What is the treatment for acute otitis media in adults?

Treatment of Acute Otitis Media in Adults

For adults with acute otitis media (AOM), the recommended first-line treatment is amoxicillin (80-90 mg/kg/day), with amoxicillin-clavulanate as the preferred second-line therapy when treatment fails or in cases with specific risk factors. 1

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis with:

• Moderate to severe bulging of the tympanic membrane
• New-onset otorrhea not due to otitis externa
• Mild bulging with either recent-onset ear pain or intense erythema of the tympanic membrane 1

Note that isolated redness of the tympanic membrane with normal landmarks is insufficient for diagnosis.

Treatment Algorithm

First-line Treatment:

• Oral Antibiotics: Amoxicillin (standard adult dose) for 5-7 days 1, 2
  • Effective against susceptible and intermediate-resistant pneumococci
  • Safe, inexpensive, and well-tolerated

Second-line Treatment (if first-line fails):

• Amoxicillin-clavulanate if:
  • No improvement within 48-72 hours of starting amoxicillin
  • Patient has used amoxicillin in the past 30 days
  • Concomitant purulent conjunctivitis is present 1

Alternative Antibiotics (for penicillin-allergic patients):

• Non-type I hypersensitivity: Cefdinir, cefpodoxime, or cefuroxime
• Type I hypersensitivity: Macrolides (azithromycin, clarithromycin) or respiratory fluoroquinolones 1

Pain Management (Essential Component):

• Oral analgesics: Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) at appropriate doses 3
  • Administer at fixed intervals rather than as needed for severe pain
  • For moderate to severe pain, consider combination with opioids (e.g., oxycodone, hydrocodone) 3
• Topical analgesics: May be used as a complement to oral medications 1

Treatment Duration and Follow-up

• Standard treatment duration for uncomplicated AOM in adults: 5-7 days 1
• Assess response to therapy within 48-72 hours 1
• If symptoms persist or worsen after 48-72 hours of antibiotic therapy, patient should be reexamined and switched to a second-line agent 1, 4

Treatment Failure

Treatment failure is defined as:

• Worsening of the patient's condition
• Persistence of symptoms for more than 48 hours after starting antibiotics
• Recurrence of symptoms within 4 days of completing treatment 3, 1

In cases of treatment failure, consider:

• Changing antibiotic therapy based on likely pathogens (S. pneumoniae, H. influenzae, and M. catarrhalis are most common) 4
• Obtaining a culture if possible, especially in severe or recurrent cases
• Referral to an otolaryngologist if symptoms persist despite appropriate therapy 1

Special Considerations

• Adults tend to seek care more quickly after symptom onset compared to children 5
• Adults are more likely to complain of ear pain, decreased hearing, sore throat, and ear discharge 5
• The likelihood of poor outcomes increases with:
  • Increasing age
  • Higher number of past AOM episodes 5
• Incidence of AOM in adults is particularly high in those with atopic conditions (7.3/1000 person-years) 6
• Incidence declines with age (from 7.1 in patients 15-39 years to 2.7/1000 person-years in those aged 64+ years) 6

Prevention

• Ensure pneumococcal and influenza vaccinations are up-to-date 1
• Reduce exposure to risk factors such as tobacco smoke 1

Remember that adequate pain control is essential for proper management, as the pain associated with AOM can be intense due to the proximity of the highly sensitive periosteum to the ear canal skin 3.