What is the treatment for otitis media?

Treatment of Acute Otitis Media

Amoxicillin 80-90 mg/kg/day divided into two doses is the first-line antibiotic treatment for acute otitis media when antibiotics are indicated, though observation without immediate antibiotics is appropriate for many children based on age, symptom severity, and diagnostic certainty. 1, 2

Pain Management (Universal Priority)

• Pain control must be addressed immediately in all patients regardless of whether antibiotics are prescribed, particularly during the first 24 hours when discomfort is most severe 1, 2
• Continue analgesics (acetaminophen, ibuprofen) as long as needed to control pain 1
• This is paramount across all treatment guidelines and should never be deferred 1

Initial Management Decision: Observation vs. Immediate Antibiotics

Immediate Antibiotic Treatment Required For:

• All children under 6 months of age 2
• Children 6-23 months with bilateral AOM (regardless of severity) 1
• Children 6-23 months with severe AOM (defined as moderate-to-severe otalgia lasting ≥48 hours or fever ≥39°C) 1
• Children ≥24 months with severe AOM 1
• Any child when follow-up cannot be ensured 2

Observation Without Immediate Antibiotics Appropriate For:

• Children 6-23 months with non-severe unilateral AOM (shared decision-making with parents required) 1
• Children ≥24 months with non-severe AOM (bilateral or unilateral) 1
• Observation requires a mechanism to ensure follow-up and ability to initiate antibiotics if the child fails to improve 1, 2

Antibiotic Selection

First-Line Treatment:

• Amoxicillin 80-90 mg/kg/day divided into 2 doses for children who have not received amoxicillin in the past 30 days, do not have concurrent purulent conjunctivitis, and are not allergic to penicillin 1, 2
• This dosing is higher than traditional regimens to overcome increasing pneumococcal resistance 2

Second-Line Treatment (Use When):

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) for children who received amoxicillin in the previous 30 days, have concurrent purulent conjunctivitis, or need coverage for beta-lactamase producing organisms (H. influenzae, M. catarrhalis) 2

Penicillin Allergy Alternatives:

• Cefdinir (14 mg/kg/day in 1-2 doses) 2
• Cefuroxime (30 mg/kg/day in 2 divided doses) 2
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 2
• Ceftriaxone (50 mg IM or IV per day for 1-3 days) 2
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these generally safe for non-severe penicillin allergy 2

Treatment Duration

• 10-day course for children younger than 2 years and those with severe symptoms 2
• 7-day course for children 2-5 years with mild or moderate AOM 2
• 5-7 day course for children ≥6 years with mild to moderate symptoms 2

Follow-Up and Treatment Failure

• Reassess at 48-72 hours if symptoms worsen or fail to improve 1, 2
• If initially managed with observation, begin antibiotics 1
• If initially treated with amoxicillin, switch to amoxicillin-clavulanate 2
• If failing amoxicillin-clavulanate, use intramuscular ceftriaxone (50 mg/kg/day for 1-3 days), with 3-day regimen superior to 1-day 2
• For multiple treatment failures, consider tympanocentesis with culture and susceptibility testing 2

Critical Pitfalls to Avoid

• Do not use corticosteroids (intranasal or systemic) for acute otitis media, as they lack efficacy and have potential adverse effects 2, 3
• Do not use antihistamines or decongestants, as they are ineffective 3
• Do not confuse AOM with otitis media with effusion (OME), which presents without acute symptoms and does not require antibiotics 2
• After successful treatment, 60-70% of children have middle ear effusion at 2 weeks (decreasing to 10-25% at 3 months), which is OME and requires monitoring but not antibiotics 2
• Antibiotics do not eliminate the risk of complications like acute mastoiditis, as 33-81% of mastoiditis patients had received prior antibiotics 2

Prevention Strategies

• Encourage breastfeeding for at least 6 months 2
• Reduce or eliminate pacifier use after 6 months of age 2
• Avoid supine bottle feeding 2
• Minimize daycare attendance when possible 2
• Eliminate tobacco smoke exposure 2
• Immunize with pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccine 2
• Do not use long-term prophylactic antibiotics for recurrent AOM 2

Recurrent AOM Considerations

• For recurrent AOM, consider tympanostomy tube placement 2
• For children <4 years, tubes alone are recommended; do not perform adenoidectomy unless there is a separate indication 3
• For children ≥4 years with recurrent or persistent AOM, adenoidectomy in addition to tubes may be beneficial 3