Treatment of Otitis Media
High-dose amoxicillin (80-90 mg/kg/day) is the first-line treatment for acute otitis media, with amoxicillin-clavulanate as the recommended second-line therapy for treatment failures. 1
Diagnosis of Acute Otitis Media
Accurate diagnosis is crucial before initiating treatment and requires:
- A history of acute onset of signs and symptoms 1
- Presence of middle ear effusion 1
- Signs and symptoms of middle ear inflammation 1
- Specific otoscopic findings including bulging of the tympanic membrane, limited mobility, air-fluid level, or otorrhea 1
- Distinct erythema of the tympanic membrane 1
Initial Management Approach
Pain Management
- Assessment and treatment of pain should be the first priority in managing AOM, regardless of whether antibiotics are prescribed 1
- Appropriate analgesics should be recommended, especially during the first 24 hours 1
Observation Option
- For selected children, observation without immediate antibiotics (watchful waiting) is an appropriate option 1
- This approach is suitable for:
Antibiotic Therapy
First-Line Treatment
- High-dose amoxicillin (80-90 mg/kg/day divided in 2 doses) is the recommended first-line therapy 1, 3
- For adults, the recommended dose is 1.5-4 g/day divided into 2-3 doses 2
- This high dosage is effective against intermediate-resistant pneumococcal strains and many highly resistant strains 1
Second-Line Treatment
- For patients who fail initial therapy after 48-72 hours, switch to: 1
- Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1
- For patients who have taken amoxicillin in the previous 30 days or have concurrent conjunctivitis, start with amoxicillin-clavulanate 1
Alternative Treatment for Penicillin Allergy
- For non-type I penicillin allergy: 1, 2
- Cefdinir (14 mg/kg/day in 1 or 2 doses)
- Cefuroxime (30 mg/kg/day in 2 divided doses)
- Cefpodoxime (10 mg/kg/day in 2 divided doses)
- For severe penicillin allergy or treatment failures: 1
- Ceftriaxone (50 mg IM or IV per day for 3 days)
- Clindamycin (30-40 mg/kg/day in 3 divided doses) with or without a third-generation cephalosporin
Duration of Therapy
- For children younger than 2 years and those with severe symptoms: 10-day course 1
- For children 2-5 years with mild or moderate AOM: 7-day course 1
- For children 6 years and older with mild to moderate symptoms: 10-day course 1
- For adults: 5-10 days 2
Follow-up
- Reassessment is recommended if symptoms persist after 48-72 hours of antibiotic therapy 1, 2
- Routine follow-up visits are not necessary for all children who show clinical improvement 1
- Persistent middle ear effusion (MEE) is common after resolution of acute symptoms and does not require additional antibiotics 1
- 60-70% of children have MEE 2 weeks after treatment
- 40% have MEE at 1 month
- 10-25% have MEE at 3 months
Special Considerations
Recurrent AOM
- Tympanocentesis may be beneficial for identifying causative pathogens in patients who have failed multiple courses of antibiotics 4
- For severe cases or when compliance is a concern, intramuscular ceftriaxone may be considered 5
Otitis Media with Effusion
- Defined as middle ear effusion without acute symptoms 3
- Antibiotics, decongestants, or nasal steroids are not recommended as they do not hasten clearance of middle ear fluid 3
- Children with evidence of hearing loss, language delay, or anatomic damage should be referred to an otolaryngologist 3, 6
Common Pitfalls to Avoid
- Mistaking otitis media with effusion (OME) for acute otitis media (AOM), leading to unnecessary antibiotic use 1
- Inadequate pain management, which should be addressed regardless of antibiotic use 1
- Using antibiotics for otitis media with effusion, which does not benefit from antimicrobial therapy 3
- Failing to reassess patients with persistent symptoms after 48-72 hours of initial therapy 1