What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

The first-line treatment for acute otitis media is high-dose amoxicillin (80-90 mg/kg/day divided into two doses for children or 1500-3000 mg/day for adults), with pain management being a critical component of initial therapy. 1, 2

Diagnosis

• Accurate diagnosis requires:
  • Acute onset of symptoms (pain, irritability, fever)
  • Middle ear effusion
  • Physical evidence of middle ear inflammation (bulging tympanic membrane)

Treatment Algorithm

Pain Management

• Pain relief should be prioritized immediately
• Options include:
  • Acetaminophen or ibuprofen at appropriate doses
  • Topical analgesics if needed

Antibiotic Therapy Decision

1. Children < 2 years old: Immediate antibiotic therapy 1
2. Children ≥ 2 years old:
   • Severe symptoms (temperature ≥39°C, severe otalgia, bilateral AOM, or otorrhea): Immediate antibiotics
   • Mild symptoms: Observation with close follow-up is appropriate (watchful waiting)
   • Tympanic membrane perforation: Immediate antibiotics regardless of age 1

Antibiotic Selection

1. First episode or no recent antibiotic use:

   • High-dose amoxicillin (80-90 mg/kg/day divided into two doses) for 10 days in children <2 years 1, 2
   • 7-day course for children 2-5 years with mild/moderate symptoms 1
   • 10-day course for children ≥6 years 1

2. Recurrent AOM or recent amoxicillin use (within 30 days):

   • Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) 1, 3
   • Clinical trials show comparable efficacy between twice-daily and three-times-daily dosing 3

3. Treatment failure with amoxicillin-clavulanate:

   • Consider ceftriaxone (single IM dose) or specialist consultation 1, 4
   • Clinical trials show ceftriaxone is effective for pediatric AOM with bacteriologic eradication rates of 80-85% for common pathogens 4

4. Penicillin allergies:

   • Non-Type I allergies: Cefdinir, cefuroxime, or cefpodoxime
   • Type I allergies: Macrolides or clindamycin 1

Follow-up

• Reassess after 48-72 hours if symptoms persist
• Switch to second-line therapy if no improvement

Preventive Measures

• Pneumococcal vaccination
• Influenza vaccination
• Exclusive breastfeeding for at least 4-6 months
• Avoid supine bottle feeding
• Limit pacifier use after 6 months
• Reduce tobacco smoke exposure

Common Pitfalls

1. Underutilization of pain management: Studies show only 10.4% of AOM patients receive analgesics despite recommendations for active pain relief 5
2. Inappropriate antibiotic selection: Cefdinir prescribing has increased contrary to guidelines, while amoxicillin/clavulanate use has decreased 6
3. Failure to distinguish AOM from otitis media with effusion: The latter does not require antibiotics 2
4. Inadequate follow-up: Children with persistent symptoms need reassessment and potential change in therapy

Special Considerations

• Consider tympanostomy tubes for children with ≥3 episodes in 6 months or ≥4 episodes in 12 months 1
• Watch for complications such as mastoiditis, which may present with worsening ear pain, new neurological symptoms, or facial weakness 1

Treatment Efficacy

Clinical trials show high-dose amoxicillin-clavulanate achieves 87% cure rates at end of therapy and 67% at follow-up, with significantly lower diarrhea rates in twice-daily dosing compared to three-times-daily dosing (14% vs 34%) 3