What is the treatment for otitis media?

Treatment of Otitis Media

Amoxicillin is the first-line treatment for acute otitis media (AOM), with a recommended high-dose of 80-90 mg/kg/day divided into two doses for children or 1500-3000 mg/day for adults. 1

Diagnosis and Initial Assessment

• AOM is diagnosed based on:

  • Acute onset of symptoms
  • Presence of middle ear effusion
  • Physical evidence of middle ear inflammation
  • Symptoms such as pain, irritability, or fever 1

• Common causative organisms:

  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis 1

Treatment Algorithm

Step 1: Pain Management

• Begin with adequate analgesia as pain is the most prominent and distressing symptom 1

Step 2: Antibiotic Selection

First-line Treatment:

• Amoxicillin (80-90 mg/kg/day divided into two doses for children or 1500-3000 mg/day for adults) 1
  • Provides excellent coverage against S. pneumoniae and non-beta-lactamase producing H. influenzae
  • Duration: 10 days for children under 2 years; 5-7 days for older children and adults 1

Second-line Treatment (for recurrent AOM, recent amoxicillin use, or treatment failure):

• Amoxicillin-clavulanate 1
  • Clinical trials show comparable efficacy between 875 mg/125 mg every 12 hours and 500 mg/125 mg every 8 hours dosing regimens 2
  • The every 12 hours regimen has significantly lower rates of severe diarrhea (1% vs 2%) 2

For Penicillin Allergy:

• Non-anaphylactoid reactions: Cefdinir, cefpodoxime, or cefuroxime 1
• Severe penicillin allergy:
  • Adults: Levofloxacin 750 mg daily or doxycycline 100 mg twice daily 1
  • Third-choice: Clindamycin 300-450 mg four times daily (limited by pneumococcal resistance) 1

Treatment Failure with Amoxicillin-Clavulanate:

• Consider ceftriaxone or consultation with a specialist 1
• Parenteral ceftriaxone is indicated when symptoms are severe or oral therapy is not tolerated 1

Special Considerations

Age-Specific Recommendations

• Children under 2 years with bilateral otitis media require immediate antibiotic therapy rather than observation 1
• Children 2 years or older with mild symptoms may be candidates for deferred antibiotic therapy 1, 3

Tympanic Membrane Perforation

• Presence of tympanic membrane perforation in a child warrants immediate antibiotic therapy regardless of age 1

Clinical Improvement Timeline

• Improvement should be noted within 48-72 hours of starting appropriate antibiotic therapy 1
• If symptoms persist after 48-72 hours, patients should be reexamined and switched to a second-line agent 3

Otitis Media with Effusion (OME)

• Defined as middle ear effusion without acute symptoms 3
• Antibiotics, decongestants, or nasal steroids are not recommended as they do not hasten clearance of middle ear fluid 3
• Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist 3

Prevention and Recurrent AOM Management

• Consider tympanostomy tubes for children with ≥3 episodes in 6 months or ≥4 episodes in 12 months, or persistent middle ear effusion with hearing loss 1

• Preventive measures include:

  • Pneumococcal vaccination
  • Limiting pacifier use after 6 months of age
  • Breastfeeding for at least 6 months (reduces episodes of AOM)
  • Avoiding supine bottle feeding
  • Reducing respiratory infections by altering daycare attendance patterns 1

Common Pitfalls to Avoid

1. Penicillin Allergy Overdiagnosis: Up to 90% of patients reporting penicillin allergy can actually tolerate penicillins. Consider formal allergy testing when appropriate 1

2. Failure to Recognize Complications: Watch for worsening ear pain, new neurological symptoms, and facial weakness or asymmetry, which may indicate complications requiring prompt medical attention 1

3. Inappropriate Use of Topical Antibiotics: Topical antibiotics are contraindicated in fungal otitis as they may promote fungal overgrowth 1

4. Inadequate Duration of Therapy: Ensure appropriate duration based on age (10 days for children under 2 years; 5-7 days for older children and adults) 1