What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day divided into two doses for children or 1500-3000 mg/day for adults) is the first-line treatment for acute otitis media. 1

Treatment Algorithm

First-line therapy:

• Amoxicillin (if no amoxicillin use in past 30 days)
  • Children: 80-90 mg/kg/day divided into two doses
  • Adults: 1500-3000 mg/day divided into two doses
  • Duration:
    • 10 days for children under 2 years or with severe symptoms
    • 7 days for children 2-5 years with mild/moderate symptoms
    • 10 days for children 6 years and older 1

Second-line therapy (for recurrent AOM or recent amoxicillin use):

• Amoxicillin-clavulanate (high-dose: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate)
  • Indicated for:
    • Recent amoxicillin use within 30 days
    • Treatment failure with amoxicillin
    • Concurrent conjunctivitis
    • When coverage for M. catarrhalis is desired 1

For treatment failure with amoxicillin-clavulanate:

• Consider ceftriaxone or consultation with a specialist 1

For penicillin allergies:

• Non-Type I allergies: cefdinir, cefuroxime, or cefpodoxime
• Type I allergies: macrolides or clindamycin 1

Special Considerations

Immediate antibiotic therapy (no observation period) for:

• Children under 2 years with bilateral otitis media
• Presence of tympanic membrane perforation (regardless of age)
• Severe symptoms 1

Azithromycin dosing for acute otitis media (alternative for penicillin allergy):

• Single-dose regimen: 30 mg/kg as a single dose
• 3-day regimen: 10 mg/kg once daily for 3 days
• 5-day regimen: 10 mg/kg on day 1, followed by 5 mg/kg on days 2-5 2

Bacterial Pathogens and Resistance

The main pathogens in acute otitis media are:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis 1, 3

Bacterial resistance is a significant concern, with amoxicillin susceptibility rates varying from 62% in the USA to 89% in Central and Eastern Europe. Intermediate penicillin resistance in S. pneumoniae increases the risk of treatment failure with amoxicillin and oral cephalosporins 1.

Risk Factors for Resistant Pathogens

• Recent antibiotic treatment
• Children in daycare facilities
• Winter infections
• Age less than 2 years 4

Preventive Measures

• Pneumococcal vaccination
• Limit pacifier use after 6 months of age
• Breastfeeding for at least 6 months (reduces episodes of AOM)
• Avoid supine bottle feeding
• Reduce respiratory infections by altering daycare attendance patterns
• Avoid tobacco smoke exposure 1

Surgical Management

Consider tympanostomy tubes for children with:

• ≥3 episodes in 6 months or ≥4 episodes in 12 months
• Persistent middle ear effusion with hearing loss 1

Common Pitfalls

1. Misdiagnosis: Differentiate acute otitis media (which requires antibiotics) from otitis media with effusion (which generally doesn't require antibiotics) 3, 5

2. Underdosing amoxicillin: Using standard doses (40-45 mg/kg/day) rather than high doses (80-90 mg/kg/day) may lead to treatment failure with resistant S. pneumoniae 1, 4

3. Inadequate pain management: Always ensure adequate analgesia before starting antibiotics 3

4. Overtreatment: Antibiotic therapy can be deferred in children 2 years or older with mild symptoms 3

5. Failure to recognize complications: Watch for worsening ear pain, new neurological symptoms, and facial weakness or asymmetry 1