What is the treatment for otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day in 2 divided 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: Antibiotics vs. Observation

The decision to prescribe immediate antibiotics versus watchful waiting depends on three key factors: age, symptom severity, and diagnostic certainty.

Immediate antibiotic treatment is mandatory for:

• All children under 6 months of age 1, 2
• Children 6-23 months with severe symptoms (moderate-to-severe otalgia or fever ≥39°C) 1, 2
• Children 6-23 months with bilateral AOM, even if non-severe 1, 2
• Children of any age with severe symptoms 1, 2
• When reliable follow-up cannot be ensured 1

Observation without immediate antibiotics is appropriate for:

• Children 6-23 months with unilateral, non-severe AOM and certain diagnosis 1, 2
• Children ≥24 months with non-severe AOM (unilateral or bilateral) 1, 2
• This requires shared decision-making with parents and a mechanism to ensure follow-up within 48-72 hours 1, 2

The observation approach does not worsen recovery outcomes, though it may prolong symptoms by 1-2 days and increase parental work absences 3. If observation is chosen, parents must understand to initiate antibiotics if symptoms worsen or fail to improve within 48-72 hours 1, 2.

Pain Management

Pain control must be addressed immediately in all patients, regardless of whether antibiotics are prescribed, especially during the first 24 hours. 1, 2 Analgesics (acetaminophen or ibuprofen) should be continued as long as needed 2. Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited 1.

First-Line Antibiotic Selection

Amoxicillin at 80-90 mg/kg/day divided into 2 doses is the recommended first-line treatment due to its effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), safety profile, low cost, acceptable taste, and narrow spectrum 1, 2.

Use amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) as first-line if:

• The child received amoxicillin in the previous 30 days 1
• Concurrent purulent conjunctivitis is present 1
• Coverage for beta-lactamase producing organisms (H. influenzae, M. catarrhalis) is needed 1

Penicillin Allergy Alternatives

For patients with penicillin allergy, alternative first-line options include: 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)
• Ceftriaxone (50 mg IM or IV per day for 1-3 days)

Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these cephalosporins generally safe for non-severe penicillin allergies 1.

Treatment Duration

Treatment duration varies by age and severity: 1

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

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. If initially managed with observation, begin antibiotics
3. If initially treated with amoxicillin, switch to amoxicillin-clavulanate
4. If failing amoxicillin-clavulanate, use intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 1
5. A 3-day course of ceftriaxone is superior to a 1-day regimen for treatment failures 1

For children with multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered to guide antibiotic selection based on actual pathogens and resistance patterns 1.

Critical Pitfalls to Avoid

Do not assume antibiotics prevent complications: 33-81% of children who develop acute mastoiditis had received prior antibiotics for AOM 1. Antibiotics reduce but do not eliminate complication risk.

Do not use the following for AOM treatment: 1

• Corticosteroids (systemic or intranasal) - not effective and have potential adverse effects
• Antihistamines or decongestants - ineffective
• Topical antibiotics - contraindicated for AOM (only for otitis externa or tube otorrhea)

Distinguish AOM from otitis media with effusion (OME): After successful treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 10-25% at 3 months 1. This persistent effusion without acute symptoms is OME and requires monitoring but not antibiotics 1.

Prevention Strategies

Modifiable risk factors to address include: 1, 2

• Encourage breastfeeding for at least 6 months
• Reduce or eliminate pacifier use after 6 months of age
• Avoid supine bottle feeding
• Minimize daycare attendance patterns when possible
• Eliminate tobacco smoke exposure
• Ensure pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccination

Long-term prophylactic antibiotics are discouraged for recurrent AOM 1. For recurrent cases, consider tympanostomy tube placement, which reduces recurrence rates (failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy in children ≥4 years) 1.

Alternative Agents: Azithromycin

While azithromycin is FDA-approved for AOM at 30 mg/kg as a single dose or 10 mg/kg daily for 3-5 days 4, it is not recommended as first-line therapy by current guidelines. Clinical trials showed azithromycin had similar efficacy to amoxicillin-clavulanate (88% vs 88% success at Day 11) but with lower gastrointestinal side effects (9% vs 31%) 4. However, amoxicillin remains preferred due to better coverage of S. pneumoniae and narrower spectrum 1, 2.