What is the treatment for Acute Otitis Media (AOM)?

Treatment of Acute Otitis Media (AOM)

The first-line treatment for acute otitis media is amoxicillin at 80-90 mg/kg/day divided into two doses, with immediate pain management regardless of whether antibiotics are prescribed. 1, 2, 3

Diagnosis

• AOM is diagnosed in patients with moderate to severe bulging of the tympanic membrane or new onset of otorrhea not due to acute otitis externa 1
• 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 1

Pain Management

• Pain management should be addressed immediately regardless of whether antibiotics are prescribed, especially during the first 24 hours 1, 3
• Use oral acetaminophen or ibuprofen at age-appropriate doses for pain control 2, 4
• Topical analgesics may provide additional brief benefit, though evidence is limited 2
• Continue analgesics as long as needed to control pain 1, 3

Treatment Algorithm Based on Age and Severity

Children 6-23 months:

• Severe AOM or bilateral AOM: Prescribe antibiotics immediately 1
• Non-severe unilateral AOM: Either prescribe antibiotics or offer observation with close follow-up based on joint decision-making with parents/caregivers 1

Children ≥24 months:

• Severe AOM: Prescribe antibiotics immediately 1
• Non-severe AOM: Either prescribe antibiotics or offer observation with close follow-up based on joint decision-making with parents/caregivers 1

Adults:

• Severe symptoms: Immediate antibiotic therapy 3
• Mild symptoms: Either antibiotic therapy or observation with close follow-up 3

Antibiotic Selection

First-line therapy:

• Amoxicillin at 80-90 mg/kg/day divided into two doses for children 1, 5
• Amoxicillin at 1.5 to 4 g/day for adults 3
• First-line therapy when patient has not received amoxicillin in the past 30 days, does not have concurrent purulent conjunctivitis, and is not allergic to penicillin 1

Second-line therapy (when first-line fails or is contraindicated):

• Amoxicillin-clavulanate if patient has taken amoxicillin in the previous 30 days, has concurrent purulent conjunctivitis, or failed initial amoxicillin treatment 1, 6
• For patients with penicillin allergy:
  • Non-type I hypersensitivity: Cefdinir, cefpodoxime, or cefuroxime 2, 3
  • Type I hypersensitivity: Azithromycin or clarithromycin 2, 7

Observation Option

• Observation without antibiotics can be considered for:
  • Children 6 months to 2 years with non-severe illness and uncertain diagnosis 1
  • Children 2 years or older without severe symptoms or with uncertain diagnosis 1
  • Adults with mild symptoms, provided there is a mechanism to ensure follow-up within 48-72 hours 3
• During observation, management is limited to analgesics and symptomatic relief 8
• A mechanism must be in place to ensure follow-up and initiation of antibiotics if the child fails observation 9

Follow-up and Treatment Failure

• If symptoms worsen or fail to improve within 48-72 hours of initial treatment, reassess to confirm AOM diagnosis and exclude other causes 1, 3
• For patients initially managed with observation, begin antibiotics if symptoms worsen or don't improve 1
• For treatment failures on amoxicillin, switch to amoxicillin-clavulanate or another agent with coverage against beta-lactamase producing organisms 3, 6

Prevention Strategies

• Reduce risk factors where possible:
  • Modify daycare attendance patterns 1
  • Encourage breastfeeding for at least six months 1, 10
  • Avoid supine bottle feeding 1
  • Reduce or eliminate pacifier use after six months of age 1
  • Avoid tobacco smoke exposure 3
• Ensure up-to-date immunization with pneumococcal conjugate vaccines and annual influenza vaccination 1, 2, 10

Common Pitfalls and Caveats

• Ensure proper visualization of the tympanic membrane and confirm signs of middle ear inflammation for accurate diagnosis 3
• Avoid widespread use of respiratory fluoroquinolones for milder disease as this may promote resistance 3
• Consider the increasing prevalence of beta-lactamase producing organisms (especially H. influenzae and M. catarrhalis) when selecting antibiotics 3, 11
• The optimal duration of treatment is 5-7 days for older children and adults, though this remains somewhat uncertain 2