Treatment of Suppurative Otitis Media
For acute suppurative otitis media (AOM), high-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line antibiotic treatment, with immediate pain management being paramount regardless of antibiotic use. 1
Distinguishing Clinical Entities
Suppurative otitis media encompasses two distinct conditions requiring different management approaches:
- Acute suppurative otitis media (AOM): Middle ear effusion with acute inflammation signs and symptoms such as ear pain, fever, and bulging tympanic membrane 2, 1
- Chronic suppurative otitis media (CSOM): Chronic discharge through a perforated tympanic membrane, defined as persistent otorrhea lasting more than 2 weeks 2, 3
Acute Suppurative Otitis Media Management
Initial Decision Algorithm
Immediate antibiotics are indicated for:
- All children <6 months of age 1
- Children with severe symptoms (moderate-to-severe otalgia, otalgia >48 hours, temperature ≥39°C) 2, 1
- Bilateral AOM in children 6-23 months 2
- When reliable follow-up cannot be ensured 1
Observation without immediate antibiotics is appropriate for:
- Children ≥2 years with mild-to-moderate symptoms and reliable follow-up 2, 1
- Approximately one-third of children with bacterial AOM improve without antibiotics 2
Pain Management (Critical First Step)
Pain control must be addressed immediately in all patients, as this is considered paramount regardless of antibiotic decision 2, 1. NSAIDs during the acute phase significantly reduce pain compared to placebo 1. Topical analgesics may provide relief within 10-30 minutes 1.
Antibiotic Selection
First-line therapy:
- Amoxicillin 80-90 mg/kg/day in 2 divided doses for 10 days (children <2 years or severe symptoms) or 7 days (children 2-5 years with mild-moderate symptoms) 1, 4, 5
- This high-dose regimen is effective against 92% of S. pneumoniae (including penicillin-nonsusceptible strains), 84% of beta-lactamase-negative H. influenzae, but only 62% of beta-lactamase-positive H. influenzae 5
Second-line therapy (use if amoxicillin taken in previous 30 days, concurrent purulent conjunctivitis, or treatment failure at 48-72 hours):
- Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses 1, 6
- This formulation (45/6.4 mg/kg/day divided every 12 hours) demonstrated 87% clinical cure rates and significantly lower diarrhea rates (14%) compared to the every-8-hour formulation (34% diarrhea) 6
Penicillin-allergic patients:
- Cefdinir 14 mg/kg/day in 1-2 doses 1
- Cefuroxime 30 mg/kg/day in 2 doses 1
- Cefpodoxime 10 mg/kg/day in 2 doses 1
- Ceftriaxone 50 mg IM or IV daily for 1-3 days 1
- Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported 1
Treatment Failure Management
If symptoms worsen or fail to improve within 48-72 hours:
- Reexamine to confirm AOM diagnosis 1, 4
- Switch to amoxicillin-clavulanate if initially on amoxicillin 1
- Consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) if failing amoxicillin-clavulanate 1
- A 3-day course of ceftriaxone is superior to a 1-day regimen for treatment-resistant AOM 1
- For multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered 1
Key Pathogens and Resistance Patterns
The three major bacterial pathogens are S. pneumoniae, H. influenzae, and M. catarrhalis 2, 4. Current resistance patterns show:
- 20-30% of H. influenzae produce beta-lactamase 2
- 50-70% of M. catarrhalis produce beta-lactamase 2
- 38% of S. pneumoniae may be penicillin-nonsusceptible 7
- The predominant pathogens in high-dose amoxicillin failures are beta-lactamase-producing organisms 5
Critical Pitfalls to Avoid
Do NOT use topical antibiotics for acute suppurative otitis media - these are contraindicated and only indicated for otitis externa or tympanostomy tube otorrhea 1. Avoid ototoxic topical preparations when tympanic membrane integrity is uncertain 1.
Antibiotics do not eliminate complication risk - 33-81% of acute mastoiditis patients had received prior antibiotics 1. However, at the population level, antibiotics halve the risk of mastoiditis (though the number needed to treat is approximately 4800 to prevent one case) 2.
Chronic Suppurative Otitis Media Management
For CSOM, topical antibiotics (particularly quinolones) combined with aural toilet are more effective than systemic antibiotics alone. 3, 8
Treatment Approach
Topical quinolones are the most effective option:
- Topical quinolones are likely to increase resolution of ear discharge compared with boric acid (one additional person achieves resolution for every 4 treated) 3
- Topical quinolones are more effective than non-quinolone topical antibiotics 8
- Topical treatment is more effective than systemic antibiotics (odds ratio 0.46) 8
Aural toilet is essential:
- Treatment with antibiotics or antiseptics accompanied by aural toilet is more effective than aural toilet alone (odds ratio 0.31) 8
- Combining topical and systemic antibiotics is not more effective than topical antibiotics alone 8
Topical antiseptics as alternatives:
- No significant difference in effectiveness between topical antibiotics and topical antiseptics was found overall 8
- However, topical quinolones are likely superior to boric acid specifically 3
- Acetic acid may increase resolution compared to aminoglycosides at 1-2 weeks 3
Post-Treatment Expectations
After successful antibiotic treatment of AOM, middle ear effusion persists in 60-70% of children at 2 weeks, 40% at 1 month, and 10-25% at 3 months 1. This persistent effusion without clinical symptoms is defined as otitis media with effusion (OME) and requires monitoring but not antibiotics 1.
Prevention Strategies
Modifiable risk factors to address:
- Encourage breastfeeding for at least 6 months 1
- Reduce or eliminate pacifier use after 6 months of age 1
- Avoid supine bottle feeding 1
- Minimize daycare attendance when possible 1
- Eliminate tobacco smoke exposure 2, 1
Immunization:
Long-term prophylactic antibiotics are discouraged for recurrent AOM 2, 1.