Treatment of Otitis Media in Adults
For adults with otitis media, amoxicillin-clavulanate is the first-line antibiotic treatment of choice, with cefuroxime-axetil and cefpodoxime-proxetil as effective alternatives. 1, 2
Diagnosis
Before initiating treatment, proper diagnosis is essential:
- Pneumatic otoscopy is the primary diagnostic method
- Look for moderate to severe bulging of the tympanic membrane, new-onset otorrhea, or mild bulging with recent-onset ear pain or intense erythema
- Note: Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotics
Treatment Algorithm
First-line Treatment:
- Amoxicillin-clavulanate (first choice)
- Provides coverage against common pathogens including beta-lactamase producing strains
- Effective against S. pneumoniae, H. influenzae, and M. catarrhalis
Alternative Options (for penicillin allergy or treatment failure):
Non-type I penicillin allergy:
- Cefuroxime-axetil
- Cefpodoxime-proxetil
Type I penicillin allergy:
- Macrolides (azithromycin, clarithromycin)
- Respiratory fluoroquinolones (in adults only)
- Erythromycin-sulfafurazole
Pain Management:
- Immediate pain control with acetaminophen or ibuprofen
- Topical analgesics can be used as complementary treatment
Treatment Duration
- 5 days of antibiotic therapy is typically sufficient for adults 1
Treatment Failure
Treatment failure is defined as:
- Worsening of patient's condition
- Persistence of symptoms for >48 hours after starting antibiotics
- Recurrence of functional and systemic signs with otoscopic signs of purulent AOM within 4 days of treatment discontinuation
If treatment fails:
- Consider paracentesis with collection of bacteriological specimen
- Change antibiotic therapy based on the first agent prescribed and bacteria isolated
- Consider second-line antibiotics if first-line treatment fails
Important Considerations
What NOT to Use:
- Antihistamines and decongestants are ineffective for otitis media and should not be used 2
- Oral steroids are not recommended for routine management 2
- NSAIDs at anti-inflammatory doses and corticosteroids have not demonstrated efficacy in acute otitis media 1
- Fluoroquinolones inactive on pneumococci (ofloxacin, ciprofloxacin) should be avoided 1
Special Situations:
- For patients with perforated tympanic membrane, topical antibiotic therapy with fluoroquinolone drops is recommended 2
- For recurrent infections not responding to antibiotics, consider referral for tympanostomy tube insertion 2
Prevention
- Ensure pneumococcal and influenza vaccinations are up-to-date
- Reduce risk factors such as tobacco smoke exposure
- Regular follow-up every 4-6 weeks until resolution or specialist consultation
When to Refer
- Persistent or recurrent cases despite appropriate treatment
- Complications such as mastoiditis
- Persistent hearing loss
- Language development delay
By following this treatment approach, you can effectively manage otitis media in adults while minimizing complications and improving quality of life outcomes.