Treatment of Acute Otitis Media
Amoxicillin at 80-90 mg/kg/day in 2 divided doses is the first-line treatment for acute otitis media due to its effectiveness against common pathogens, safety, low cost, acceptable taste, and narrow microbiologic spectrum. 1, 2
Diagnosis and Initial Management
- Acute otitis media (AOM) is diagnosed based on the presence of middle ear effusion with signs of acute inflammation and symptoms 1
- Pain management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 1, 2, 3
- Management options include observation without antibiotics for selected children or antibiotic therapy based on specific criteria 1
Antibiotic Treatment Algorithm
First-line therapy:
- Amoxicillin 80-90 mg/kg/day in 2 divided doses 1, 2, 3
- This high-dose regimen is effective against most strains of Streptococcus pneumoniae, including penicillin-resistant strains 4
When to use amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses):
- Patients who have taken amoxicillin in the previous 30 days 1
- Patients with concurrent purulent conjunctivitis 1
- When coverage for beta-lactamase producing organisms like Moraxella catarrhalis is needed 1, 5
- Treatment failure with amoxicillin 6, 2, 3
For penicillin-allergic patients:
- Cefdinir (14 mg/kg/day in 1-2 doses) 1
- Cefuroxime (30 mg/kg/day in 2 divided doses) 1, 5
- Cefpodoxime (10 mg/kg/day in 2 divided doses) 1
- Azithromycin for severe penicillin allergy (10 mg/kg on day 1, followed by 5 mg/kg on days 2-5) 7
Duration of Therapy
- For children younger than 2 years and those with severe symptoms: standard 10-day course 6, 2
- For children 2-5 years with mild or moderate AOM: 7-day course is equally effective 6, 2
- For children 6 years and older with mild to moderate symptoms: standard 10-day course 6
Management of Treatment Failure
- If symptoms worsen or fail to improve within 48-72 hours of initial treatment, reassess to confirm AOM diagnosis 1, 2
- For patients failing amoxicillin therapy, switch to amoxicillin-clavulanate 6, 3
- For patients failing amoxicillin-clavulanate, consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 6, 1
- A 3-day course of ceftriaxone has been shown to be better than a 1-day regimen for AOM unresponsive to initial antibiotics 6
- For multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered 6, 3
Special Considerations
- After successful antibiotic treatment of AOM, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months 6, 3
- The presence of middle ear effusion without clinical symptoms after AOM resolution is defined as otitis media with effusion (OME) and requires monitoring but not antibiotics 6, 3
- Bacterial resistance is a main reason for treatment failure in AOM, particularly with beta-lactamase producing H. influenzae and drug-resistant S. pneumoniae 3, 5, 4
- Recurrent AOM (defined as 3 or more episodes in 6 months or 4 episodes in 12 months) may benefit from tympanostomy tube placement 2