What is the treatment for otitis media?

Treatment of Acute Otitis Media

Amoxicillin at 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

Pain Management (First Priority)

• Analgesics must be addressed immediately in all patients regardless of antibiotic decision, as pain control is paramount and should continue as long as needed 1, 2
• Pain relief should be initiated within the first 24 hours, with topical analgesics potentially providing relief within 10-30 minutes 1, 2

Initial Management Decision: Observation vs. Immediate Antibiotics

Immediate Antibiotic Indications

• Children under 6 months: Always treat with antibiotics immediately 2
• Children 6-23 months with severe symptoms or bilateral AOM: Prescribe antibiotics immediately 1
• Children ≥24 months with severe symptoms: Prescribe antibiotics immediately 1
• Severe symptoms include moderate-to-severe otalgia, otalgia lasting ≥48 hours, or temperature ≥39°C (102.2°F) 1

Observation Option (Watchful Waiting)

• Children 6-23 months with non-severe unilateral AOM: Either prescribe antibiotics or offer observation with close follow-up 1
• Children ≥24 months with non-severe AOM: Either prescribe antibiotics or offer observation with close follow-up 1
• A reliable mechanism for follow-up within 48-72 hours must be in place before choosing observation 3, 1
• Observation requires shared decision-making with parents/caregivers and assurance of medication access if symptoms worsen 1

Antibiotic Selection

First-Line Treatment

• Amoxicillin 80-90 mg/kg/day divided into two doses is the preferred initial antibiotic due to effectiveness against common pathogens (S. pneumoniae, H. influenzae, M. catarrhalis), safety profile, low cost, acceptable taste, and narrow spectrum 1, 2
• This dose should be used when the child has not received amoxicillin in the past 30 days, does not have concurrent purulent conjunctivitis, and is not allergic to penicillin 1, 2

Second-Line Treatment (Enhanced Beta-Lactamase Coverage)

• Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses should be used when: 2
  • Child received amoxicillin in the previous 30 days
  • Concurrent purulent conjunctivitis is present
  • Coverage for beta-lactamase producing organisms (H. influenzae, M. catarrhalis) is needed

Penicillin Allergy Alternatives

• For non-severe penicillin allergy, use second or third-generation cephalosporins: 1, 2
  • 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
• For severe penicillin allergy or treatment failure, use ceftriaxone 50 mg/kg IM or IV daily for 1-3 days 2
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these generally safe options 2

Alternative Agent (Not First-Line)

• Azithromycin 30 mg/kg as a single dose or 10 mg/kg daily for 3-5 days showed clinical success rates of 83-89% at Day 11-12 and 73-85% at Day 24-32 in FDA trials, but is not recommended as first-line due to increasing resistance 4

Treatment Duration

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

Treatment Failure Management

• If symptoms worsen at any time or fail to improve within 48-72 hours, reassess the patient 1, 2
• Confirm AOM diagnosis and exclude other causes of symptoms 1
• If initially managed with observation, begin antibiotics 1
• If initially treated with amoxicillin, switch to amoxicillin-clavulanate 1, 2
• If failing amoxicillin-clavulanate, use ceftriaxone 50 mg/kg/day IM for 1-3 days (3-day course superior to 1-day) 2
• For multiple treatment failures, consider tympanocentesis with culture and susceptibility testing 2

Post-Treatment Follow-Up

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

Prevention Strategies

• Encourage breastfeeding for at least 6 months 1
• Avoid supine bottle feeding 1
• Reduce or eliminate pacifier use after 6 months of age 1
• Minimize daycare exposure when possible 1
• Ensure pneumococcal conjugate vaccine and influenza vaccine are up to date 1, 2
• Eliminate tobacco smoke exposure 2

Critical Pitfalls to Avoid

• Do not use topical antibiotics for acute otitis media - these are contraindicated and only indicated for otitis externa or tube otorrhea 2
• Do not use ototoxic topical preparations when tympanic membrane integrity is uncertain 2
• Antibiotics do not eliminate the risk of complications like acute mastoiditis (33-81% of mastoiditis patients had received prior antibiotics) 2
• Do not use antihistamines, decongestants, or corticosteroids for AOM or OME - they are ineffective 5, 6
• Ensure reliable follow-up mechanism is in place before choosing observation strategy 3, 1