What is the management of pediatric otitis media (ear infection)?

From the Guidelines

The management of pediatric otitis media should prioritize pain relief, monitoring, and sometimes antibiotics, with a focus on watchful waiting for mild cases in children over 6 months, as recommended by the most recent clinical practice guideline update in 2022 1.

Key Considerations

• Pain management is crucial, and acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) can be used, along with a warm compress for comfort.
• A "watchful waiting" approach is often recommended for mild cases in children over 6 months, as many ear infections resolve without antibiotics within 2-3 days.
• Antibiotics like amoxicillin (40-45 mg/kg/day divided twice daily for 10 days) may be prescribed for severe symptoms, very young children, or infections that don't improve, considering the bacterial pathogens and potential resistance 1.

Important Factors

• Keeping the child's ear dry during bathing and having them rest with the affected ear facing up can help with drainage.
• It's essential to contact a doctor immediately if symptoms worsen, fever exceeds 102.2°F (39°C), symptoms persist beyond 2-3 days, or if the child experiences severe pain, hearing problems, or fluid draining from the ear.
• The anatomy of a child's eustachian tubes, being shorter and more horizontal than adults', makes them more prone to ear infections when mucus builds up during colds or allergies.

Treatment Goals

• The primary goal is to rapidly resolve signs and symptoms of the disease, sterilize the middle ear fluid, prevent suppurative sequelae, reduce relapse and recurrences, and decrease the time spent with middle ear fluid, as outlined in the clinical practice guideline update 1.
• The preferred antimicrobial agent should be active against the most common bacterial pathogens, including S. pneumoniae, H. influenzae, and M. catarrhalis, with consideration of potential resistance and the use of β-lactamase-stable agents or combination therapies 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

PEDIATRIC DOSAGE GUIDELINES FOR OTITIS MEDIA, ACUTE BACTERIAL SINUSITIS AND COMMUNITY-ACQUIRED PNEUMONIA (Age 6 months and above, see PRECAUTIONS—Pediatric Use.)

Based on Body Weight OTITIS MEDIA AND COMMUNITY-ACQUIRED PNEUMONIA: (5-Day Regimen)

• Dosing Calculated on 10 mg/kg/day Day 1 and 5 mg/kg/day Days 2 to 5.

In two adequate and well-controlled U. S. clinical trials a single IM dose of ceftriaxone was compared with a 10 day course of oral antibiotic in pediatric patients between the ages of 3 months and 6 years

The management of pediatric otitis media includes:

• Azithromycin: 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5 2
• Ceftriaxone: a single IM dose compared with a 10 day course of oral antibiotic in pediatric patients between the ages of 3 months and 6 years 3 Key points:
• The dosage of azithromycin varies based on the weight of the child
• Ceftriaxone was compared with a 10-day course of oral antibiotic in clinical trials
• The effectiveness of the 3-day or 1-day regimen in pediatric patients with community-acquired pneumonia has not been established for azithromycin 2

From the Research

Management of Pediatric Otitis Media

The management of pediatric otitis media (ear infection) involves the use of antimicrobial agents to treat the infection. The choice of antimicrobial agent depends on several factors, including the severity of the infection, the age of the child, and the presence of any underlying medical conditions.

• First-line treatment: Amoxicillin is recommended as the first-line agent to treat uncomplicated acute otitis media (AOM) 4.
• Alternative treatments: For clinical treatment failures after 3 days of amoxicillin, recommended antimicrobial agents include oral amoxicillin/clavulanate, cefuroxime axetil, cefprozil, cefpodoxime proxetil, and intramuscular (i.m.) ceftriaxone 4.
• Severe cases: I.m. ceftriaxone should be reserved for severe cases or patients in whom noncompliance is expected 4.
• Tympanocentesis: Tympanocentesis for identification of pathogens and susceptibility to antimicrobial agents is recommended for selection of third-line agents 4.

Comparison of Antimicrobial Agents

Several studies have compared the efficacy of different antimicrobial agents in the treatment of AOM.

• Amoxicillin/clavulanate vs. azithromycin: Amoxicillin/clavulanate has been shown to be more effective than azithromycin in eradicating bacterial pathogens, including Streptococcus pneumoniae and Haemophilus influenzae, from middle ear fluid 5, 6.
• Amoxicillin/clavulanate vs. other antimicrobials: Amoxicillin/clavulanate has also been compared to other antimicrobials, including cefdinir, cefaclor, and penicillin V, and has been shown to be superior or comparable in efficacy 7.

Treatment Guidelines

Several guidelines have been developed for the treatment of AOM in children.

• Italian intersociety Consensus: A recent consensus statement recommends the use of amoxicillin as the first-line treatment for AOM in children, with amoxicillin/clavulanate reserved for cases with a risk of infection by β-lactamase-producing bacteria 8.
• Watchful waiting: The consensus statement also recommends a period of "watchful waiting" before initiating antibiotic therapy, during which symptoms are treated while monitoring the patient clinically to see if symptoms resolve 8.