What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

For acute otitis media (AOM), amoxicillin is the first-line antibiotic treatment when antibiotics are indicated, though observation without antibiotics is appropriate for selected children based on age, symptom severity, and diagnostic certainty. 1

Pain Management

• Pain management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 1
• Analgesics should be continued as long as needed to control pain 1
• Pain relief is considered paramount in all treatment guidelines 1

Initial Management Decision: Observation vs. Antibiotics

Observation Option (without antibiotics):

• Appropriate for:
  • Children 6 months to 2 years with non-severe illness and uncertain diagnosis 1
  • Children 2 years or older without severe symptoms or with uncertain diagnosis 1
• Involves deferring antibiotics for 48-72 hours while providing symptomatic relief 1
• Requires assurance of follow-up and mechanism to start antibiotics if needed 1

Immediate Antibiotic Treatment:

• Indicated for:
  • Children under 2 years with bilateral AOM or severe signs/symptoms 1
  • Children with temperature ≥39°C (102.2°F) 1, 2
  • Children who appear toxic or have severe otalgia 2
  • Children with craniofacial abnormalities or who are immunocompromised 2
  • When follow-up cannot be assured 1

Antibiotic Selection

First-Line Treatment:

• Amoxicillin at 80-90 mg/kg/day divided into two doses 1
• Recommended because it is:
  • Effective against susceptible and intermediate resistant pneumococci 1
  • Safe, inexpensive, with acceptable taste and narrow spectrum 1

Alternative First-Line Options (for penicillin allergy):

• For non-type I hypersensitivity reactions: cefdinir, cefpodoxime, or cefuroxime 1
• For type I hypersensitivity reactions: consider macrolides like azithromycin 3

Second-Line Treatment (if initial therapy fails):

• If no improvement after 48-72 hours of initial therapy, reassess and consider: 1
• Amoxicillin-clavulanate for beta-lactamase producing organisms 4, 5
• Consider amoxicillin-clavulanate initially if:
  • Child received amoxicillin in past 30 days 1
  • Child has concurrent purulent conjunctivitis 1
  • History of recurrent AOM unresponsive to amoxicillin 1

Follow-up

• If symptoms worsen or don't improve within 48-72 hours:
  • Reassess to confirm AOM diagnosis and exclude other causes 1
  • If initially managed with observation, begin antibiotics 1
  • If initially treated with antibiotics, change to a second-line agent 1

Prevention Strategies

• Reduce risk factors where possible:
  • Consider modifying daycare attendance patterns 1
  • Encourage breastfeeding for at least six months 1
  • Avoid supine bottle feeding 1
  • Reduce or eliminate pacifier use after six months of age 1
• Immunization with pneumococcal conjugate vaccines and influenza vaccine 1

Common Pitfalls

• Failing to adequately address pain management 1
• Misdiagnosing otitis media with effusion (OME) as AOM, leading to unnecessary antibiotic use 1
• Using broad-spectrum antibiotics as first-line when amoxicillin would be sufficient 6
• Not reassessing patients who fail to respond to initial therapy within 48-72 hours 1
• Prescribing antibiotics for all cases without considering observation for appropriate candidates 6