Initial Treatment for Acute Otitis Media
The initial treatment for acute otitis media (AOM) is high-dose amoxicillin at 80-90 mg/kg/day divided twice daily for children with no recent antibiotic use in the past 30 days. 1
Diagnosis and Classification
Before initiating treatment, it's important to correctly diagnose AOM and distinguish it from otitis media with effusion (OME):
- Acute Otitis Media (AOM): Requires antibiotic therapy
- Otitis Media with Effusion (OME): Does not require initial antibiotic therapy 2
The CDC recommends differentiating between these two conditions to rationalize antibiotic use 2.
First-Line Treatment
For Children:
- Standard first-line therapy: Amoxicillin 80-90 mg/kg/day divided twice daily for 5-10 days 1
- Duration: 10 days for children under 2 years; 5-7 days for older children 1
- Pain management: Analgesics should be provided regardless of antibiotic prescription 2
For Adults:
Second-Line Treatment Options
Switch to second-line therapy if:
- Patient has taken amoxicillin in the previous 30 days
- Patient has concurrent conjunctivitis
- Treatment failure after 48-72 hours of amoxicillin therapy 1, 3
Second-line options:
- Amoxicillin-clavulanate: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate (14:1 ratio) divided twice daily 1
- For penicillin allergies:
Treatment Algorithm
| Patient Characteristics | Recommended Treatment |
|---|---|
| First episode, no recent antibiotics | Amoxicillin 80-90 mg/kg/day |
| Recent amoxicillin use (within 30 days) | Amoxicillin-clavulanate |
| Concurrent conjunctivitis | Amoxicillin-clavulanate |
| Treatment failure with amoxicillin | Amoxicillin-clavulanate |
| Treatment failure with amoxicillin-clavulanate | Consider ceftriaxone or specialist consultation |
Special Considerations
Children under 2 years with bilateral AOM: Require immediate antibiotic therapy rather than observation 1
Observation option: For unilateral AOM in children 6-23 months without severe symptoms, clinicians may offer observation with close follow-up based on joint decision-making with parents 2
Tympanic membrane perforation: Warrants immediate antibiotic therapy regardless of age 1
Pain management: Essential component of treatment regardless of antibiotic use 2
- Analgesics should be continued as long as needed
- Pain relief should be addressed within the first 24 hours
Bacterial Resistance Considerations
The effectiveness of amoxicillin may be reduced by:
- β-lactamase-mediated resistance in H. influenzae 2
- Intermediate penicillin resistance in S. pneumoniae 2
This is why higher doses (80-90 mg/kg/day) are now recommended to overcome resistance patterns 1, 3.
Prevention of Recurrent Episodes
For children with recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months):
- Consider tympanostomy tubes 1
- Preventive measures include:
- Pneumococcal vaccination
- Limiting pacifier use after 6 months
- Breastfeeding for at least 6 months
- Avoiding supine bottle feeding
- Reducing tobacco smoke exposure 1
By following this treatment algorithm and considering the special circumstances of each patient, clinicians can effectively manage acute otitis media while minimizing complications and reducing the risk of antimicrobial resistance.