What is the treatment for otitis media?

Treatment of Otitis Media

Amoxicillin is the recommended first-line treatment for acute otitis media when antibiotic therapy is indicated, at a dose of 80-90 mg/kg/day in two divided doses. 1

Diagnosis and Initial Management

• Acute otitis media (AOM) should be diagnosed based on the presence of middle ear effusion with signs of acute inflammation and symptoms 1
• Management options include:
  • Observation without antibiotics for selected children with uncomplicated AOM based on diagnostic certainty, age, illness severity, and assured follow-up 1
  • Antibiotic therapy for children under 6 months, those with severe symptoms, or when observation is not feasible 1
• Pain management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 1

Antibiotic Selection Algorithm

First-line Treatment:

• Amoxicillin (80-90 mg/kg/day in 2 divided doses) for most patients due to its effectiveness against common pathogens, safety, low cost, acceptable taste, and narrow microbiologic spectrum 1

Alternative First-line Treatment (use when):

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) should be used if: 1
  • Patient has taken amoxicillin in the previous 30 days
  • Patient has concurrent purulent conjunctivitis
  • Coverage for Moraxella catarrhalis is desired
  • Patient has a history of recurrent AOM unresponsive to amoxicillin

For Penicillin-Allergic Patients:

• Cefdinir (14 mg/kg/day in 1-2 doses) 1
• Cefuroxime (30 mg/kg/day in 2 divided doses) 1
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 1
• Ceftriaxone (50 mg IM or IV per day for 1-3 days) 1

Treatment Failure:

• If symptoms worsen or fail to improve within 48-72 hours of initial treatment: 1
  • Reassess the patient to confirm AOM diagnosis
  • If initially observed without antibiotics, begin antibiotic therapy
  • If initially treated with amoxicillin, switch to amoxicillin-clavulanate
  • If initially treated with amoxicillin-clavulanate, consider ceftriaxone (50 mg/kg IM or IV for 3 days)

Microbiology and Resistance Considerations

• Major pathogens causing AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
• Resistance patterns vary geographically, with increasing prevalence of beta-lactamase producing organisms (especially H. influenzae and M. catarrhalis) 1, 2
• The choice of antibiotic should consider local resistance patterns 1

Special Considerations

• For children with multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered 1
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making cefdinir, cefuroxime, cefpodoxime, and ceftriaxone generally safe options for patients with non-severe penicillin allergy 1
• For azithromycin in pediatric patients with AOM, the FDA-approved dosing is 30 mg/kg as a single dose, or 10 mg/kg once daily for 3 days, or 10 mg/kg on day 1 followed by 5 mg/kg/day on days 2-5 3
• In obese children, physicians often prescribe lower-than-recommended amoxicillin doses when the weight-based calculation exceeds the standard adult dose of 1500 mg/day 4

Follow-up

• Once clinical improvement occurs, routine follow-up is based on the usual clinical course of AOM 1
• Persistent middle ear effusion is common after AOM resolution (60-70% at 2 weeks, 40% at 1 month, 10-25% at 3 months) 1
• This persistent effusion without clinical symptoms is defined as otitis media with effusion (OME) and generally does not require antibiotic treatment 1

Prevention

• Risk reduction strategies should be encouraged, including:
  • Breastfeeding
  • Avoiding tobacco smoke exposure
  • Limiting pacifier use in older infants and children
  • Pneumococcal vaccination 1