When should antibiotics be administered in acute otitis media (AOM)?

When to Administer Antibiotics in Acute Otitis Media

Antibiotics should be administered immediately in children with severe AOM (moderate-to-severe otalgia or fever ≥39°C/102.2°F), children under 6 months of age, and children 6-23 months with bilateral AOM, while observation with close follow-up is appropriate for non-severe cases in older children based on shared decision-making with caregivers. 1, 2

Immediate Antibiotic Therapy Required

Always prescribe antibiotics immediately for:

• Children <6 months of age with any AOM diagnosis 3
• Severe AOM in any child ≥6 months: defined as moderate-to-severe otalgia OR fever ≥39°C (102.2°F) 1, 2
• Bilateral AOM in children 6-23 months, even if non-severe 1, 2
• New-onset otorrhea not due to otitis externa (indicates tympanic membrane perforation) 1
• Children with specific risk factors: immune deficiency, Down syndrome, craniofacial abnormalities, cochlear implants 1, 3

Observation Option (Watchful Waiting)

Observation without immediate antibiotics is appropriate for:

• Unilateral AOM in children 6-23 months with non-severe symptoms (mild otalgia <48 hours AND fever <39°C) - requires shared decision-making with parents 1, 2
• Any AOM (bilateral or unilateral) in children ≥24 months with non-severe symptoms - requires shared decision-making with parents 1, 2

Critical Requirements for Observation Strategy

A mechanism MUST be in place to ensure:

• Close follow-up within 48-72 hours 1, 2
• Ability to initiate antibiotics promptly if symptoms worsen or fail to improve 1, 2
• Parent/caregiver understanding and agreement with the plan 1

Antibiotic Selection When Treatment Indicated

First-line therapy:

• Amoxicillin 80-90 mg/kg/day divided into two doses (high-dose) 1, 2, 4, 5
• Use for 10 days in children <2 years; 5-7 days may be adequate for children ≥2 years 6, 4

Use amoxicillin-clavulanate instead of amoxicillin if:

• Child received amoxicillin in past 30 days 1, 4
• Concurrent purulent conjunctivitis present 1, 7, 4
• History of recurrent AOM unresponsive to amoxicillin 1

For penicillin allergy:

• Cefdinir, cefpodoxime, or cefuroxime (if non-type I hypersensitivity) 2, 7, 4
• Azithromycin (if type I hypersensitivity) 4

Reassessment and Treatment Failure

Reassess within 48-72 hours if:

• Symptoms worsen at any time 1, 2
• No improvement after initial observation period 1, 2
• No improvement despite antibiotic therapy 1

If treatment failure occurs:

• Switch to amoxicillin-clavulanate if initially used amoxicillin 1, 5
• Consider ceftriaxone 50 mg/kg IM daily for 3 days for resistant cases 7

Pain Management - Universal Requirement

Analgesics should be provided to ALL children with AOM regardless of antibiotic decision:

• Address pain within first 24 hours as antibiotics do not provide immediate symptom relief 1, 2
• Use acetaminophen or ibuprofen at age-appropriate doses 2, 7
• Continue as long as needed for symptom control 2

Common Pitfalls to Avoid

• Do not substitute two 250 mg/125 mg amoxicillin-clavulanate tablets for one 500 mg/125 mg tablet - they contain different amounts of clavulanic acid 6
• Do not use trimethoprim-sulfamethoxazole due to high pneumococcal resistance rates 7
• Do not interpret persistent middle ear effusion at 2 weeks as treatment failure - occurs in 60-70% of successfully treated cases 7
• Do not diagnose AOM based solely on tympanic membrane erythema without bulging or effusion 1, 5