What is the recommended treatment for adult otitis media?

Treatment of Adult Otitis Media

The recommended first-line treatment for adult otitis media is amoxicillin at a dosage of 80-90 mg/kg/day in two divided doses. 1, 2

Diagnosis and Assessment

• Acute otitis media (AOM) requires a history of acute onset, presence of middle ear effusion, and signs of middle ear inflammation 1
• Diagnosis should differentiate between AOM and otitis media with effusion (OME), as antibiotics are indicated for AOM but not typically for OME 2
• Main bacterial pathogens in otitis media are Streptococcus pneumoniae and Haemophilus influenzae 2

Initial Treatment Approach

• Pain management should be addressed regardless of antibiotic use, especially during the first 24 hours 1
• Amoxicillin is recommended as first-line therapy due to its effectiveness against common pathogens, safety, low cost, and narrow spectrum 1, 2
• The recommended dosage is 80-90 mg/kg/day in two divided doses 1, 2
• Once or twice daily dosing of amoxicillin has been shown to be as effective as three times daily dosing, which may improve compliance 3

Alternative Treatment Options

• For patients with penicillin allergy, alternatives include:
  • Macrolides 1
  • First-generation cephalosporins (for non-type I hypersensitivity) 1
  • Doxycycline 1
  • Pristinamycin 1

Second-line Treatment (Treatment Failure)

• If no improvement after 48-72 hours of initial therapy, the patient should be reassessed 2
• Second-line options include:
  • Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1, 2
  • Cefuroxime axetil 1, 4
  • Cefpodoxime proxetil 1, 4
  • Ceftriaxone (for severe cases) 2, 4

Special Considerations

• Amoxicillin-clavulanate should be used first-line in patients who have taken amoxicillin in the previous 30 days or when coverage for β-lactamase-positive organisms is desired 2
• Increasing antimicrobial resistance is a significant factor in treatment failure and should guide empiric therapy choices 2, 4
• Watchful waiting with delayed antibiotic treatment may be appropriate in some adult cases with mild symptoms, similar to the approach used in children over 2 years 1, 5

Treatment Duration

• Standard treatment duration is typically 5-7 days for uncomplicated cases 5
• Patients should begin improving within 48-72 hours of starting appropriate antibiotic therapy 2

Common Pitfalls and Caveats

• Over-diagnosis of AOM occurs in 40-80% of patients, leading to unnecessary antibiotic use 1
• Antibiotics are not indicated for otitis media with effusion in the absence of acute symptoms 2, 5
• Decongestants and nasal steroids have not been shown to hasten clearance of middle ear fluid and are not recommended 5
• Resistance to antimicrobials is increasingly influencing treatment success and should be considered when selecting therapy 2, 6