What is the recommended treatment for otitis media?

Treatment of Acute 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

Pain Management

Pain management should be addressed in all cases of AOM, regardless of whether antibiotics are prescribed:

• Analgesics should be provided for pain relief, especially during the first 24 hours 1
• Pain management should be continued as long as needed to control symptoms 1

Initial Management Decision: Observation vs. Antibiotics

Treatment decisions should be based on the child's age and symptom severity:

Immediate Antibiotic Treatment Indicated For:

• Children <6 months of age with AOM 1
• Children 6-23 months with severe AOM (defined as moderate to severe otalgia or fever ≥39°C/102.2°F) 2, 1
• Children 6-23 months with bilateral AOM, even if non-severe 1
• Children ≥24 months with severe AOM 2, 1

Observation Option Appropriate For:

• Children 6-23 months with non-severe unilateral AOM 2, 1
• Children ≥24 months with non-severe AOM (bilateral or unilateral) 2, 1

When choosing observation, a mechanism must be in place to ensure follow-up and initiation of antibiotics if the child fails to improve within 48-72 hours 1

Antibiotic Selection

When antibiotics are indicated:

• First-line therapy: Amoxicillin at 80-90 mg/kg/day divided into two doses 2, 1, 3
• Second-line therapy (use when any of these conditions are present):
  • Child has received amoxicillin in the past 30 days 2
  • Child has concurrent purulent conjunctivitis 2
  • Child has history of recurrent AOM unresponsive to amoxicillin 2
  • Treatment failure after 48-72 hours of amoxicillin 2, 1

For second-line therapy, use amoxicillin-clavulanate or another antibiotic with β-lactamase coverage 2, 1, 3

For penicillin-allergic patients, alternative options include:

• Cefdinir, cefpodoxime, or cefuroxime 1, 4
• Azithromycin can be used for acute otitis media at a dose of 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on day 1 followed by 5 mg/kg/day on days 2-5 5

Follow-up and Treatment Failure

• Reassess patients whose symptoms worsen or fail to improve within 48-72 hours of starting treatment 2, 1
• If initially managed with observation, begin antibiotics if symptoms persist or worsen 1
• If initially treated with amoxicillin, change to a second-line agent with β-lactamase coverage 2, 1

Special Considerations for Otitis Media with Perforation

• When treating otitis media with perforation, non-ototoxic preparations should be used 6
• Drainage from the ear (otorrhea) may be present, and the tympanic membrane will show a visible perforation 6

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
  • Limit exposure to tobacco smoke 7
• Immunization with pneumococcal conjugate vaccines and influenza vaccine is recommended 1, 6
• Xylitol may be effective for prevention, though compliance can be an issue 7

Common Pitfalls to Avoid

• Misdiagnosing otitis media with effusion (OME) as acute otitis media, leading to unnecessary antibiotic use 6
• Inadequate pain management 1, 6
• Using ototoxic preparations in patients with perforated tympanic membranes 6
• Delayed initiation of antibiotics in indicated cases may prolong symptoms and lead to economic losses due to parents missing work 8

Remember that while observation is appropriate in many cases, studies show that delayed antibiotic treatment can be associated with prolonged resolution of fever, ear pain, poor appetite, and decreased activity 8. A balanced approach that considers both antibiotic stewardship and symptom management is essential.