First-Line Treatment for Otitis Media

Amoxicillin at a dosage of 80-90 mg/kg/day in two divided doses is the recommended first-line treatment for acute otitis media. 1

Diagnosis and Confirmation

Accurate diagnosis of acute otitis media (AOM) requires three elements: history of acute onset of signs and symptoms, presence of middle-ear effusion, and signs of middle ear inflammation 1
Clinical findings that predict AOM include fullness or bulging of the tympanic membrane combined with changes in color and mobility 1
It's important to differentiate AOM from otitis media with effusion (OME), as antibiotics are indicated for AOM but not typically for effusion without acute symptoms 2

Amoxicillin remains the first-line antibiotic treatment for most children with AOM due to its effectiveness against common pathogens, safety profile, low cost, acceptable taste, and narrow microbiologic spectrum 1
The recommended dosage is 80-90 mg/kg/day in two divided doses to overcome increasingly resistant strains of Streptococcus pneumoniae 1, 2
Pain management should be addressed regardless of whether antibacterial agents are used, especially during the first 24 hours of an episode of AOM 1

For selected children, observation without immediate antibiotics (watchful waiting) is an option based on diagnostic certainty, age, illness severity, and assurance of follow-up 1
This approach is suitable for otherwise healthy children 6 months to 2 years with non-severe illness and uncertain diagnosis, or children 2 years or older without severe symptoms 1
If using the observation approach, symptomatic relief should be provided with reassessment in 48-72 hours 1

For patients with non-type I hypersensitivity to penicillin, alternative options include:
- Cefdinir (14 mg/kg/day in 1-2 doses) 2
- Cefuroxime (30 mg/kg/day in 2 divided doses) 2
- Cefpodoxime (10 mg/kg/day in 2 divided doses) 1, 2
For patients with type I hypersensitivity reactions to penicillin, macrolides may be considered, though they have higher failure rates due to resistance patterns 1

If a patient fails to respond to initial treatment within 48-72 hours, the patient should be reassessed to confirm AOM and exclude other causes of illness 1
For patients who fail initial amoxicillin therapy, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) is recommended 2, 3
Clinical studies have shown that high-dose amoxicillin-clavulanate is effective for treatment failures, with clinical success rates of 87% at end of therapy 3

The optimal duration of therapy for patients with AOM is typically 10 days for children under 2 years of age 1
For children over 2 years with uncomplicated AOM, shorter courses (5-7 days) may be considered, though 7-day regimens are generally preferred over 5-day regimens 4

Resistance to antimicrobials is increasingly influencing the selection of empiric antibiotic therapy for otitis media and is a major reason for treatment failure 2, 5
In areas with high prevalence of resistant pneumococci, the higher dose of amoxicillin (80-90 mg/kg/day) is particularly important 6, 5
For children who weigh more than 40 kg, the adult dose of amoxicillin (maximum 1500 mg/day) is often prescribed, though this may represent underdosing based on weight 7
Diarrhea is a common side effect of amoxicillin and amoxicillin-clavulanate treatment, occurring in 14-15% of patients on amoxicillin and higher rates with amoxicillin-clavulanate 3

Risk factor reduction is important for preventing recurrent otitis media, including reducing exposure to tobacco smoke, breastfeeding for at least six months, and avoiding supine bottle feeding 1, 2
Pneumococcal vaccination is recommended for prevention of recurrent AOM 8