What is the treatment for otitis media?

Treatment of Otitis Media

For acute otitis media (AOM), pain management is paramount for all patients, and high-dose amoxicillin (80-90 mg/kg/day in children; 1.5-4 g/day in adults) is the first-line antibiotic when treatment is indicated, though observation without antibiotics is appropriate for children ≥6 months with nonsevere symptoms when close follow-up is ensured. 1, 2

Initial Management Decision: Antibiotics vs. Observation

The decision to prescribe antibiotics versus observation depends on age, symptom severity, and laterality:

Immediate antibiotics are indicated for: 1, 2

• All children <6 months of age
• Children 6-23 months with bilateral AOM (even if nonsevere)
• Any child with severe symptoms (moderate-to-severe otalgia >48 hours or fever ≥39°C/102.2°F)
• Adults with severe symptoms

Observation with close follow-up (48-72 hours) is appropriate for: 1, 2

• Children 6-23 months with unilateral, nonsevere AOM
• Children ≥24 months with nonsevere AOM (bilateral or unilateral)
• Adults with mild symptoms

Critical caveat: Observation requires a reliable mechanism for follow-up and ability to initiate antibiotics if symptoms worsen or fail to improve within 48-72 hours. 1, 2

Pain Management

Pain relief must be addressed immediately in all patients, regardless of antibiotic decision. 1, 2

• Analgesics (acetaminophen or ibuprofen) should be continued as long as needed, especially during the first 24 hours 1, 2
• Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited 2

Antibiotic Selection

First-Line Treatment

High-dose amoxicillin is the first-line antibiotic for most patients: 1, 2, 3

• Children: 80-90 mg/kg/day divided into 2 doses
• Adults: 1.5-4 g/day

This recommendation is based on effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), excellent safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 2, 3

Second-Line Treatment (Initial)

Amoxicillin-clavulanate should be used instead of amoxicillin for: 1, 2

• Patients who received amoxicillin in the previous 30 days (children) or 4-6 weeks (adults)
• Concurrent purulent conjunctivitis
• Need for coverage against beta-lactamase-producing organisms

Dosing: 2, 4

• Children: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate, divided into 2 doses
• Adults: 1.75-4 g/250 mg per day

Penicillin Allergy Alternatives

For patients with penicillin allergy, use: 1, 2, 5

• Cefdinir (14 mg/kg/day in 1-2 doses for children)
• Cefuroxime (30 mg/kg/day in 2 divided doses for children)
• Cefpodoxime (10 mg/kg/day in 2 divided doses for children)
• Ceftriaxone (50 mg/kg IM or IV daily for 1-3 days)

Important note: Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these cephalosporins generally safe for non-severe penicillin allergies. 2

Avoid macrolides (azithromycin, clarithromycin) and trimethoprim-sulfamethoxazole as first-line agents due to bacteriologic failure rates of 20-25%. 5, 6

Treatment Duration

Antibiotic duration varies by age and severity: 2

• Children <2 years or those with severe symptoms: 10 days
• Children 2-5 years with mild-to-moderate AOM: 7 days
• Children ≥6 years with mild-to-moderate symptoms: 5-7 days

Management of Treatment Failure

If symptoms worsen or fail to improve within 48-72 hours: 1, 2, 3

1. Reassess to confirm AOM diagnosis (ensure proper visualization of tympanic membrane with signs of middle ear inflammation)

2. Switch antibiotics:

   • If initially on amoxicillin → switch to amoxicillin-clavulanate
   • If initially on amoxicillin-clavulanate → switch to ceftriaxone (50 mg/kg/day IM for 1-3 days)
   • A 3-day course of ceftriaxone is superior to 1-day regimen for treatment failures 2

3. Consider tympanocentesis with culture for multiple treatment failures 2

Common Pitfalls to Avoid

Antibiotics do not eliminate complication risk: 33-81% of acute mastoiditis patients had received prior antibiotics, emphasizing the importance of proper diagnosis and follow-up. 2

Accurate diagnosis is essential: Ensure stringent diagnostic criteria including tympanic membrane bulging or new-onset otorrhea, use pneumatic otoscopy when possible. 1

Avoid overuse of broad-spectrum antibiotics: Increasing prevalence of beta-lactamase-producing organisms (especially H. influenzae and M. catarrhalis) should be considered, but reserve broader agents for appropriate indications to minimize resistance. 2, 5

Otitis Media with Effusion (OME)

After successful AOM treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 10-25% at 3 months. 2

For OME (effusion without acute symptoms): 1

• Watchful waiting is recommended initially with hearing testing at diagnosis
• Antibiotics are NOT indicated for OME
• Follow-up at 3 months with repeated hearing testing
• Tympanostomy tubes are indicated for: bilateral OME >3 months with hearing loss (>25-40 dB HL in better ear, varies by guideline) or documented impact on development/behavior

Recurrent AOM Prevention

Risk reduction strategies include: 1, 2

• Pneumococcal conjugate vaccine (PCV) and influenza vaccination
• Reducing daycare attendance when possible
• Eliminating tobacco smoke exposure
• Limiting pacifier use in older infants
• Breastfeeding

Long-term prophylactic antibiotics are discouraged. 1

For recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months), consider tympanostomy tube placement, which reduces recurrence rates with failure rates of 21% for tubes alone and 16% for tubes with adenoidectomy. 2