What is the treatment for otitis media and bacterial sinusitis?

Treatment of Otitis Media and Bacterial Sinusitis

For both otitis media and bacterial sinusitis, amoxicillin is the first-line treatment, with amoxicillin-clavulanate recommended when there are risk factors for resistant organisms. 1, 2

Acute Otitis Media (AOM)

First-line Treatment

• Amoxicillin: 80-90 mg/kg/day divided in 2 doses for children 1
  • Standard dose for adults: 500-875 mg twice daily for 5-7 days 2
  • For uncomplicated cases without risk factors for resistance

When to Consider Amoxicillin-Clavulanate (Augmentin):

• Recent antibiotic use (within past 30 days)
• Concurrent conjunctivitis
• Need for coverage of β-lactamase producing organisms
• Dosing: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate in 2 divided doses 2

For Penicillin Allergy:

• Non-type I hypersensitivity reactions (e.g., rash):
  • Cefdinir (14 mg/kg/day)
  • Cefuroxime (30 mg/kg/day)
  • Cefpodoxime (10 mg/kg/day) 2
• Type I hypersensitivity reactions:
  • Azithromycin or clarithromycin (note: less effective against common pathogens) 1

Observation Option

• May be appropriate for:
  • Children 6 months to 2 years with non-severe illness and uncertain diagnosis
  • Children over 2 years without severe symptoms 1
• Requires follow-up within 48-72 hours

Acute Bacterial Sinusitis

First-line Treatment

• Amoxicillin: Same dosing as for AOM 1
• Amoxicillin-clavulanate: For patients with risk factors for resistant organisms 1, 2

Risk Factors for Resistant Organisms:

• Recent antibiotic use
• Daycare attendance
• Age <2 years
• Severe symptoms or worsening course 1

For Penicillin Allergy:

• Non-type I reactions: Cephalosporins (cefdinir, cefpodoxime, cefuroxime) 1
• Type I reactions: Respiratory fluoroquinolones (adults only), doxycycline, or clindamycin plus rifampin for severe cases 2

When to Treat vs. Observe

• Treat immediately for:
  • Severe symptoms (fever ≥39°C with purulent nasal discharge for ≥3 days)
  • Worsening symptoms (new fever, increased nasal discharge after initial improvement)
  • Coexisting conditions (acute otitis media, pneumonia, adenitis) 1
• Observation option for:
  • Persistent symptoms >10 days without improvement
  • Mild symptoms in otherwise healthy children 1

Treatment Failure Management

If No Improvement After 48-72 Hours:

1. Reassess diagnosis to confirm infection and exclude other causes
2. Change antibiotic therapy:
   • If started with amoxicillin → switch to high-dose amoxicillin-clavulanate
   • If started with amoxicillin-clavulanate → consider clindamycin plus cefixime or levofloxacin (adults) 1

For Complicated Cases:

• Consider imaging (CT scan for sinusitis)
• Consider ENT referral for:
  • Orbital or intracranial complications
  • Persistent symptoms despite appropriate therapy
  • Recurrent episodes 1, 2

Duration of Therapy

• Acute otitis media: 5-7 days for children >2 years; 10 days for younger children
• Acute bacterial sinusitis: 5-7 days for uncomplicated cases; 10-14 days for severe or complicated cases 2

Common Pathogens

• Streptococcus pneumoniae (most common)
• Haemophilus influenzae
• Moraxella catarrhalis (more common in children) 1

Important Considerations

• The emergence of resistant bacteria, particularly β-lactamase-producing H. influenzae and M. catarrhalis, necessitates careful antibiotic selection 3
• Antibiotic overuse contributes to resistance; use observation when appropriate 1
• Adjunctive treatments (pain management, decongestants, nasal saline) should be used for symptom relief 2

Warning Signs for Complications

• Severe headache or facial pain
• Orbital swelling or visual changes
• Mental status changes
• Persistent high fever despite appropriate therapy
• These require immediate referral and possibly hospitalization 2