What is the management for a 2-year-old with fever and acute otitis media (AOM)?

From the Guidelines

For a 2-year-old with fever and acute otitis media (AOM), antibiotic therapy is recommended, with amoxicillin as the first-line treatment at a dose of 80-90 mg/kg/day divided twice daily for 10 days, as it is generally effective against susceptible and intermediate resistant pneumococci, and has an acceptable taste and narrow microbiologic spectrum 1. The management of AOM in children involves a combination of symptomatic relief and antibiotic therapy.

• Symptomatic management includes the use of analgesics such as acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) to relieve ear pain and reduce fever.
• Antibiotic therapy is essential in children under 2 years of age or with prolonged fever duration, as these factors increase the risk of complications and decrease the likelihood of spontaneous resolution.
• The goal of treatment is to relieve symptoms, prevent complications such as mastoiditis or hearing loss, and eradicate the bacterial infection, which is commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
• For children with penicillin allergy, alternatives to amoxicillin include azithromycin or cefdinir, which can be used as second-line treatments.
• It is essential to ensure adequate hydration and monitor the child for improvement within 48-72 hours of starting antibiotics, and reassess if symptoms worsen or do not improve after 3 days of antibiotics. The use of a "safety net" or "wait-and-see prescription" can be considered in select cases, where the parent is given an antibiotic prescription but instructed to fill it only if the child fails to improve within 2-3 days or if symptoms worsen at any time 1. However, the most recent and highest quality study recommends antibiotic therapy as the first-line treatment for AOM in children under 2 years of age, due to the increased risk of complications and decreased likelihood of spontaneous resolution 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

For a 2-year-old patient with fever and acute otitis media (AOM), the management would be to administer azithromycin according to the recommended dosage guidelines.

• The dose can be either 30 mg/kg as a single dose or
• 10 mg/kg once daily for 3 days or
• 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5 2. It is essential to follow the prescribed dosage and administration instructions to ensure effective treatment and minimize potential side effects.

From the Research

Management of Acute Otitis Media (AOM) in a 2-year-old with Fever

• The management of AOM in children typically begins with adequate analgesia to relieve pain and discomfort 3.
• For children 2 years or older with mild symptoms, antibiotic therapy can be deferred, and a "watchful waiting" approach can be taken 3, 4.
• However, for children with severe symptoms or those who do not improve with observation, antibiotic therapy is recommended.
• The first-line antibiotic treatment for AOM is high-dose amoxicillin (80-90 mg/kg/day) 5, 3, 6, 7.
• For patients who do not respond to amoxicillin, second-line therapy options include amoxicillin-clavulanate, ceftriaxone, or other oral cephalosporins 5, 6, 7.
• The choice of antibiotic should be guided by the suspected causative pathogen and the patient's clinical presentation.
• Tympanocentesis may be useful in identifying the causative pathogen in patients who have failed multiple courses of antibiotics 5.
• The pneumococcal conjugate vaccine has been shown to reduce the incidence of AOM and should be administered to all children less than 2 years old and those at risk for recurrent AOM 5, 4.

Considerations for Antibiotic Resistance

• The increasing prevalence of antibiotic-resistant pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae, poses a challenge for the management of AOM 5, 4.
• The use of pharmacokinetic/pharmacodynamic principles and consideration of minimum inhibitory concentrations can help guide the selection of antibiotics 5.
• Adherence to treatment guidelines and the use of an age-stratified approach to AOM management can help reduce the use of antibiotics and decrease antibiotic resistance 4.