What is the treatment for otitis media?

Treatment of Otitis Media

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

Diagnosis and Initial Management

• Accurate diagnosis of acute otitis media (AOM) is essential and should be based on the presence of middle ear effusion with signs of acute inflammation and symptoms 1
• Pain management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 1, 2
• Watchful waiting (observation without antibiotics) is an option for selected children with mild to moderate AOM who are over 2 years of age 3, 2
• Antibiotics do shorten symptoms and duration of middle ear effusion 3, 2

Antibiotic Selection and Dosing

• First-line therapy: High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) for 10 days 1, 2
• For patients who have taken amoxicillin in the previous 30 days, have concurrent purulent conjunctivitis, or require coverage for Moraxella catarrhalis, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) is recommended 1
• For penicillin-allergic patients, alternative antibiotics 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), or ceftriaxone (50 mg IM or IV per day for 1-3 days) 1
• Once or twice daily dosing of amoxicillin has been shown to be as effective as three times daily dosing, which may improve compliance 4

Duration of Therapy

• For children younger than 2 years and those with severe symptoms, a standard 10-day course of antibiotic therapy is recommended 1
• For children 2-5 years with mild or moderate AOM, a 7-day course of antibiotic therapy is equally effective 1
• For children 6 years and older with mild to moderate symptoms, a 10-day course is recommended 1

Treatment Failure Management

• If symptoms worsen or fail to improve within 48-72 hours of initial treatment, reassess to confirm AOM diagnosis 1, 2
• Consider switching to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) if initial treatment fails 1, 5
• For patients failing amoxicillin-clavulanate, consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 1, 5
• A 3-day course of ceftriaxone has been shown to be better than a 1-day regimen for AOM unresponsive to initial antibiotics 1
• In children with multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered 1, 5

Special Considerations

• Beta-lactamase producing organisms (especially H. influenzae and M. catarrhalis) are the predominant pathogens isolated from children with AOM failing high-dose amoxicillin therapy 6
• After successful antibiotic treatment of AOM, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months 1, 5
• The presence of middle ear effusion without clinical symptoms after AOM resolution is defined as otitis media with effusion (OME) and requires monitoring but not antibiotics 1, 5

Management of Otitis Media with Effusion (OME)

• OME is characterized by the presence of middle ear effusion behind an intact tympanic membrane without signs and symptoms of acute infection 5
• Watchful waiting is the recommended initial approach for most children with OME 5
• Antibiotics, decongestants, antihistamines, and nasal steroids are not recommended for OME as they do not hasten clearance of middle ear fluid 5
• Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes 3, 2

Recurrent Acute Otitis Media

• Recurrent acute otitis media may benefit from tympanostomy tube placement 2
• The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media is controversial and age dependent 3
• Topical antibiotics are the treatment of choice for acute tube otorrhea 3, 2

Prevention Strategies

• Risk reduction strategies include breastfeeding, avoiding tobacco smoke exposure, limiting pacifier use in older infants and children, and pneumococcal vaccination 1, 2