What is the treatment for otitis media?

Treatment of Acute Otitis Media

Amoxicillin at 80-90 mg/kg/day divided into 2 doses is the first-line antibiotic for acute otitis media in children, while watchful waiting without antibiotics is appropriate for children ≥2 years with mild-to-moderate symptoms. 1, 2

Initial Management Decision

The approach depends on age, symptom severity, and clinical presentation:

• Immediate antibiotics are indicated for: 1, 2

  • All children <6 months of age
  • Children <2 years with confirmed AOM
  • Any child with severe symptoms (moderate-to-severe otalgia, otalgia >48 hours, or temperature ≥39°C/102.2°F)
  • Concurrent purulent conjunctivitis

• Watchful waiting (observation without antibiotics) is appropriate for: 1, 2

  • Children ≥2 years with mild-to-moderate symptoms
  • Requires reliable follow-up within 48-72 hours
  • Parents must have access to antibiotics if symptoms worsen

• Pain management must be addressed immediately in ALL patients, regardless of antibiotic decision, especially during the first 24 hours. 1, 2 Topical analgesics may provide relief within 10-30 minutes, and NSAIDs are significantly more effective than placebo. 1

First-Line Antibiotic Selection

Amoxicillin 80-90 mg/kg/day in 2 divided doses is the standard first-line therapy due to its effectiveness against common pathogens (S. pneumoniae, H. influenzae, M. catarrhalis), excellent safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 1, 2

Second-Line Antibiotic Selection

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate in 2 divided doses) for: 1, 2

• Amoxicillin use within the previous 30 days
• Concurrent purulent conjunctivitis
• Coverage needed for beta-lactamase-producing organisms (H. influenzae, M. catarrhalis)

Penicillin Allergy Alternatives

For patients with penicillin allergy, use: 1

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

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

Treatment Duration

• Children <2 years and those with severe symptoms: 10-day course 1, 2
• Children 2-5 years with mild-to-moderate AOM: 7-day course (equally effective to 10 days) 1, 2
• Children ≥6 years with mild-to-moderate symptoms: 5-7 day course 1

Management of Treatment Failure

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

1. Reassess to confirm AOM diagnosis
2. Switch to amoxicillin-clavulanate if initially on amoxicillin
3. If already on amoxicillin-clavulanate, use ceftriaxone 50 mg/kg IM daily for 1-3 days (3-day course superior to 1-day regimen) 1
4. Consider tympanocentesis with culture and susceptibility testing for multiple treatment failures 1, 2

Alternative Regimen: Azithromycin

While not first-line per guidelines, azithromycin is FDA-approved for pediatric acute otitis media: 3

• 30 mg/kg as single dose (1-day regimen)
• 10 mg/kg once daily for 3 days (3-day regimen)
• 10 mg/kg Day 1, then 5 mg/kg Days 2-5 (5-day regimen)

Clinical success rates at Day 11-14 ranged from 83-89% across trials, comparable to amoxicillin-clavulanate. 3 However, azithromycin is not recommended as first-line by AAP guidelines due to increasing macrolide resistance. 1

Post-Treatment Follow-Up

• 60-70% of children have middle ear effusion at 2 weeks post-treatment, decreasing to 40% at 1 month and 10-25% at 3 months. 1
• Middle ear effusion without acute symptoms after AOM resolution is otitis media with effusion (OME), which requires monitoring but NOT antibiotics. 1, 2

Recurrent AOM Management

For recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months): 1, 2

• Consider tympanostomy tube placement (failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy)
• Antimicrobial prophylaxis is an alternative but less preferred option

Prevention Strategies

Risk reduction includes: 1, 2

• Breastfeeding
• Avoiding tobacco smoke exposure
• Limiting pacifier use in older infants/children
• Pneumococcal vaccination

Critical Pitfalls to Avoid

• Do NOT use topical antibiotics for AOM - these are contraindicated and only indicated for otitis externa or tube otorrhea. 1
• Do NOT use ototoxic topical preparations when tympanic membrane integrity is uncertain. 1
• Antibiotics do NOT eliminate the risk of complications like acute mastoiditis - 33-81% of mastoiditis patients had received prior antibiotics. 1