Should a patient with resolved Acute Otitis Media (AOM) continue or stop antibiotics?

Should Antibiotics Be Stopped or Continued in Resolved AOM?

If your patient's AOM symptoms have clinically resolved (no fever, improved pain, normalized behavior), you should complete the full antibiotic course as prescribed—do not stop early. 1, 2

How to Determine if AOM Has Truly Resolved

Clinical Resolution Timeline

• Expect improvement within 48-72 hours of starting antibiotics: fever should decline, irritability should lessen, and sleeping/drinking patterns should normalize 1
• Symptom worsening in the first 24 hours is normal and does not indicate treatment failure 1
• After 24-48 hours, symptoms should begin improving; if not, consider treatment failure or concurrent viral infection 1

Key Clinical Indicators of Resolution

• Fever resolution within 48-72 hours 1
• Decreased irritability and fussiness 1
• Normalized sleep and feeding patterns 1
• Reduced or absent ear pain 1

Complete the Full Antibiotic Course

Duration Guidelines

• Children <2 years and those with severe symptoms: Complete full 10-day course 3, 4
• Children 2-5 years with mild-moderate AOM: 7-day course is sufficient 3, 4
• Children ≥6 years with mild-moderate symptoms: 10-day course recommended 3, 4
• Treatment should continue 48-72 hours beyond symptom resolution to ensure bacterial eradication 2

Why Complete the Course Despite Resolution

• Early symptom resolution does not guarantee bacterial eradication 2
• Stopping antibiotics prematurely risks recurrence and promotes antibiotic resistance 1
• The standard duration is designed to prevent treatment failure, which occurs in 21% of inadequately treated cases versus 5% with complete treatment 1

Middle Ear Effusion Does NOT Mean Persistent AOM

Critical Distinction

• Middle ear effusion (MEE) persists after clinical resolution in most children and is NOT an indication to continue or restart antibiotics 1, 4
• 60-70% have MEE at 2 weeks post-treatment 1, 4
• 40% have MEE at 1 month post-treatment 1, 4
• 10-25% have MEE at 3 months post-treatment 1, 4

Common Pitfall to Avoid

Do not confuse persistent MEE (otitis media with effusion/OME) with active AOM—OME requires monitoring but not antibiotics 1, 4. The presence of fluid on otoscopy or tympanometry without acute symptoms (fever, severe pain, bulging tympanic membrane) is OME, not AOM 1, 4.

When to Consider Treatment Failure (Not Resolution)

Signs That AOM Has NOT Resolved

• No improvement or worsening after 48-72 hours of appropriate antibiotics 1, 3
• Persistent fever beyond 48-72 hours 1
• Continued severe ear pain 1
• Persistent irritability and sleep disruption 1
• Unimproved otoscopic findings (persistent TM bulging or intense erythema) 1

Action for Treatment Failure

If true treatment failure occurs (not just persistent MEE), switch antibiotics rather than extending the same antibiotic 1, 3:

• If initially on amoxicillin, switch to amoxicillin-clavulanate 1, 3
• If on amoxicillin-clavulanate or oral cephalosporins, use IM ceftriaxone 50 mg/kg for 3 days 1, 3

Follow-Up Considerations

When Follow-Up Is Needed

• Routine follow-up is not necessary for uncomplicated AOM that resolves clinically 1, 4
• Follow-up IS indicated for children with cognitive/developmental delays where transient hearing loss from persistent MEE could be problematic 1
• Reassessment is warranted if symptoms recur or never fully resolved 1

What to Monitor

• Verify that MEE eventually resolves over weeks to months (this is expected and normal) 1, 4
• Ensure hearing normalizes, particularly in high-risk children 1
• Watch for recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months), which may warrant different management strategies 1, 3