What is the treatment approach for acute otitis media?

Treatment of Acute Otitis Media

Amoxicillin is the first-line antibiotic treatment for acute otitis media (AOM) when antibiotics are indicated, though observation without antibiotics is appropriate for selected children based on age, symptom severity, and diagnostic certainty. 1

Pain Management

Pain management should be addressed immediately in all patients with AOM, regardless of whether antibiotics are prescribed:

• Analgesics should be provided for pain relief, especially during the first 24 hours 1
• Continue analgesics as long as needed to control pain 1
• Pain relief is considered paramount in all treatment guidelines 1

Initial Management Decision: Observation vs. Antibiotics

The decision to prescribe antibiotics or observe depends on the patient's age, symptom severity, and diagnostic certainty:

For Children 6 months to 2 years:

• Immediate antibiotics for:
  • Severe symptoms (moderate to severe otalgia or fever ≥39°C in past 48 hours) 2
  • Bilateral AOM 2
  • Otorrhea 2
• Observation or antibiotics for:
  • Non-severe unilateral AOM 2, 1

For Children ≥2 years:

• Immediate antibiotics for:
  • Severe symptoms 2
  • Otorrhea 2
• Observation or antibiotics for:
  • Non-severe AOM (unilateral or bilateral) 2, 1

For Adults:

• Immediate antibiotics for:
  • Severe symptoms (moderate to severe otalgia or fever) 3
• Observation or antibiotics for:
  • Mild symptoms 3

Observation Protocol

When choosing observation:

• A mechanism must be in place to ensure follow-up within 48-72 hours 1
• Provide adequate analgesia 1, 4
• Consider a "safety net" or "wait-and-see prescription" that parents can fill if symptoms worsen or don't improve within 48-72 hours 2

Antibiotic Selection

First-Line Therapy:

• Amoxicillin is the first-line antibiotic when:
  • Patient has not received amoxicillin in the past 30 days
  • No concurrent purulent conjunctivitis
  • No penicillin allergy 2, 1
• Dosing:
  • Children: 80-90 mg/kg/day divided into two doses 1, 4
  • Adults: 1.5 to 4 g/day 3

Second-Line/Alternative Therapy:

• Amoxicillin-clavulanate when:
  • Patient received amoxicillin in the past 30 days
  • Has concurrent purulent conjunctivitis
  • Initial treatment failure with amoxicillin 2, 1

For Penicillin Allergy:

• Alternatives include:
  • Cefdinir, cefpodoxime, or cefuroxime 1, 3
  • For severe penicillin allergy: azithromycin, clarithromycin, or trimethoprim/sulfamethoxazole 3, 5

Follow-up and Treatment Failure

• If symptoms worsen or don't improve within 48-72 hours:
  • Reassess to confirm AOM diagnosis 1
  • Begin antibiotics if initially managed with observation 1
  • Change to a second-line agent if initially treated with amoxicillin 1, 4

Common Pathogens

The most common bacterial pathogens in AOM are:

• Streptococcus pneumoniae 4
• Haemophilus influenzae 4
• Moraxella catarrhalis 4

Prevention Strategies

• Reduce risk factors where possible:
  • Modify daycare attendance patterns 1
  • Encourage breastfeeding for at least six months 1
  • Avoid supine bottle feeding 1
  • Reduce or eliminate pacifier use after six months of age 1
  • Avoid tobacco smoke exposure 3
• Immunization with pneumococcal conjugate vaccines and influenza vaccine 1, 3

Common Pitfalls and Caveats

• Accurate diagnosis is essential - ensure proper visualization of the tympanic membrane 3
• Avoid widespread use of respiratory fluoroquinolones for milder disease as this may promote resistance 3
• Consider the increasing prevalence of beta-lactamase producing organisms when selecting antibiotics 3
• Antibiotics, decongestants, or nasal steroids do not hasten the clearance of middle ear fluid in otitis media with effusion and are not recommended 4