Treatment of Ear Infections (Otitis)
For ear infections, the recommended first-line treatment depends on the type of infection, with topical antimicrobials being the treatment of choice for otitis externa and high-dose amoxicillin for acute otitis media in most cases.
Types of Ear Infections
Acute Otitis Media (AOM)
- AOM is a bacterial superinfection of the middle ear with purulent or mucopurulent fluid 1
- Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
Otitis Externa (OE)
- OE is a cellulitis of the ear canal skin and subdermis with acute inflammation 3
- Nearly 98% of cases in North America are bacterial, primarily Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%) 3
Treatment for Acute Otitis Media
Antibiotic Indications
- For children under 2 years: antibiotic therapy is recommended (Grade A) 1
- For children over 2 years: antibiotics may be deferred unless there are marked symptoms (high fever, intense earache) 1
- When deferring antibiotics, reassessment after 48-72 hours of symptomatic therapy is necessary 1
First-Line Treatment
- High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line treatment for AOM 1, 4
- This dosage is recommended to overcome resistant Streptococcus pneumoniae, particularly during viral coinfection 5, 4
Alternative Treatments (Penicillin Allergy)
- For non-severe penicillin allergy: cefdinir (14 mg/kg/day), cefuroxime (30 mg/kg/day), or cefpodoxime (10 mg/kg/day) 1
- For severe penicillin allergy: consider macrolides, though resistance is increasing 1
Treatment Failure
- If symptoms persist after 48-72 hours of initial treatment, consider changing antibiotics 1
- For amoxicillin failure, switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) 1
- For amoxicillin-clavulanate failure, consider intramuscular ceftriaxone (50 mg/kg) for 3 days 1, 6
Treatment for Otitis Externa
First-Line Treatment
- Topical antimicrobial therapy is the treatment of choice for otitis externa 3
- Topical preparations deliver 100-1000 times higher concentrations than systemic therapy 3
- Options include antibiotics (aminoglycosides, polymyxin B, quinolones), steroids, or low-pH antiseptics 3
- No significant differences in clinical outcomes exist between different topical preparations 3, 7
Administration of Ear Drops
- Patient should lie with affected ear upward 1
- Fill ear canal with drops and remain in position for 3-5 minutes 1
- Gentle to-and-fro movement of the ear or tragal pumping helps medication penetration 1
Aural Toilet
- The ear canal should be cleared of debris to improve medication penetration 1, 3
- This can be done via gentle lavage with body-temperature water/saline or by physically removing debris with suction or dry mop 1
Systemic Antibiotics
- Systemic antibiotics should NOT be prescribed as initial therapy for uncomplicated otitis externa 3
- Reserve oral antibiotics for extension of infection beyond the ear canal, diabetes, immunocompromised status, or when topical therapy cannot reach infected area 3, 7
Special Considerations
Non-Intact Tympanic Membrane
- For patients with perforations or tympanostomy tubes, use non-ototoxic preparations such as quinolones 3
- Avoid aminoglycosides in these patients due to potential ototoxicity 3
Diabetes and Immunocompromised Patients
- These patients require special consideration as they are susceptible to otomycosis and necrotizing otitis externa 3
- Consider early specialist referral and possibly systemic antibiotics 3
Pain Management
- Assess pain severity and recommend appropriate analgesics 3
- Pain typically improves within 48-72 hours of starting appropriate treatment 3, 7
Treatment Expectations
- Most patients with otitis externa feel better within 48-72 hours and have minimal symptoms by 7 days 1
- For AOM, clinical improvement should be seen within 48-72 hours of starting appropriate antibiotics 1
- Persistent middle ear effusion is common after AOM resolution (60-70% at 2 weeks, 40% at 1 month) 1
Common Pitfalls to Avoid
- Overusing oral antibiotics for uncomplicated otitis externa 3
- Using ototoxic preparations when tympanic membrane integrity is compromised 3
- Inadequate pain management 3
- Failure to remove debris before administering ear drops 1, 3
- Missing fungal infections in patients with diabetes or treatment failures 3