What is the first-line treatment for acute otitis media (AOM) in pediatric (peds) patients?

First-Line Treatment for Acute Otitis Media in Pediatric Patients

The first-line treatment for acute otitis media (AOM) in pediatric patients is amoxicillin at a dosage of 80-90 mg/kg/day. 1, 2

Diagnosis Criteria

• AOM is diagnosed in children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not due to acute otitis externa 2
• AOM can also be diagnosed with mild bulging of the tympanic membrane and recent onset of ear pain (less than 48 hours) or intense erythema of the tympanic membrane 2

Treatment Algorithm Based on Age and Severity

Children 6-23 months:

• Severe AOM or bilateral AOM (regardless of severity): Immediate antibiotic therapy 2
• Non-severe unilateral AOM: Either immediate antibiotics or observation with close follow-up based on joint decision-making with parents/caregivers 2

Children ≥24 months:

• Severe AOM: Immediate antibiotic therapy 2
• Non-severe AOM (unilateral or bilateral): Either immediate antibiotics or observation with close follow-up 2

Antibiotic Selection and Dosing

• First-line therapy: Amoxicillin 80-90 mg/kg/day divided into 2-3 doses 3, 1, 2

  • Duration: 10 days for children <2 years; 5-7 days for children ≥2 years with mild/moderate symptoms 3, 4

• Second-line therapy (treatment failure or high-risk situations): Amoxicillin-clavulanate 3, 2

  • Indications for second-line therapy:
    • Amoxicillin treatment in the past 30 days
    • Concurrent purulent conjunctivitis
    • Recurrent AOM unresponsive to amoxicillin 2

• For penicillin allergy: 1, 4

  • Non-type I hypersensitivity: Cefdinir, cefpodoxime, or cefuroxime
  • Type I hypersensitivity: Azithromycin or clarithromycin

Pain Management

• Pain control should be addressed immediately regardless of whether antibiotics are prescribed 1, 2
• Appropriate analgesics include acetaminophen or ibuprofen at age-appropriate doses 4
• Continue analgesics as long as needed to control pain 2

Follow-up and Treatment Failure

• If symptoms worsen or fail to improve within 48-72 hours, reassess to confirm diagnosis 3, 2
• For treatment failure, switch to a second-line agent such as amoxicillin-clavulanate 1, 2
• Consider tympanocentesis for bacteriologic diagnosis in patients who fail multiple courses of antibiotics 3

Important Considerations

• The WHO Expert Committee strongly recommends amoxicillin as first choice and amoxicillin-clavulanic acid as second choice for AOM 3
• Observation without antibiotics is appropriate in select cases, with approximately two-thirds of children improving without antibiotics 3
• Persistent middle ear effusion after AOM resolution is common (60-70% at 2 weeks, 40% at 1 month) and does not require additional antibiotics 3
• Completing the full course of antibiotics is essential, even if symptoms improve before completion 1

Prevention Strategies

• Ensure up-to-date immunization with pneumococcal conjugate vaccines 4, 2
• Consider annual influenza vaccination 4
• Encourage breastfeeding for at least six months 2
• Reduce or eliminate pacifier use after six months of age 2