What is the initial treatment for chronic otitis media?

Initial Treatment for Chronic Otitis Media

The initial treatment for chronic otitis media is high-dose amoxicillin (80-90 mg/kg/day for children or 1500-3000 mg/day for adults divided into two doses), which is recommended as first-line therapy by multiple medical societies including the American Academy of Family Physicians and European Society of Clinical Microbiology and Infectious Diseases. 1

Diagnosis and Pathogen Considerations

• Chronic otitis media is characterized by persistent or recurrent inflammation of the middle ear mucosa, causing otorrhea and hearing loss that significantly affect quality of life 2
• Main bacterial pathogens involved:
  • Streptococcus pneumoniae (most common in Central and Eastern Europe)
  • Haemophilus influenzae (more common in Israel and USA)
  • Moraxella catarrhalis 3, 1
• Bacterial resistance is considered the main reason for treatment failure in chronic otitis media 3

Treatment Algorithm

First-Line Treatment:

• High-dose amoxicillin: 80-90 mg/kg/day divided into two doses for children or 1500-3000 mg/day for adults 1
  • Provides excellent coverage against S. pneumoniae and non-beta-lactamase producing H. influenzae
  • Duration: 10 days for children under 2 years or with severe symptoms; 7 days for children 2-5 years with mild/moderate symptoms 1

For Recurrent Episodes or Recent Amoxicillin Use:

• Amoxicillin-clavulanate: High-dose (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) 1
  • Indicated for patients with recent amoxicillin use, concurrent conjunctivitis, or when coverage for M. catarrhalis is desired
  • Effective against beta-lactamase-producing bacteria 4

For Treatment Failure with Amoxicillin-Clavulanate:

• Consider ceftriaxone or consultation with a specialist 1

For Patients with Penicillin Allergies:

• Non-Type I allergies: Cefdinir, cefuroxime, or cefpodoxime 1
• Type I allergies: Macrolides or clindamycin 1
• Alternative for β-lactam allergies: Trimethoprim-Sulfamethoxazole (TMP-SMX), though bacteriologic failure rates of 20-25% are possible 1
• For patients allergic to both penicillin and azithromycin: Clindamycin (effective against approximately 90% of S. pneumoniae isolates) 1

Special Considerations

For Chronic Suppurative Otitis Media with Perforated Tympanic Membrane:

• Ofloxacin otic solution: Ten drops (0.5 mL, 1.5 mg ofloxacin) instilled into the affected ear twice daily for fourteen days 5
  • The solution should be warmed by holding the bottle in hand for 1-2 minutes to avoid dizziness
  • Patient should lie with affected ear upward before instilling drops
  • The tragus should be pumped 4 times to facilitate penetration into the middle ear
  • Position should be maintained for five minutes 5

Follow-up and Referral:

• Assess response to therapy within 48-72 hours 1
• If no improvement occurs within this timeframe:
  • Confirm diagnosis
  • Switch to amoxicillin-clavulanate
  • Consider referral to ENT specialist, especially with tympanic membrane perforation 1
• Consider tympanostomy tubes for children with ≥3 episodes in 6 months or ≥4 episodes in 12 months, or persistent middle ear effusion with hearing loss 1

Evidence Quality and Considerations

• The recommendation for amoxicillin as first-line therapy is supported by multiple medical societies and has moderate to high certainty of evidence 1
• Recent research suggests that topical quinolones are likely more effective than boric acid for resolution of ear discharge in chronic suppurative otitis media (moderate-certainty evidence) 6
• Bacterial resistance patterns vary geographically, with amoxicillin susceptibility rates ranging from 62% in the USA to 89% in Central and Eastern Europe 3

Common Pitfalls and Caveats

• Avoid treating isolated redness of the tympanic membrane with normal landmarks with antibiotics 1
• Do not delay treatment in children under 2 years with bilateral otitis media or in patients with tympanic membrane perforation 1
• Be aware that intermediate penicillin resistance in S. pneumoniae increases the risk of bacteriologic failure with amoxicillin and oral cephalosporins 3
• Consider preventive measures including pneumococcal vaccination, limiting pacifier use after 6 months, breastfeeding for at least 6 months, and avoiding supine bottle feeding 1