Treatment of Otitis Media in Pregnancy
Amoxicillin at high doses (80-90 mg/kg/day) is the first-line antibiotic for acute otitis media in pregnancy, with azithromycin as an excellent alternative given its established safety profile and effectiveness. 1, 2, 3
Initial Assessment and Pain Management
- Pain control should be addressed immediately, regardless of whether antibiotics are prescribed, as this is a priority in the first 24 hours of acute otitis media 1
- Acetaminophen (paracetamol) is safe for pain and fever control during pregnancy 4
- Avoid NSAIDs, particularly after 32 weeks gestation, due to risk of premature ductus arteriosus closure 5
Antibiotic Selection
First-Line Treatment:
- Amoxicillin 80-90 mg/kg/day is the preferred antibiotic due to effectiveness against susceptible and intermediate-resistant Streptococcus pneumoniae, established safety in pregnancy, low cost, and narrow spectrum 1, 4
- Azithromycin is an excellent alternative, particularly recommended by CDC for pregnant patients, with proven safety and effectiveness against common otitis media pathogens including S. pneumoniae, H. influenzae, and M. catarrhalis 2, 6
For Penicillin Allergy:
- If non-anaphylactic penicillin allergy: First-generation cephalosporins (e.g., cefazolin) are appropriate 4, 2
- If true penicillin allergy: Azithromycin becomes the preferred choice 2, 5
- Clindamycin or erythromycin may be used if bacterial isolate susceptibility is confirmed 4, 5
Antibiotics to Avoid:
- Tetracyclines, aminoglycosides, trimethoprim-sulfamethoxazole, and fluoroquinolones are contraindicated due to fetal risks 4
Supportive Measures
- Saline nasal rinses are safe and effective for associated upper respiratory symptoms 2, 3
- Intranasal corticosteroids (budesonide, fluticasone, mometasone) may be used safely for nasal congestion and inflammation 1, 3, 5
- Adequate hydration and rest provide additional comfort 2
Medications to Avoid
- Oral decongestants should NOT be used, especially in the first trimester, due to association with fetal gastroschisis and maternal hypertension 1, 3, 5
- First-generation antihistamines should be avoided due to sedative and anticholinergic properties 1
Treatment Duration and Follow-up
- Reassess at 48-72 hours if symptoms persist or worsen 1
- If initial antibiotic fails, switch to amoxicillin-clavulanate or azithromycin (depending on initial choice) 1, 7
- The first trimester carries highest risk for medication-induced teratogenicity, so risk-benefit assessment is critical during this period 4
Key Clinical Pitfalls
- Do not defer pain management while waiting to see if antibiotics work—address pain immediately 1
- Avoid the temptation to prescribe oral decongestants for symptomatic relief, as topical options are safer 1
- Remember that observation without antibiotics is an option in non-pregnant patients with mild disease, but pregnancy may warrant more aggressive treatment to prevent complications 1
- Monitor for treatment failure indicators: persistent high fever, severe headache, or worsening symptoms requiring immediate reassessment 2