What is the recommended treatment for acute otitis media?

Treatment of Acute Otitis Media

Amoxicillin at high-dose (80-90 mg/kg/day in 2 divided doses) is the first-line antibiotic for acute otitis media, with amoxicillin-clavulanate as the second-line option. 1

Initial Management Approach

When Antibiotics Are Not Immediately Necessary

• Watchful waiting without antibiotics is a reasonable first-line option for most cases of acute otitis media, particularly in children older than 2 years with non-severe illness. 1
• Children younger than 2 years with bilateral otitis media should receive antibiotics rather than observation. 1
• This strategy reduces unnecessary antibiotic use while maintaining good outcomes in appropriately selected patients. 1

Pain Management

• Address pain immediately with oral analgesics (acetaminophen or ibuprofen) regardless of whether antibiotics are prescribed, especially during the first 24 hours. 2, 3
• Pain relief is a primary treatment goal, not a secondary consideration. 2, 3

Antibiotic Selection Algorithm

First-Line Treatment

• Amoxicillin 80-90 mg/kg/day in 2 divided doses is the recommended first-line antibiotic. 1, 2
• This high-dose regimen provides adequate coverage against drug-resistant Streptococcus pneumoniae, the most common pathogen. 2, 4
• Amoxicillin is preferred due to its effectiveness against common AOM pathogens, safety profile, low cost, and narrow microbiologic spectrum. 2
• Standard treatment duration is 8-10 days for most cases. 3

Second-Line Treatment (Use When First-Line Fails or in Specific Circumstances)

• 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, 2
  • Patients who received amoxicillin in the previous 30 days
  • Concurrent purulent conjunctivitis
  • Treatment failure after 48-72 hours of amoxicillin
  • When coverage for β-lactamase-producing organisms is needed
• The predominant cause of amoxicillin treatment failure is β-lactamase-producing Haemophilus influenzae (present in 34% of isolates), which justifies amoxicillin-clavulanate as the appropriate second-line agent. 2, 4

Penicillin Allergy Alternatives

• For non-type I hypersensitivity to penicillin: 2, 3
  • 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 true penicillin allergy: erythromycin-sulfafurazole is an alternative option. 3

Severe Cases or Treatment Failure

• Ceftriaxone 50 mg IM or IV for 3 days can be used for severe cases or when oral therapy has failed. 2, 3
• However, ceftriaxone and cefuroxime were deliberately excluded from routine recommendations to avoid overemphasis on empiric treatment for penicillin-resistant S. pneumoniae and to favor oral over parenteral options. 1

Evidence Supporting Antibiotic Use

• Antibiotics reduce residual pain at 2-3 days (RR 0.70; 95% CI 0.57-0.86) and decrease tympanic membrane perforations (RR 0.37; 95% CI 0.18-0.76). 1
• However, antibiotics also increase adverse events (RR 1.38; 95% CI 1.19-1.59), primarily gastrointestinal symptoms. 1
• No difference exists in clinical cure rates between once- or twice-daily dosing versus three- or four-times-daily dosing of amoxicillin. 1

Management of Treatment Failure

Definition and Timing

• Treatment failure is defined as: worsening condition, persistence of symptoms beyond 48 hours after antibiotic initiation, or recurrence within 4 days of treatment discontinuation. 3
• Patients should stabilize within the first 24 hours and begin improving during the second 24-hour period. 2

Reassessment Strategy

• Reassess at 48-72 hours if symptoms worsen or fail to improve to confirm the diagnosis and exclude other causes of illness. 2, 3
• Switch to amoxicillin-clavulanate if initial amoxicillin therapy fails. 2, 5
• Consider ceftriaxone for persistent failure or severe cases. 2, 3

Common Pitfalls to Avoid

• Do not diagnose AOM based solely on isolated tympanic membrane redness with normal landmarks—this does not warrant antibiotic therapy. 3
• Do not confuse otitis media with effusion (OME) with acute otitis media—antibiotics are not indicated for OME in the absence of acute symptoms. 2, 6
• Avoid fluoroquinolones as first-line therapy due to antimicrobial resistance concerns and side effects. 3
• NSAIDs at anti-inflammatory doses and corticosteroids have not demonstrated efficacy for AOM treatment. 3
• Antimicrobial resistance, particularly β-lactamase-producing H. influenzae, is the main reason for treatment failure, not resistant S. pneumoniae in most communities. 2, 4

Causative Pathogens

• The primary bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2, 3, 6
• All 24 S. pneumoniae isolates in one study had amoxicillin MIC ≤2.0 μg/mL, supporting high-dose amoxicillin efficacy. 4
• Beta-lactamase-producing H. influenzae accounts for the majority of bacteriologic failures with amoxicillin monotherapy. 4