What is the treatment for otitis media (middle ear infection)?

Treatment of Otitis Media

First-Line Antibiotic Therapy

High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line treatment for acute otitis media in patients without penicillin allergy, based on its effectiveness against common pathogens, safety profile, low cost, and narrow spectrum. 1, 2

• The primary bacterial pathogens are Streptococcus pneumoniae and Haemophilus influenzae, with regional variations in prevalence 1
• Amoxicillin remains effective despite beta-lactamase resistance concerns, which affect only a subset of cases 1

Pain Management (Essential First Step)

• Analgesic management is essential for all patients, especially during the first 24 hours, regardless of whether antibiotics are prescribed 1, 3
• Systemic analgesics (acetaminophen or ibuprofen) should be offered to all patients 3
• Topical analgesics may reduce ear pain within 10-30 minutes, though evidence quality is low 3

When to Use Amoxicillin-Clavulanate Instead

Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) for the following situations: 1

• Amoxicillin use within the previous 30 days
• Concurrent purulent conjunctivitis
• Treatment failure after 48-72 hours of amoxicillin
• When coverage for β-lactamase-producing organisms is specifically desired

Critical pitfall: Beta-lactamase-producing H. influenzae (present in 17-34% of isolates) is the predominant cause of amoxicillin-alone treatment failure, making amoxicillin-clavulanate superior in these scenarios 1

Penicillin Allergy Alternatives

For Non-Type I Hypersensitivity:

• Cefdinir (14 mg/kg/day in 1-2 doses) 1
• Cefuroxime (30 mg/kg/day in 2 divided doses) 1
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 1

For Type I Penicillin Allergy:

• Macrolides (azithromycin, clarithromycin, erythromycin-sulfisoxazole) are fallback options only, with bacterial failure rates of 20-25% due to increasing pneumococcal resistance 1
• The American Academy of Otolaryngology-Head and Neck Surgery advises against switching to azithromycin for treatment failure 2
• Critical caveat: Azithromycin should be reserved for documented type I penicillin allergy when cephalosporins cannot be used 1

Pediatric Dosing for Azithromycin (When Necessary)

For acute otitis media in children 6 months and older: 4

• 30 mg/kg as a single dose (1-day regimen), OR
• 10 mg/kg once daily for 3 days (3-day regimen), OR
• 10 mg/kg on Day 1, then 5 mg/kg/day on Days 2-5 (5-day regimen)

Treatment Failure Management

If no improvement occurs within 48-72 hours, reassess to confirm acute otitis media and exclude other diagnoses 1, 3

• Do not continue the same antibiotic beyond 72 hours without improvement—change therapy 3
• For confirmed treatment failure after amoxicillin, switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) 1
• Alternative: Ceftriaxone 50 mg IM or IV for 3 days for severe cases or compliance concerns 1

Critical Diagnostic Distinction

Distinguish acute otitis media (AOM) from otitis media with effusion (OME) before initiating treatment—antibiotics are indicated for AOM but NOT for OME 1, 2

• AOM requires: acute onset, middle ear effusion, AND symptoms (pain, fever, irritability) 2
• OME (middle ear fluid without acute symptoms) does not warrant antibiotic therapy 2
• Common pitfall: Over-diagnosis of AOM occurs in 40-80% of patients; strict diagnostic criteria must be met to minimize unnecessary antibiotic use and resistance development 2

Immediate vs. Watchful Waiting

Immediate antibiotics are indicated for: 2

• All children under 6 months with AOM
• Children 6-23 months with bilateral AOM or severe symptoms
• Any child with severe AOM (moderate-to-severe otalgia, otalgia >48 hours, or temperature ≥39°C)

Watchful waiting may be appropriate for: 2

• Children over 2 years with nonsevere unilateral AOM
• Close follow-up must be ensured

Adult-Specific Considerations

• For adults with confirmed acute otitis media, amoxicillin-clavulanate is recommended as first-line systemic therapy 3
• Standard dose: 1.75 g/250 mg per day for mild-to-moderate disease 3
• High-dose formulation (4 g amoxicillin/250 mg clavulanate per day) for recent antibiotic exposure or moderate disease 3
• For penicillin allergy: respiratory fluoroquinolones (levofloxacin, moxifloxacin) provide 90-92% clinical efficacy 3

Resistance Considerations

• Antimicrobial resistance is increasingly influencing empiric therapy selection and is the main reason for treatment failure 1
• Beta-lactamase production (17-34% of H. influenzae, 100% of M. catarrhalis) justifies preference for amoxicillin-clavulanate or cephalosporins in high-risk scenarios 1
• Approximately 1% of azithromycin-susceptible S. pyogenes isolates become resistant following therapy 4