What is the treatment for otitis media?

Treatment of Otitis Media

Amoxicillin 80-90 mg/kg/day divided into two doses is the first-line antibiotic treatment for acute otitis media when antibiotics are indicated, though observation without immediate antibiotics is appropriate for selected children based on age, symptom severity, and diagnostic certainty. 1, 2

Initial Management Decision: Observation vs. Immediate Antibiotics

The decision to observe versus treat immediately depends on three key factors: age, symptom severity, and diagnostic certainty. 1, 2

Immediate antibiotics are required for:

• All children under 6 months of age 1
• Children 6-23 months with bilateral AOM (regardless of severity) 2
• Children 6-23 months with severe unilateral AOM 2
• Any child ≥24 months with severe symptoms (moderate-to-severe otalgia or fever ≥39°C/102.2°F) 1, 2

Observation without immediate antibiotics is appropriate for:

• Children 6-23 months with non-severe unilateral AOM 2
• Children ≥24 months with non-severe AOM 2
• Children ≥2 years with uncertain diagnosis 2

Critical requirement for observation: A reliable mechanism must be in place to ensure follow-up within 48-72 hours and immediate initiation of antibiotics if the child's condition worsens or fails to improve. 3, 2 This approach requires shared decision-making with parents/caregivers and confidence in their ability to monitor and return if needed. 2

Pain Management (Always Required)

Pain control must be addressed immediately in all patients, regardless of whether antibiotics are prescribed, especially during the first 24 hours. 1, 2 Analgesics should be continued as long as needed to control pain. 2 This is considered paramount across all treatment guidelines. 2

Antibiotic Selection

First-Line Treatment

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

Second-Line Treatment (Use Instead of Amoxicillin When):

Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) should be used for: 1

• Child received amoxicillin in the previous 30 days 1
• Concurrent purulent conjunctivitis 1
• Need for coverage against β-lactamase-producing organisms (H. influenzae, M. catarrhalis) 1

Penicillin Allergy Alternatives

For non-severe penicillin allergy, cephalosporins are generally safe due to lower cross-reactivity than historically reported: 1

• 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

Treatment Duration

Age-based duration recommendations: 1

• Children <2 years: 10-day course 1
• Children 2-5 years with mild-moderate AOM: 7-day course 1
• Children ≥6 years with mild-moderate symptoms: 5-7 day course 1

Treatment Failure Management

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

1. Reassess to confirm AOM diagnosis and exclude other causes 2
2. If initially observed without antibiotics: Start amoxicillin 2
3. If initially treated with amoxicillin: Switch to amoxicillin-clavulanate 1, 2
4. If failing amoxicillin-clavulanate: Consider ceftriaxone 50 mg/kg IM/IV daily for 1-3 days (3-day course superior to 1-day) 1
5. For multiple treatment failures: Consider tympanocentesis with culture and susceptibility testing 1

Common Pitfalls to Avoid

Do not use antibiotics for otitis media with effusion (OME). After successful AOM treatment, 60-70% of children have middle ear effusion at 2 weeks, 40% at 1 month, and 10-25% at 3 months—this is OME and requires monitoring but not antibiotics. 1

Antibiotics do not eliminate the risk of complications. In studies of acute mastoiditis, 33-81% of patients had received prior antibiotics, so maintain vigilance for complications even with appropriate treatment. 1

Azithromycin is not recommended as first-line therapy despite FDA approval for AOM, as it has inferior efficacy compared to amoxicillin and promotes resistance. 4 Reserve it only for true penicillin and cephalosporin allergies.

Prevention Strategies

Risk reduction measures include: 1, 2

• Breastfeeding for at least 6 months 2
• Avoiding tobacco smoke exposure 1
• Reducing/eliminating pacifier use after 6 months of age 2
• Pneumococcal conjugate and influenza vaccination 2
• Modifying daycare attendance patterns when feasible 2

Recurrent AOM

For recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months with ≥1 in past 6 months), consider tympanostomy tube placement, which reduces recurrence rates (failure rate 21% for tubes alone, 16% for tubes with adenoidectomy). 1