What is the recommended treatment for pediatric patients with acute otitis media?

Treatment of Acute Otitis Media in Pediatric Patients

High-dose amoxicillin (80-90 mg/kg/day) is the recommended first-line treatment for pediatric patients with acute otitis media when antibiotic therapy is indicated. 1, 2

Diagnosis

Proper diagnosis of acute otitis media (AOM) requires:

• History of acute onset of signs and symptoms 1
• Presence of middle ear effusion 1
• Signs of middle ear inflammation (bulging tympanic membrane, limited mobility, air-fluid level, or otorrhea) 1
• Symptoms such as otalgia, irritability, or fever 3, 4

Treatment Decision Algorithm

When to Prescribe Antibiotics Immediately:

• Children <6 months of age with confirmed AOM 1, 2
• Children 6-23 months with bilateral AOM (even without severe symptoms) 1
• Children with severe symptoms (moderate to severe otalgia or fever ≥39°C/102.2°F) 1, 3
• Children with otorrhea (drainage from the ear) 1

When Observation May Be Appropriate:

• Children 6-23 months with unilateral AOM without severe symptoms 1
• Children ≥24 months with non-severe illness (mild otalgia <48 hours and temperature <39°C) 1

Antibiotic Selection

First-Line Therapy:

• Amoxicillin at 80-90 mg/kg/day divided into 2 doses for most children 1, 2
• Duration: 10 days for children <2 years; 5-7 days for children ≥2 years 1, 2

Alternative First-Line Therapy (in specific situations):

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) when: 1
  • Child has received amoxicillin in the past 30 days
  • Child has concurrent purulent conjunctivitis
  • Coverage for β-lactamase producing organisms is desired

For Penicillin Allergy:

• Non-type I hypersensitivity: Cefdinir (14 mg/kg/day), cefuroxime (30 mg/kg/day), or cefpodoxime (10 mg/kg/day) 1, 2, 3
• Type I hypersensitivity: Azithromycin or clarithromycin 3, 5

Pain Management

• Pain assessment and management is essential regardless of antibiotic use 1, 3
• Appropriate analgesics should be recommended, especially during the first 24 hours 1, 3

Treatment Failure Management

• Reassess if symptoms worsen or fail to improve within 48-72 hours 1, 3
• For treatment failure, switch to: 1
  • Amoxicillin-clavulanate if initially treated with amoxicillin
  • Ceftriaxone (50 mg IM or IV for 3 days) if initially treated with amoxicillin-clavulanate
  • Consider tympanocentesis/drainage if skilled in the procedure or refer to otolaryngologist 1, 6

Common Pitfalls and Considerations

• Avoid macrolides as first-line therapy due to high rates of pneumococcal resistance 3, 6
• Complete the full antibiotic course even if symptoms improve before completion 2, 3
• Adverse effects of amoxicillin-clavulanate include diarrhea and diaper dermatitis 3
• Differentiate AOM from otitis media with effusion (OME), which does not require antibiotics 1, 4
• The most common pathogens in AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 6, 4

Special Considerations

• Increasing prevalence of drug-resistant S. pneumoniae and β-lactamase-producing organisms presents challenges for practitioners 6, 7
• For recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months), consider referral to an otolaryngologist 7
• Otitis media with effusion (fluid in the middle ear without signs of infection) does not require antibiotics 1, 4