What is the initial treatment for otitis media suppurative?

Initial Treatment of Suppurative Otitis Media

High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the recommended first-line treatment for suppurative otitis media due to its effectiveness against common pathogens, safety profile, low cost, and narrow microbiologic spectrum. 1, 2

Diagnosis Considerations

• Proper diagnosis requires differentiating acute otitis media (AOM) from otitis media with effusion (OME), as antibiotics are indicated for AOM but not for OME in the absence of acute symptoms 2
• The main bacterial pathogens in suppurative otitis media are Streptococcus pneumoniae and Haemophilus influenzae, with regional variations in prevalence 1, 2
• Diagnosis should be based on acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever 3

First-Line Treatment

• Amoxicillin at 80-90 mg/kg/day in 2 divided doses is the recommended initial treatment 1, 2
• Pain management should be addressed regardless of antibiotic therapy, especially during the first 24 hours of treatment 2
• During treatment, patients may worsen slightly initially but should stabilize within 24 hours and begin improving during the second 24-hour period 1
• Clinical improvement should be noted within 48-72 hours of starting antibiotics 1

Alternative First-Line Options

• 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) 2
• For patients who have taken amoxicillin in the previous 30 days, those with concurrent conjunctivitis, or when coverage for β-lactamase-positive organisms is desired, use high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 2, 4

Management of Treatment Failure

• If a patient fails to respond to initial treatment within 48-72 hours, reassess to confirm the diagnosis and exclude other causes of illness 1
• For patients who fail initial amoxicillin therapy, switch to:
  • Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1, 4
  • If the patient was initially treated with amoxicillin-clavulanate or oral third-generation cephalosporins, consider intramuscular ceftriaxone (50 mg/kg) 1, 5
  • A 3-day course of ceftriaxone has been shown to be more effective than a 1-day regimen for AOM unresponsive to initial antibiotics 1

Special Considerations

• For chronic suppurative otitis media, treatment with antibiotics or antiseptics accompanied by aural toilet (cleaning) is more effective than no treatment or aural toilet alone 6
• Topical treatment with antibiotics or antiseptics is more effective than systemic antibiotics for chronic suppurative otitis media 6
• Topical quinolones are more effective than non-quinolones for chronic suppurative otitis media 6
• In cases of multiple treatment failures, tympanocentesis should be considered for bacteriologic diagnosis and susceptibility testing 1

Potential Adverse Effects

• Diarrhea is the most common adverse effect of amoxicillin-clavulanate, with significantly higher rates compared to cefdinir (35% vs. 10-13%) 7
• The incidence of diarrhea is significantly lower with twice-daily dosing compared to three-times-daily dosing of amoxicillin-clavulanate 4

Important Caveats

• Antimicrobial resistance is increasingly influencing the selection of empiric antibiotic therapy and is now regarded as the main reason for treatment failure 1
• The role of antibiotics in otitis media remains somewhat controversial, with meta-analyses suggesting modest benefits, but evidence from double-tympanocentesis studies shows that bacterial eradication contributes to improved clinical outcomes 1, 2
• For chronic suppurative otitis media, the definitive treatment is surgical (tympanoplasty), not conservative antimicrobial therapy 8