What is the treatment for acute otitis media (AOM)?

Treatment of Acute Otitis Media

The first-line treatment for acute otitis media is high-dose amoxicillin (80-90 mg/kg/day divided into two doses) with immediate pain management using acetaminophen or ibuprofen, while observation without antibiotics may be appropriate for children ≥2 years with mild symptoms. 1, 2

Diagnosis Confirmation

• AOM diagnosis requires three key elements: acute onset of signs and symptoms, presence of middle ear effusion, and signs of middle ear inflammation 2
• Proper visualization of the tympanic membrane is essential, with findings such as bulging, limited mobility, or distinct erythema indicating AOM 2
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3

Treatment Algorithm

Pain Management

• Address pain immediately with oral analgesics (acetaminophen or ibuprofen) regardless of antibiotic decision 1, 2
• Topical analgesics may provide additional brief benefit, though evidence is limited 1

Antibiotic Decision

• Immediate antibiotic therapy is indicated for:

  • Children <2 years with bilateral AOM 2
  • Patients with otorrhea 2
  • Patients with severe symptoms (moderate to severe otalgia or fever ≥39°C/102.2°F) 1, 2
  • Adults with AOM (due to higher likelihood of bacterial etiology) 4

• Observation option (48-72 hours) is appropriate for:

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

Antibiotic Selection

• First-line therapy: High-dose amoxicillin (80-90 mg/kg/day divided in two doses) for 10 days 1, 2
• For penicillin allergy:
  • Non-type I hypersensitivity: cefdinir, cefpodoxime, or cefuroxime 1, 2
  • Type I hypersensitivity: azithromycin or clarithromycin 1, 2
• For treatment failure or recent amoxicillin use within 30 days: amoxicillin-clavulanate 5

Duration of Therapy

• Children <2 years and those with severe symptoms: standard 10-day course 6
• Children 2-5 years with mild or moderate AOM: 7-day course may be sufficient 6
• Children ≥6 years with mild to moderate AOM: standard 10-day course 6
• Adults: 5-7 day course is typically recommended 1

Treatment Failure Management

• If symptoms worsen or fail to improve within 48-72 hours, reassess to confirm diagnosis 1, 2
• Consider changing to a second-line agent such as amoxicillin-clavulanate 2
• For multiple treatment failures, consider tympanocentesis for culture and susceptibility testing 6
• For resistant cases, options include clindamycin (with or without cefdinir, cefixime, or cefuroxime) 6
• In severe cases with multiple treatment failures, consultation with specialists (otolaryngologist, infectious disease) may be necessary 6

Common Pitfalls and Considerations

• Avoid macrolides as first-line therapy due to high rates of pneumococcal resistance 2
• Complete the full antibiotic course even if symptoms improve before completion 2
• Persistent middle ear effusion is common after AOM treatment (60-70% at 2 weeks, 40% at 1 month, 10-25% at 3 months) and does not require antibiotics 6
• Mistaking otitis media with effusion (OME) for AOM can lead to unnecessary antibiotic use 4

Prevention Strategies

• Ensure up-to-date immunization with pneumococcal conjugate vaccines 1
• Consider annual influenza vaccination 1
• Reduce modifiable risk factors such as smoking exposure and treating underlying allergies 4
• Exclusive breastfeeding until at least six months of age can reduce AOM risk 5

Follow-up Recommendations

• Routine follow-up visits are not necessary for all children with AOM 6
• Consider reassessment for young children with severe symptoms, recurrent AOM, or when specifically requested by parents 6
• For recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months), consider referral for tympanostomy tube placement 5