What are the treatment options for acute otitis media (AOM) in adults?

Treatment Options for Acute Otitis Media in Adults

Amoxicillin is the first-line antibiotic treatment for acute otitis media (AOM) in adults, with dosage adjustment needed for drug-resistant strains. 1

Diagnosis of Acute Otitis Media

Proper diagnosis of AOM requires:

• A history of acute onset of signs and symptoms 1
• Presence of middle ear effusion 1
• Signs of middle ear inflammation (distinct erythema of tympanic membrane or ear pain) 1

First-Line Treatment

Pain Management

• Pain management should be addressed immediately regardless of antibiotic use 1
• Analgesics (acetaminophen or NSAIDs) should be administered regularly at adequate doses to control pain 1
• NSAIDs during acute phase significantly reduce pain compared to placebo 1

Antibiotic Therapy

• First-line treatment: Amoxicillin (80-90 mg/kg/day) 1, 2

  • Effective against susceptible and intermediate resistant pneumococci
  • Safe, inexpensive, and has acceptable taste profile
  • Most common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2

• Duration of therapy: While optimal duration is uncertain in adults, typical courses range from 5-10 days 1

Second-Line Treatment Options

If patient fails to respond to initial treatment within 48-72 hours, reassess and consider:

• Amoxicillin-clavulanate - effective against β-lactamase producing strains 1, 2

• Cephalosporins (if non-type I penicillin allergy):

  • Cefuroxime axetil 1
  • Cefpodoxime proxetil 1
  • Cefdinir 1

• For penicillin allergic patients:

  • Trimethoprim-sulfamethoxazole 3
  • Macrolides (including azithromycin) 1, 4

Special Considerations

• Concurrent middle ear disease: May require systemic antimicrobials, imaging studies, or surgery 1

• Fungal otitis: Should be suspected if patient fails to respond to initial topical therapy; management may include debridement plus topical antifungal therapy 1

• Post-radiotherapy patients: Management of AOE may require systemic antimicrobials 1

• Incidence in adults: 5.3/1000 person-years, with higher rates in atopic patients (7.3/1000 person-years) 5

Treatment Failure

If patient fails to respond within 48-72 hours:

• Reassess to confirm diagnosis and exclude other causes 1
• If initially managed with observation, begin antibacterial therapy 1
• If initially managed with antibiotics, change to a second-line agent 1
• Consider referral to specialist if symptoms persist 1

Prevention Strategies

• Reduction of risk factors where possible 1
• Consider pneumococcal vaccination in recurrent cases 3
• Consider influenza vaccination for cases that worsen during flu season 3

Common Pitfalls

• Failing to provide adequate pain management 1
• Not reassessing patients who fail to improve within 48-72 hours 1
• Using topical antibiotics inappropriately (21% of adult cases receive these) 5
• Treating isolated redness of tympanic membrane with normal landmarks as AOM 1
• Not distinguishing between AOM and otitis media with effusion (which generally doesn't require antibiotics) 2