What is the treatment for otitis media (middle ear infection)?

Treatment of Otitis Media

High-dose amoxicillin (80-90 mg/kg/day divided in two doses) is the first-line antibiotic for acute otitis media in patients without penicillin allergy, based on its proven efficacy against common bacterial pathogens including drug-resistant Streptococcus pneumoniae, excellent safety profile, and low cost. 1, 2

Initial Diagnostic Considerations

Before initiating treatment, distinguish between acute otitis media (AOM) and otitis media with effusion (OME), as this fundamentally changes management:

• AOM requires: Acute onset, middle ear effusion, physical evidence of middle ear inflammation (such as tympanic membrane bulging or new-onset otorrhea), and symptoms like pain, irritability, or fever 1, 3
• OME (middle ear effusion without acute symptoms) does NOT warrant initial antibiotic therapy 1

The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2, 3

Treatment Algorithm for Acute Otitis Media

Step 1: Pain Management

Always begin with adequate analgesia regardless of antibiotic decision 1, 3. Topical analgesics may reduce ear pain within 10-30 minutes of administration 1.

Step 2: Decide Between Immediate Antibiotics vs. Watchful Waiting

Immediate antibiotics are indicated for: 1

• Children under 6 months with AOM
• Children 6-23 months with bilateral AOM or severe symptoms
• Any child with severe AOM (high fever ≥39°C or 102.2°F, moderate-to-severe otalgia)
• Adults with bilateral AOM 2

Watchful waiting (observation for 48-72 hours with symptomatic treatment) may be appropriate for: 1

• Children over 2 years with nonsevere unilateral AOM
• Children 6-23 months with nonsevere unilateral AOM

This approach balances the modest benefits of antibiotics shown in meta-analyses against adverse effects like vomiting, diarrhea, and rash 1. However, bacterial eradication does contribute to improved clinical outcomes in culture-positive patients 1.

Step 3: First-Line Antibiotic Selection

High-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 5-10 days 1, 2, 3

This achieves middle ear fluid levels exceeding the minimum inhibitory concentration for intermediately resistant and many highly resistant S. pneumoniae serotypes 2.

For penicillin-allergic patients (non-severe allergy): 1, 2

• Cefdinir (14 mg/kg/day in 1-2 doses)
• Cefuroxime axetil
• Cefpodoxime (10 mg/kg/day in 2 divided doses)

Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported 2.

For true penicillin allergy with severe reactions: 4

• Azithromycin is an option but NOT preferred due to increasing resistance patterns and bacteriologic failure against H. influenzae 4
• Macrolide resistance in S. pneumoniae significantly impairs efficacy 4

Step 4: Second-Line Treatment (Treatment Failure)

If symptoms persist or worsen after 48-72 hours of amoxicillin, switch to: 1, 2, 3

Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate) 1, 2

This provides coverage for β-lactamase-producing H. influenzae and M. catarrhalis 2, 5.

Also use amoxicillin-clavulanate as first-line if: 1, 2

• Patient received amoxicillin within the previous 30 days
• Concurrent purulent conjunctivitis
• History of recurrent AOM unresponsive to amoxicillin

Alternative second-line options: 2

• Ceftriaxone (intramuscular) for severe cases or noncompliance concerns
• Cefuroxime axetil
• Cefpodoxime proxetil

Do NOT switch from amoxicillin to azithromycin for treatment failure 4. Azithromycin should only be reserved for patients with true penicillin allergy who cannot tolerate cephalosporins 4.

Special Considerations and Common Pitfalls

Age-Specific Dosing

For pediatric patients, azithromycin dosing when indicated: 6

• 3-day regimen: 10 mg/kg once daily for 3 days
• 5-day regimen: 10 mg/kg on Day 1, then 5 mg/kg on Days 2-5
• Single-dose regimen: 30 mg/kg as a single dose (for otitis media only)

However, amoxicillin remains superior to macrolides and should be considered first-line 1.

Duration of Therapy

Standard treatment duration is 5-10 days, with longer courses (10 days) recommended for: 1

• Children under 2 years
• Children with severe symptoms
• Children with recurrent AOM

Otitis Media with Effusion (OME)

Antibiotics are NOT indicated for initial treatment of OME 1, 3. Consider antibiotics only for effusions persisting longer than 3 months, though evidence for benefit is limited 7, 3. Decongestants and nasal steroids do not hasten clearance 3.

Recurrent AOM

For recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months): 1

• Reduce risk factors (daycare attendance, tobacco smoke exposure)
• Pneumococcal conjugate vaccine (PCV) and influenza vaccine
• Long-term prophylactic antibiotics are discouraged 1
• Consider tympanostomy tube referral for children with documented language delay or anatomic damage 8, 3

Critical Pitfall to Avoid

Over-diagnosis occurs in 40-80% of patients compared to tympanocentesis confirmation 1. Ensure strict diagnostic criteria are met before prescribing antibiotics to minimize unnecessary antibiotic use and resistance development 1.

When to Refer

Refer to otolaryngology for: 3

• Evidence of anatomic damage
• Hearing loss
• Language delay
• OME persisting beyond 3 months with complications
• Suspected complications (mastoiditis, intracranial extension)