What is the recommended treatment for acute otitis media?

Treatment of Acute Otitis Media

The recommended first-line treatment for acute otitis media (AOM) is high-dose amoxicillin (80-90 mg/kg/day in 2 divided doses), with immediate pain management using appropriate analgesics regardless of antibiotic decision. 1, 2

Diagnosis

• AOM requires evidence of acute onset of symptoms, presence of middle ear effusion, signs of middle ear inflammation, and symptoms such as otalgia, irritability, or fever 1, 3
• The main bacterial pathogens in AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 3

Treatment Algorithm

Pain Management

• Address pain immediately with appropriate analgesics (acetaminophen or ibuprofen) regardless of antibiotic decision 1, 4
• Pain management is especially important during the first 24 hours of illness 1, 2

Antibiotic Decision

• Immediate antibiotic therapy is indicated for:

  • Children <2 years with bilateral AOM 1
  • Patients with otorrhea 1
  • Patients with severe symptoms (moderate to severe otalgia or fever ≥39°C/102.2°F) 1, 4
  • Adults with moderate to severe otalgia, otalgia lasting ≥48 hours, or temperature ≥39°C 4

• Observation for 48-72 hours (delayed antibiotic approach) can be considered for:

  • Children ≥2 years with non-severe illness 1
  • Patients with uncertain diagnosis 1
  • Otherwise healthy children with mild symptoms 1

Antibiotic Selection

• First-line therapy: High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) for patients without penicillin allergy 1, 2, 5

  • Justification: Effectiveness against common AOM pathogens, safety, low cost, and narrow microbiologic spectrum 2

• For patients with penicillin allergy:

  • Non-type I hypersensitivity: Cefdinir (14 mg/kg/day in 1-2 doses), cefpodoxime (10 mg/kg/day in 2 doses), or cefuroxime (30 mg/kg/day in 2 doses) 1, 2, 4
  • Type I hypersensitivity: Azithromycin or clarithromycin 1, 4
    • Azithromycin dosing for pediatric AOM: 30 mg/kg as a single dose, or 10 mg/kg once daily for 3 days, or 10 mg/kg on day 1 followed by 5 mg/kg/day on days 2-5 6

• Second-line therapy (for treatment failure or recent amoxicillin use):

  • High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 2, 5
  • Consider for patients who have taken amoxicillin in the previous 30 days or those with concurrent conjunctivitis 2

Management of Treatment Failure

• Reassess patients if symptoms worsen or fail to improve within 48-72 hours 1, 4
• Signs of treatment failure include worsening condition, persistence of symptoms beyond 48 hours after starting antibiotics, and recurrence within 4 days of completing treatment 1
• For patients who fail initial amoxicillin therapy, switch to amoxicillin-clavulanate or ceftriaxone (50 mg IM or IV for 3 days) 2, 4
• For persistent failure after second-line therapy, consider tympanocentesis for culture and susceptibility testing 4

Important Considerations and Pitfalls

• Avoid macrolides as first-line therapy due to high rates of pneumococcal resistance, unless patient has severe penicillin allergy 1, 4
• Complete the full antibiotic course even if symptoms improve before completion 1
• Adverse effects of amoxicillin-clavulanate include diarrhea and diaper dermatitis 1
• Beta-lactamase-producing organisms (particularly H. influenzae) are the predominant pathogens in children failing high-dose amoxicillin therapy 5
• Avoid fluoroquinolones (except in specific cases of treatment failure) due to concerns about antimicrobial resistance and side effects 4

Follow-up

• During treatment with antibiotics, patients may worsen slightly initially but should stabilize within the first 24 hours and begin improving during the second 24-hour period 2
• Otitis media with effusion (fluid in the middle ear without acute symptoms) does not require antibiotics 3
• Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist 3