What is the treatment for otitis media?

Treatment of Acute Otitis Media

First-Line Antibiotic Therapy

Amoxicillin at 80-90 mg/kg/day divided into 2 doses is the first-line treatment for acute otitis media in patients without penicillin allergy. 1, 2

• This recommendation is based on amoxicillin's effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), excellent safety profile, low cost, acceptable taste, and narrow microbiologic spectrum 1
• Amoxicillin remains the standard despite increasing rates of beta-lactamase-producing organisms, as it is effective for most causative bacterial pathogens 1

Initial Management Decision: Antibiotics vs. Observation

Immediate antibiotic therapy is mandatory for:

• All children younger than 6 months of age 1
• Children with severe symptoms (moderate to severe otalgia, otalgia lasting ≥48 hours, or temperature ≥39°C) 1
• Children who have taken amoxicillin in the previous 30 days 1
• Children with concurrent purulent conjunctivitis 1

Watchful waiting (observation without immediate antibiotics) is appropriate for:

• Children 2 years or older with mild-to-moderate symptoms 1, 2
• This approach requires reliable follow-up and ability to reassess if symptoms worsen 1

Pain Management

Address pain immediately in all patients, regardless of antibiotic decision. 1, 2

• Pain management is crucial during the first 24 hours 1
• Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited 1

Treatment Duration

Duration varies by age and severity:

• 10-day course: Children younger than 2 years and those with severe symptoms 1, 2
• 7-day course: Children 2-5 years with mild or moderate symptoms 1, 2
• 5-7 day course: Children 6 years and older with mild to moderate symptoms 1

Second-Line Therapy for Treatment Failure

If symptoms worsen or fail to improve within 48-72 hours, switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses). 1, 2

• Reassess the patient to confirm the diagnosis of acute otitis media before changing antibiotics 1
• This addresses beta-lactamase-producing H. influenzae and M. catarrhalis 1

Third-Line Therapy

For patients failing amoxicillin-clavulanate, use intramuscular ceftriaxone 50 mg/kg/day for 1-3 days. 1

• A 3-day course of ceftriaxone is superior to a 1-day regimen for treatment-resistant cases 1
• Consider tympanocentesis with culture and susceptibility testing for children with multiple treatment failures 1

Penicillin-Allergic Patients

Alternative antibiotics for penicillin allergy include:

• Cefdinir: 14 mg/kg/day in 1-2 doses 1

• Cefuroxime: 30 mg/kg/day in 2 divided doses 1

• Cefpodoxime: 10 mg/kg/day in 2 divided doses 1

• Ceftriaxone: 50 mg IM or IV per day for 1-3 days 1

• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these generally safe options for non-severe penicillin allergy 1

Azithromycin Considerations

Azithromycin is FDA-approved for acute otitis media but is NOT recommended as first-line therapy based on current guidelines. 3

• FDA-approved dosing: 30 mg/kg as single dose, OR 10 mg/kg once daily for 3 days, OR 10 mg/kg Day 1 then 5 mg/kg Days 2-5 3
• Clinical trials showed 82-89% success rates at Day 11-12, but this is not superior to amoxicillin 3
• Guidelines prioritize amoxicillin due to narrower spectrum and concerns about macrolide resistance 1, 2

Critical Pitfalls to Avoid

Antibiotics do not eliminate the risk of complications like acute mastoiditis—33-81% of mastoiditis patients had received prior antibiotics. 1

• Do not assume antibiotic treatment guarantees prevention of all complications 1
• Maintain appropriate follow-up even with antibiotic therapy 1

Post-Treatment Expectations

Middle ear effusion persists after successful treatment in 60-70% of children at 2 weeks, 40% at 1 month, and 10-25% at 3 months. 1

• This is defined as otitis media with effusion (OME) when symptoms resolve 1
• OME requires monitoring but NOT antibiotics 1, 2

Recurrent Acute Otitis Media

For recurrent cases, consider tympanostomy tube placement:

• Tubes alone have 21% failure rate; tubes with adenoidectomy have 16% failure rate 1
• This is appropriate after multiple antibiotic courses fail to prevent recurrences 1, 2

Prevention Strategies

Risk reduction includes:

• Breastfeeding 1, 2
• Avoiding tobacco smoke exposure 1, 2
• Limiting pacifier use in older infants and children 1, 2
• Pneumococcal vaccination 1, 2