What is the treatment for otitis media?

Treatment of Acute Otitis Media

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

Diagnosis Criteria

• Acute otitis media (AOM) diagnosis requires:

  • History of acute onset of signs and symptoms
  • Presence of middle ear effusion
  • Signs and symptoms of middle ear inflammation 3

• Specific diagnostic findings include:

  • Bulging of the tympanic membrane
  • Limited or absent mobility of the tympanic membrane
  • Air-fluid level behind the tympanic membrane
  • Otorrhea
  • Distinct erythema of the tympanic membrane 3

Initial Management Approach

• Pain management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 3, 1

• Treatment options include:

  1. Observation without antibiotics (watchful waiting) for selected patients
  2. Immediate antibiotic therapy 1, 2

Watchful Waiting Criteria

• Observation without antibiotics is appropriate for:

  • Children 6 months to 2 years with non-severe illness and uncertain diagnosis
  • Children 2 years or older with mild to moderate symptoms 3, 2

• Watchful waiting should be limited to 48-72 hours with symptomatic relief 3

Immediate Antibiotic Therapy Indications

• Immediate antibiotics are indicated for:
  • Children younger than 6 months
  • Children with severe symptoms (moderate to severe otalgia, otalgia for ≥48 hours, or temperature ≥39°C)
  • Bilateral AOM in children younger than 2 years
  • When observation is not feasible 1, 2

Antibiotic Selection

First-Line Therapy

• Amoxicillin at 80-90 mg/kg/day in 2 divided doses is the first-line treatment 1, 2
  • This high dose is necessary to overcome resistant Streptococcus pneumoniae 4, 5
  • Common pathogens include S. pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 5

Second-Line Therapy

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) is recommended when:

  • Initial treatment fails
  • Patient has taken amoxicillin in the previous 30 days
  • Patient has concurrent purulent conjunctivitis
  • Coverage for beta-lactamase producing organisms is needed 1, 2, 5

• 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)
  • Ceftriaxone (50 mg IM or IV per day for 1-3 days) 1

Duration of Therapy

• For children younger than 2 years and those with severe symptoms: 10-day course 1, 2
• For children 2-5 years with mild or moderate AOM: 7-day course 1
• For children 6 years and older with mild to moderate symptoms: 5-day course 1

Treatment Failure Management

• If symptoms worsen or fail to improve within 48-72 hours:

  • Reassess to confirm AOM diagnosis
  • Consider switching to amoxicillin-clavulanate or ceftriaxone 1, 2

• For patients failing amoxicillin-clavulanate, consider:

  • Intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 1
  • A 3-day course of ceftriaxone is better than a 1-day regimen for AOM unresponsive to initial antibiotics 1

Special Considerations

• Beta-lactamase producing H. influenzae is the predominant pathogen in children failing high-dose amoxicillin therapy 4

• After successful antibiotic treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months 1

• Middle ear effusion without clinical symptoms after AOM resolution (otitis media with effusion) requires monitoring but not antibiotics 1

• For recurrent AOM or persistent otitis media with effusion causing hearing loss, consider referral for tympanostomy tube placement 2, 6

• Topical antibiotics are the treatment of choice for acute tube otorrhea 2

Prevention Strategies

• Risk reduction strategies include:
  • Breastfeeding
  • Avoiding tobacco smoke exposure
  • Limiting pacifier use in older infants and children
  • Pneumococcal vaccination 1, 2