What is the recommended treatment for otitis media?

Treatment of Acute Otitis Media

Amoxicillin at 80-90 mg/kg/day divided into two doses is the first-line antibiotic for acute otitis media when treatment is indicated, though observation without immediate antibiotics is appropriate for many children aged 6 months and older with non-severe symptoms. 1, 2

Initial Management Decision: Antibiotics vs. Observation

The treatment approach depends critically on age, symptom severity, and laterality:

Immediate Antibiotic Indications

• All children under 6 months require immediate antibiotic therapy regardless of severity 1, 2
• Children 6-23 months with bilateral AOM should receive immediate antibiotics even if symptoms are non-severe 1
• Any child with severe symptoms (moderate to severe otalgia lasting ≥48 hours OR temperature ≥39°C/102.2°F) requires immediate antibiotics 3, 1

Observation Option (Watchful Waiting)

• Children 6-23 months with unilateral, non-severe AOM can be offered observation with close follow-up based on shared decision-making with parents 3, 1
• Children ≥24 months with non-severe AOM (bilateral or unilateral) can be offered observation with close follow-up 3, 1
• A reliable mechanism for follow-up within 48-72 hours must be in place before choosing observation 1, 2

Pain Management (Critical First Step)

• Pain control must be addressed immediately in all patients, regardless of whether antibiotics are prescribed 1, 2
• Analgesics (acetaminophen, ibuprofen) should be provided during the first 24 hours and continued as needed 1
• Pain relief is paramount and should never be delayed while deciding on antibiotic therapy 1

Antibiotic Selection Algorithm

First-Line Treatment

• Amoxicillin 80-90 mg/kg/day in 2 divided doses is the standard first-line choice 3, 1, 2
• This high-dose regimen provides adequate coverage for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 4

When to Use Second-Line Agents Initially

Use amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) instead of amoxicillin if: 3, 2

• Child received amoxicillin within the past 30 days 3, 2
• Concurrent purulent conjunctivitis is present 3, 2
• History of recurrent AOM unresponsive to amoxicillin 3

Penicillin Allergy Alternatives

For non-severe penicillin allergy: 1, 2

• 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

For severe penicillin allergy or treatment failure: 2

• Ceftriaxone 50 mg IM or IV daily for 1-3 days 2
• A 3-day course of ceftriaxone is superior to 1-day for treatment failures 2

Important caveat: Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically believed, making cephalosporins generally safe for non-severe penicillin allergies 2

Treatment Duration

• Children <2 years and those with severe symptoms: 10-day course 2
• Children 2-5 years with mild-moderate AOM: 7-day course is equally effective 2
• Children ≥6 years with mild-moderate symptoms: 5-7 day course 2

Management of Treatment Failure

• Reassess within 48-72 hours if symptoms worsen or fail to improve 3, 1, 2
• Confirm AOM diagnosis and exclude other causes 1

If Initially Managed with Observation:

• Initiate amoxicillin at standard dosing 1

If Initially Treated with Amoxicillin:

• Switch to amoxicillin-clavulanate (90/6.4 mg/kg/day) 3, 2

If Failing Amoxicillin-Clavulanate:

• Administer ceftriaxone 50 mg/kg IM/IV daily for 3 days 2
• Consider tympanocentesis with culture for multiple treatment failures 2

Common Pitfalls to Avoid

• Do NOT use topical antibiotics for AOM—these are contraindicated and only indicated for otitis externa or tube otorrhea 1
• Do NOT use corticosteroids (oral or intranasal) as they lack efficacy and have potential adverse effects 1, 5
• Do NOT use antihistamines or decongestants as they are ineffective 5
• Do NOT assume antibiotics prevent complications—33-81% of mastoiditis patients had received prior antibiotics 1
• Do NOT confuse AOM with otitis media with effusion (OME)—60-70% of children have middle ear effusion at 2 weeks post-treatment, which requires monitoring but not antibiotics 2

Prevention Strategies

• 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 exposure when feasible 1
• Eliminate tobacco smoke exposure 1, 2
• Ensure pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccination 1
• Do NOT use long-term prophylactic antibiotics for recurrent AOM 1

Recurrent AOM Considerations

• For children with recurrent episodes despite preventive measures, consider tympanostomy tube placement 1
• Tubes alone have a 21% failure rate; tubes with adenoidectomy have a 16% failure rate 1
• For children <4 years, only tubes are recommended unless there is a separate indication for adenoidectomy 5
• For children ≥4 years with recurrent/persistent AOM, adenoidectomy plus tubes may provide additional benefit 5