What is the treatment for otitis media?

Treatment of Otitis Media

Amoxicillin is the first-line antibiotic treatment for acute otitis media (AOM) when antibiotics are indicated, though observation without antibiotics is appropriate for selected children based on age, symptom severity, and diagnostic certainty. 1

Initial Management Approach

Pain Management

• Pain management should be addressed regardless of whether antibiotics are prescribed, especially during the first 24 hours 1
• Analgesics should be continued as long as needed to control pain 1
• Pain relief is considered paramount in all treatment guidelines 1

Decision: Observation vs. Antibiotics

• For children 6-23 months with severe AOM or non-severe bilateral AOM, prescribe antibiotics immediately 1
• For children 6-23 months with non-severe unilateral AOM, either prescribe antibiotics or offer observation with close follow-up 1
• For children ≥24 months with severe AOM, prescribe antibiotics immediately 1
• For children ≥24 months with non-severe AOM, either prescribe antibiotics or offer observation with close follow-up 1
• Observation without antibiotics is appropriate for children 6 months to 2 years with non-severe illness and uncertain diagnosis 1
• When using observation approach, a mechanism must be in place to ensure follow-up and initiation of antibiotics if the child fails observation 1

Antibiotic Treatment

First-line Treatment

• Amoxicillin at 80-90 mg/kg/day divided into two doses is the recommended first-line treatment 1, 2
• The high dose is necessary to overcome resistant strains of Streptococcus pneumoniae 2

Alternative Treatments

• For penicillin allergy, alternative first-line options include cefdinir, cefpodoxime, or cefuroxime 1
• For treatment failure or high-risk situations, amoxicillin-clavulanate is recommended as second-line therapy 1, 3
• Clinical trials have shown comparable efficacy between amoxicillin-clavulanate dosed every 12 hours versus every 8 hours, with lower incidence of diarrhea in the every 12 hours regimen 3

Treatment Duration

• Standard duration is typically 10 days, especially for children under 2 years 3
• Clinical efficacy rates at the end of therapy (2-4 days after completion) were 87% for the 45 mg/kg/day every 12 hours regimen 3

Follow-up and Treatment Failure

• If symptoms worsen or don't improve within 48-72 hours:
  • Reassess to confirm AOM diagnosis and exclude other causes 1
  • Begin antibiotics if initially managed with observation 1
  • Change to a second-line agent (such as amoxicillin-clavulanate) if initially treated with antibiotics 1, 2

Otitis Media with Effusion (OME)

• OME is defined as middle ear effusion in the absence of acute symptoms 2
• Observation for 3 months is recommended as first-line approach for patients without risk factors for language or developmental problems 4
• Antibiotics, decongestants, or nasal steroids are not recommended for OME as they do not hasten clearance of middle ear fluid 2, 4
• For persistent OME (>3 months), hearing evaluation is recommended 4
• Surgical intervention with tympanostomy tubes should be considered for:
  • OME persisting 4 months or more with persistent hearing loss or other symptoms 4
  • Children with evidence of anatomic damage, hearing loss, or language delay 2

Prevention Strategies

• Reduce risk factors where possible:
  • Encourage breastfeeding for at least six months 1
  • Avoid supine bottle feeding 1
  • Reduce or eliminate pacifier use after six months of age 1
  • Consider modifying daycare attendance patterns 1
• Immunization with pneumococcal conjugate vaccines and influenza vaccine is recommended 1

Special Considerations

• For recurrent AOM, antibiotic prophylaxis may be beneficial 5
• Complementary approaches like xylitol may be effective but compliance limits applicability 6
• Delayed antibiotic treatment does not worsen overall recovery but may be associated with prolonged symptoms 7