Amoxicillin for Otitis Media in Adults

High-dose amoxicillin (3 g/day) is the recommended first-line antibiotic treatment for acute otitis media in adults. 1

Diagnosis and Treatment Decision

Acute otitis media (AOM) is characterized by purulent or mucopurulent middle ear fluid, though it is relatively rare in adults compared to children 1
The bacteria involved in adult AOM are the same as those observed in children: primarily Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
Antibiotic therapy is indicated in adults with marked symptoms (high fever, intense earache) 1
Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotic therapy 1

Amoxicillin at a dose of 3 g/day is the recommended first-line treatment for adults with AOM 1
The justification for using amoxicillin relates to its effectiveness against common AOM bacterial pathogens, safety, low cost, acceptable taste, and narrow microbiologic spectrum 1
Amoxicillin is generally effective when used in sufficient doses against susceptible and intermediate resistant pneumococci 1

For patients with penicillin allergy:

Second-generation cephalosporins (cefuroxime) 1
Third-generation cephalosporins (cefpodoxime) 1
Note: Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported and is generally negligible 1

If the 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
Consider switching to amoxicillin-clavulanate as second-line therapy 1
Other options include cefuroxime-axetil or cefpodoxime-proxetil 1
In cases of severe symptoms or when compliance is a concern, intramuscular ceftriaxone may be considered 2

For patients who have taken amoxicillin in the previous 30 days, consider starting with amoxicillin-clavulanate instead 1
In geographic areas with high prevalence of drug-resistant S. pneumoniae, high-dose amoxicillin is particularly important 3
Beta-lactamase-producing H. influenzae is a common cause of treatment failure with amoxicillin alone 3

Avoid treating otitis media with effusion (OME) with antibiotics unless it persists beyond 3 months 1
Do not confuse isolated redness of the tympanic membrane (which does not require antibiotics) with true AOM 1
Ensure adequate visualization of the tympanic membrane before making a diagnosis; if visualization is difficult, consider referral to an ENT specialist 1
The patient should begin to improve during the second 24-hour period of treatment; if not improved by 48-72 hours, consider treatment failure 1

While the optimal duration of therapy is uncertain 1, a typical course of 5-10 days is generally recommended based on clinical practice guidelines.