What is the treatment for otitis media?

Treatment of Acute Otitis Media

Amoxicillin at 80-90 mg/kg/day divided into two doses is the first-line antibiotic treatment for acute otitis media when antibiotics are indicated, though observation without immediate antibiotics is appropriate for many children based on age, symptom severity, and diagnostic certainty. 1

Pain Management (Universal First Step)

• Analgesics must be provided to all patients regardless of antibiotic decision, especially during the first 24 hours. 1
• Continue pain relief as long as needed to control symptoms—this is paramount in all treatment approaches. 1

Decision Algorithm: Observation vs. Immediate Antibiotics

Immediate Antibiotics Required For:

• Children under 6 months of age (any presentation) 1
• Children 6-23 months with bilateral AOM (regardless of severity) 1
• Children 6-23 months with severe AOM (defined as moderate-to-severe otalgia or fever ≥39°C) 1
• Children ≥24 months with severe AOM 1
• Children with concurrent purulent conjunctivitis 1

Observation Option Appropriate For:

• Children 6-23 months with non-severe unilateral AOM (shared decision-making with parents) 1
• Children ≥24 months with non-severe AOM (bilateral or unilateral) 1
• Children with uncertain diagnosis and non-severe illness 1

Critical caveat: A reliable follow-up mechanism must be in place—if symptoms worsen at any time or fail to improve within 48-72 hours, antibiotics must be initiated. 2, 1

Antibiotic Selection

First-Line Treatment:

• Amoxicillin 80-90 mg/kg/day divided twice daily for children who have not received amoxicillin in the past 30 days, have no concurrent purulent conjunctivitis, and are not penicillin-allergic. 1, 3

Second-Line Treatment (Use if treatment failure at 48-72 hours OR if received amoxicillin in past 30 days OR concurrent purulent conjunctivitis):

• Amoxicillin-clavulanate (provides β-lactamase coverage) 1
• The 90 mg/kg/day amoxicillin component formulation is preferred for resistant organisms. 1

Penicillin Allergy Alternatives:

• Cefdinir, cefpodoxime, or cefuroxime for non-severe penicillin allergy 1
• For severe penicillin allergy (Type I hypersensitivity), alternative agents must be selected based on allergy history 1

Third-Line Option:

• Ceftriaxone IM (single dose or 3-day course) can be considered for treatment failure or inability to tolerate oral medications 4
• Clinical cure rates with single-dose ceftriaxone were 74% at day 14 and 58% at day 28 in U.S. trials, which were lower than 10-day oral comparators. 4

Treatment Duration

• Standard course is 10 days for children under 2 years and those with severe disease 1
• Shorter courses (5-7 days) may be considered for children ≥2 years with mild-to-moderate disease, though 10 days remains standard in guidelines 1

Reassessment and Treatment Failure

• Reassess at 48-72 hours if symptoms worsen or fail to improve. 1
• If initially observed without antibiotics: start amoxicillin 1
• If initially treated with amoxicillin: switch to amoxicillin-clavulanate 1
• If already on amoxicillin-clavulanate: consider ceftriaxone IM or refer to otolaryngology 1

Prevention Strategies

• Pneumococcal conjugate vaccine and annual influenza vaccine reduce AOM incidence 1
• Breastfeeding for at least 6 months provides protective benefit 1
• Avoid supine bottle feeding (increases eustachian tube dysfunction) 1
• Reduce or eliminate pacifier use after 6 months of age 1
• Modify daycare attendance patterns when feasible to reduce viral exposure 1

Common Pitfalls to Avoid

• Do not use antibiotics, antihistamines, decongestants, or corticosteroids for otitis media with effusion (OME)—these are ineffective and potentially harmful. 5
• Do not confuse AOM with OME—AOM requires acute onset with middle ear effusion AND signs of middle ear inflammation (bulging tympanic membrane or new otorrhea). 2, 3
• Do not use observation without ensuring reliable 48-72 hour follow-up—this is the most critical safety requirement for watchful waiting. 2, 1
• Avoid underdosing amoxicillin—the 80-90 mg/kg/day dose (not the traditional 40-45 mg/kg/day) is necessary for pneumococcal coverage in the post-PCV era. 1, 3