What is the treatment for acute 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 antibiotics is appropriate for selected children based on age, symptom severity, and diagnostic certainty. 1, 2

Pain Management (First Priority)

• Address pain immediately in all patients regardless of antibiotic decision, especially during the first 24 hours 1, 2
• Use oral acetaminophen or ibuprofen at age-appropriate doses 3
• Continue analgesics as long as needed to control pain 1
• Topical analgesics may provide additional brief relief within 10-30 minutes, though evidence quality is limited 2, 3

Initial Management Decision: Observation vs. Immediate Antibiotics

Immediate antibiotics are indicated for:

• All children <6 months of age 2
• Children 6-23 months with severe AOM (moderate to severe otalgia, otalgia ≥48 hours, or temperature ≥39°C/102.2°F) 1, 3
• Children 6-23 months with non-severe bilateral AOM 1
• Children ≥24 months with severe AOM 1, 3
• Any age when follow-up cannot be ensured 2

Observation without antibiotics is appropriate for:

• Children 6-23 months with non-severe unilateral AOM (based on shared decision-making with parents) 1
• Children ≥24 months with non-severe AOM (based on shared decision-making with parents) 1, 2
• A mechanism must be in place to ensure follow-up and initiation of antibiotics if the child fails observation 1

Antibiotic Selection

First-line therapy:

• Amoxicillin 80-90 mg/kg/day divided into two doses for patients who have not received amoxicillin in the past 30 days, do not have concurrent purulent conjunctivitis, and are not allergic to penicillin 1, 2, 3
• This dosing is effective against susceptible and intermediate-resistant pneumococci, has excellent safety profile, low cost, and narrow microbiologic spectrum 2, 3

Second-line therapy (use if patient received amoxicillin in past 30 days, has concurrent purulent conjunctivitis, or requires β-lactamase coverage):

• Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate in 2 divided doses 2
• This formulation provides coverage for β-lactamase producing organisms including H. influenzae and M. catarrhalis 2

Penicillin allergy alternatives:

• For non-type I hypersensitivity: cefdinir (14 mg/kg/day in 1-2 doses), cefuroxime (30 mg/kg/day in 2 divided doses), or cefpodoxime (10 mg/kg/day in 2 divided doses) 1, 2, 3
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these generally safe options 2
• For type I hypersensitivity: azithromycin or clarithromycin 3

Treatment Duration

• Children <2 years: 10-day course 2
• Children 2-5 years with mild or moderate AOM: 7-day course 2
• Children ≥6 years: 10-day course 2
• Adolescents: 5-7 days (though optimal duration remains uncertain) 3

Treatment Failure Management

If symptoms worsen or fail to improve within 48-72 hours:

• Reassess to confirm AOM diagnosis and exclude other causes 1, 2, 3
• If initially managed with observation, begin antibiotics 1
• If initially treated with amoxicillin, switch to amoxicillin-clavulanate 1, 2
• If failing amoxicillin-clavulanate, use intramuscular ceftriaxone 50 mg/kg/day for 1-3 days (3-day course superior to 1-day regimen) 2, 4
• For multiple treatment failures, consider tympanocentesis with culture and susceptibility testing 2

Post-Treatment Follow-Up

• After successful treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months 2
• Middle ear effusion without clinical symptoms after AOM resolution is otitis media with effusion (OME) and requires monitoring but not antibiotics 2

Prevention Strategies

• Encourage breastfeeding for at least 6 months 1, 2
• Reduce or eliminate pacifier use after 6 months of age 1, 2
• Avoid supine bottle feeding 1
• Minimize daycare attendance patterns when possible 1, 2
• Eliminate tobacco smoke exposure 2
• Ensure immunization with pneumococcal conjugate vaccines (PCV-13) 1, 2, 3
• Consider annual influenza vaccination 1, 2, 3

Critical Pitfalls to Avoid

• Do not use corticosteroids (including prednisone) routinely in AOM treatment, as current evidence does not support their effectiveness 2
• Do not use topical antibiotics for suppurative otitis media—these are contraindicated and only indicated for otitis externa or tube otorrhea 2
• Do not use ototoxic topical preparations when tympanic membrane integrity is uncertain 2
• Do not use long-term prophylactic antibiotics for recurrent AOM 2
• Recognize that antibiotics do not eliminate the risk of complications like acute mastoiditis (33-81% of mastoiditis patients had received prior antibiotics) 2