusion 2 weeks after successful AOM treatment, representing OME, not treatment failure 1
• Beta-lactamase-producing organisms are the predominant pathogens in children failing high-dose amoxicillin therapy 5