What is the recommended treatment for acute otitis media (AOM)?

Treatment of Acute Otitis Media (AOM)

The recommended first-line treatment for acute otitis media is amoxicillin at 80-90 mg/kg/day divided into two doses, with pain management as an essential component of care regardless of antibiotic prescription. 1, 2

Diagnosis Criteria

• AOM is diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa 1
• AOM can also be diagnosed with mild bulging of the tympanic membrane and either recent-onset ear pain (<48 hours) or intense erythema of the tympanic membrane 1

Treatment Algorithm Based on Age and Symptom Severity

Pain Management

• Pain control should be addressed immediately for all patients with AOM, regardless of whether antibiotics are prescribed 1, 3
• Use acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) for mild to moderate pain 4
• For severe pain, consider acetaminophen or NSAIDs in fixed combination with an opioid 4
• Continue analgesics as long as needed to control pain 1

Antibiotic Decision-Making

• For children 6-23 months:

  • With severe AOM or bilateral AOM (regardless of severity): Prescribe antibiotics immediately 1
  • With non-severe unilateral AOM: Either prescribe antibiotics or offer observation with close follow-up based on joint decision-making with parents/caregivers 1

• For children ≥24 months and adolescents:

  • With severe symptoms (moderate to severe otalgia, otalgia ≥48 hours, or temperature ≥39°C/102.2°F): Prescribe antibiotics immediately 1, 3
  • With non-severe symptoms: Consider observation without antibiotics if the child is otherwise healthy and reliable follow-up is assured 1, 3

Antibiotic Selection

• First-line therapy: Amoxicillin at 80-90 mg/kg/day divided into two doses 1, 2, 5
• Second-line therapy (use if patient has taken amoxicillin in the past 30 days, has concurrent purulent conjunctivitis, or fails initial therapy): Amoxicillin-clavulanate at 90 mg/kg/day based on the amoxicillin component 1, 6, 5
• For penicillin allergy:
  • Non-type I hypersensitivity: Cefdinir, cefpodoxime, or cefuroxime 1, 3
  • Type I hypersensitivity: Azithromycin or clarithromycin 3, 7

Treatment Duration

• 5-7 days for children ≥2 years and adolescents 3
• 10 days for children <2 years 1

Follow-up and Treatment Failure

• If symptoms worsen or fail to improve within 48-72 hours:
  • Reassess to confirm AOM diagnosis and exclude other causes 1, 3
  • If initially managed with observation, begin antibiotics 1
  • If initially treated with antibiotics, change to a second-line agent 1, 5

Special Considerations

• For patients with tympanostomy tubes or tympanic membrane perforation, use non-ototoxic topical preparations 4
• Consider tympanostomy tubes for children with recurrent AOM (three or more episodes within six months or four episodes within one year with one episode in the preceding six months) 2
• Fungal otitis externa (otomycosis) requires different management with antifungal therapy; topical antibiotics are contraindicated 4

Prevention Strategies

• Encourage pneumococcal conjugate vaccination and annual influenza vaccination 1, 3, 8
• Promote exclusive breastfeeding for at least six months 1, 2
• Reduce modifiable risk factors such as:
  • Modifying daycare attendance patterns 1
  • Avoiding supine bottle feeding 1
  • Reducing or eliminating pacifier use after six months of age 1
  • Avoiding cigarette smoke exposure 8