What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line treatment for most patients with acute otitis media due to its effectiveness against common pathogens, safety, low cost, and narrow microbiologic spectrum. 1, 2, 3

Diagnosis

• Accurate diagnosis of acute otitis media (AOM) requires:
  • History of acute onset of signs and symptoms
  • Presence of middle ear effusion
  • Signs of middle ear inflammation 1
• Key diagnostic findings include bulging tympanic membrane, limited mobility of tympanic membrane, air-fluid level behind the tympanic membrane, or otorrhea 1
• Distinguishing AOM from otitis media with effusion is crucial, as antibiotics are indicated for AOM but not for effusion without acute symptoms 2, 4

Initial Management

Pain Management

• Pain assessment and management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 1, 3
• Pain relief is considered paramount in all guidelines 1

Antibiotic Therapy vs. Observation

• Observation without antibiotics ("watchful waiting") is an option for selected children with uncomplicated AOM 1, 3
• Immediate antibiotics are recommended for:
  • Children under 6 months of age
  • Children with severe symptoms (moderate to severe otalgia, otalgia for ≥48 hours, or temperature ≥39°C)
  • Bilateral AOM in children under 2 years
  • When follow-up cannot be ensured 1, 3

Antibiotic Selection

First-Line Therapy

• High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is recommended as first-line therapy 1, 2, 3, 4
• The rationale for amoxicillin includes its effectiveness against common AOM pathogens (including intermediate-resistant S. pneumoniae), safety, low cost, and narrow spectrum 2, 3, 5

Alternative First-Line Options

• For patients with non-type I penicillin allergy, alternatives include:
  • Cefdinir (14 mg/kg/day in 1-2 doses)
  • Cefuroxime (30 mg/kg/day in 2 divided doses)
  • Cefpodoxime (10 mg/kg/day in 2 divided doses) 1, 2, 3

Second-Line Therapy

• High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) should be used for:
  • Patients who have taken amoxicillin in the previous 30 days
  • Those with concurrent purulent conjunctivitis
  • When coverage for β-lactamase-positive organisms is desired 2, 3, 6
• Amoxicillin-clavulanate has shown clinical cure rates of 80-87% in clinical trials 6

Duration of Therapy

• For children younger than 2 years and those with severe symptoms: 10-day course 3
• For children 2-5 years with mild or moderate AOM: 7-day course 3
• For children 6 years and older with mild to moderate symptoms: 5-10 day course 3

Management of Treatment Failure

• If symptoms worsen or fail to improve within 48-72 hours of initial treatment:
  • Reassess the patient to confirm AOM diagnosis 1, 3
  • Consider switching to amoxicillin-clavulanate if initially treated with amoxicillin 3, 5
  • For patients failing amoxicillin-clavulanate, consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 3, 7
• A 3-day course of ceftriaxone has been shown to be more effective than a 1-day regimen for treatment-resistant AOM 3

Follow-Up and Complications

• After successful antibiotic treatment, 60-70% of children still have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months 3
• Middle ear effusion without clinical symptoms after AOM resolution is defined as otitis media with effusion (OME) and requires monitoring but not antibiotics 3, 4
• Consider referral to an otolaryngologist for:
  • Multiple treatment failures
  • Evidence of anatomic damage
  • Hearing loss
  • Language delay 4, 8

Special Considerations

• Bacterial resistance is increasingly influencing empiric antibiotic selection for AOM 2, 5
• The most common pathogens in AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 4, 5
• Beta-lactamase-producing H. influenzae is the predominant pathogen isolated in children failing high-dose amoxicillin therapy 5
• Risk reduction strategies for preventing recurrent AOM include breastfeeding, avoiding tobacco smoke exposure, limiting pacifier use, and pneumococcal vaccination 1, 3