When treating otitis media, when do you give oral antibiotics and ear drops?

Treatment of Acute Otitis Media: When to Use Oral Antibiotics vs. Ear Drops

For acute otitis media (AOM), oral antibiotics should be used for children under 2 years with bilateral infection, those with severe symptoms, or when observation is not feasible, while ear drops are primarily indicated for patients with tympanostomy tubes or external ear canal infections. 1, 2

Oral Antibiotics for Acute Otitis Media

When to Use Oral Antibiotics:

• Children younger than 2 years with confirmed AOM diagnosis 1, 2
• Patients with severe symptoms (moderate to severe ear pain, ear pain for ≥48 hours, or temperature ≥39°C/102.2°F) 1, 2
• Bilateral AOM in children under 2 years 1
• When watchful waiting is not feasible due to follow-up concerns 2

First-Line Oral Antibiotic Therapy:

• Amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line treatment due to its effectiveness against common pathogens, safety, low cost, and narrow spectrum 1, 2
• Duration: 10 days for children <2 years and those with severe symptoms; 7 days for children 2-5 years with mild/moderate AOM 1

Second-Line Oral Antibiotic Therapy:

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) for patients who:
  • Have taken amoxicillin in the previous 30 days 1
  • Have concurrent purulent conjunctivitis 1
  • Show no improvement after 48-72 hours of initial treatment 1, 2

Ear Drops: Indications and Usage

When to Use Ear Drops:

• Primary treatment for acute otitis externa (AOE) or "swimmer's ear" 3
• First-line treatment for acute tube otorrhea (ear drainage through tympanostomy tubes) 3, 2
• Not indicated for uncomplicated AOM with intact tympanic membrane 3

Ear Drop Options:

• For acute tube otorrhea: Quinolone ear drops (e.g., ofloxacin, ciprofloxacin with dexamethasone) are recommended 3, 4, 5

  • Ofloxacin: Five drops (0.25 mL) instilled into affected ear twice daily for ten days for children 1-12 years old 4
  • Ciprofloxacin/dexamethasone: Four drops twice daily for seven days 5

• For otitis externa: Antibiotic ear drops with or without corticosteroids 3

  • Combination antibiotic-corticosteroid drops may be superior to antibiotic-only drops 3

Special Considerations

Treatment Failure Management:

• If symptoms worsen or fail to improve within 48-72 hours of initial oral antibiotic treatment:
  • Reassess diagnosis 1, 2
  • Consider switching to amoxicillin-clavulanate 1, 2
  • For patients failing amoxicillin-clavulanate, consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 1

Recurrent and Persistent AOM:

• Consider referral for tympanostomy tube placement for children with recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months) 2, 6
• For persistent middle ear effusion beyond 3 months with hearing loss, tympanostomy tubes are recommended 2, 7

Common Pitfalls to Avoid:

• Overdiagnosis of AOM leading to unnecessary antibiotic use 3
• Using oral antibiotics for otitis externa instead of topical treatment 3
• Using ear drops in patients with AOM and intact tympanic membrane 3
• Failing to provide adequate pain management regardless of antibiotic prescription 1, 2

Watchful Waiting Approach

• Appropriate for children ≥2 years with mild to moderate symptoms 3, 2
• Requires reliable follow-up and ability to start antibiotics if symptoms worsen 2
• Pain management should be addressed regardless of antibiotic prescription 1, 2

Remember that accurate diagnosis is crucial to determine the appropriate treatment approach, and pain management should be addressed in all cases of otitis media regardless of whether antibiotics are prescribed 1, 2.