What is the treatment for otitis media?

Treatment of Acute 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 antibiotics is appropriate for selected children based on age, symptom severity, and diagnostic certainty. 1, 2

Pain Management (First Priority)

• Pain control must be addressed immediately in all patients regardless of antibiotic decision, as this is paramount in all treatment guidelines 1, 2
• Analgesics should be continued as long as needed to control pain, especially during the first 24 hours 1
• Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited 2

Initial Management Decision: Observation vs. Immediate Antibiotics

Immediate Antibiotics Are Indicated For:

• All children under 6 months of age 2
• Children 6-23 months with severe AOM (moderate to severe otalgia or otalgia ≥48 hours or temperature ≥39°C) 1
• Children 6-23 months with bilateral AOM, even if non-severe 1
• Children ≥24 months with severe AOM 1
• Any child when follow-up cannot be ensured 2

Observation Without Antibiotics Is Appropriate For:

• Children 6-23 months with non-severe unilateral AOM (based on shared decision-making with parents) 1
• Children ≥24 months with non-severe AOM (based on shared decision-making with parents) 1
• A mechanism must be in place to ensure follow-up and initiation of antibiotics if the child fails observation 1

Antibiotic Selection

First-Line Treatment:

• Amoxicillin 80-90 mg/kg/day in 2 divided doses for children who have not received amoxicillin in the past 30 days, do not have concurrent purulent conjunctivitis, and are not allergic to penicillin 1, 2

Second-Line Treatment (Use When):

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) for children who received amoxicillin in the previous 30 days, have concurrent purulent conjunctivitis, or require coverage for beta-lactamase producing organisms 2

Penicillin Allergy Alternatives:

• Cefdinir (14 mg/kg/day in 1-2 doses) 2
• Cefuroxime (30 mg/kg/day in 2 divided doses) 2
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 2
• Ceftriaxone (50 mg IM or IV per day for 1-3 days) 2
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these generally safe options for non-severe penicillin allergy 2

Treatment Duration

• 10-day course for children younger than 2 years and those with severe symptoms 2
• 7-day course for children 2-5 years with mild or moderate AOM 2
• 5-7 day course for children 6 years and older with mild to moderate symptoms 2

Treatment Failure Management

• Reassess if symptoms worsen or fail to improve within 48-72 hours 1, 2
• Confirm AOM diagnosis and exclude other causes 1
• If initially managed with observation, begin antibiotics 1
• If initially treated with amoxicillin, switch to amoxicillin-clavulanate 2
• If failing amoxicillin-clavulanate, use intramuscular ceftriaxone (50 mg/kg/day for 1-3 days), with a 3-day course superior to 1-day regimen 2
• For children with multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered 2

Critical Pitfalls to Avoid

• Do not use antibiotics for otitis media with effusion (OME), which is defined as middle ear effusion without acute symptoms and requires monitoring but not antibiotics 2
• After successful treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months—this is OME, not treatment failure 2
• Antibiotics do not eliminate the risk of complications like acute mastoiditis, as 33-81% of mastoiditis patients had received prior antibiotics 2
• Do not use topical antibiotics for acute otitis media, as these are contraindicated and only indicated for otitis externa or tube otorrhea 2

Prevention Strategies

• Encourage breastfeeding for at least 6 months 1, 2
• Reduce or eliminate pacifier use after 6 months of age 1, 2
• Avoid supine bottle feeding 1, 2
• Eliminate tobacco smoke exposure 1, 2
• Minimize daycare attendance patterns when possible 2
• Immunization with pneumococcal conjugate vaccines (PCV-13) and annual influenza vaccination 1, 2
• Long-term prophylactic antibiotics are discouraged for recurrent AOM 2

Recurrent AOM Considerations

• For recurrent AOM, consider tympanostomy tube placement, which can reduce recurrence rates 2
• Failure rates are 21% for tubes alone and 16% for tubes with adenoidectomy 2