What is the treatment for otitis media?

Treatment of Otitis Media

For acute otitis media (AOM), immediate pain management is mandatory for all patients, while antibiotic therapy with high-dose amoxicillin (80-90 mg/kg/day in children, 1.5-4 g/day in adults) is the first-line treatment when antibiotics are indicated—though watchful waiting is appropriate for children ≥2 years with non-severe symptoms and reliable follow-up. 1, 2

Initial Management Decision: Antibiotics vs. Observation

The decision to use immediate antibiotics versus observation depends on specific patient factors:

Immediate antibiotics are required for: 3, 1, 2

• All children <6 months of age
• Children 6-23 months with severe AOM or bilateral non-severe AOM
• Any child ≥6 months with severe symptoms (moderate-to-severe otalgia, fever ≥39°C/102.2°F, or toxic appearance)
• Adults with severe symptoms
• When reliable follow-up cannot be ensured

Observation without immediate antibiotics is appropriate for: 3, 2

• Children 6-23 months with non-severe unilateral AOM (with shared decision-making)
• Children ≥24 months with non-severe AOM (unilateral or bilateral)
• Adults with mild symptoms

A critical caveat: observation requires a mechanism to ensure follow-up within 48-72 hours and immediate antibiotic initiation if symptoms worsen or fail to improve. 2

Pain Management (Paramount in All Cases)

Pain control must be addressed immediately in every patient, regardless of antibiotic decision. 3, 1, 2, 4

• Analgesics (acetaminophen, ibuprofen) should be continued as long as needed to control pain 1, 2
• Pain relief is particularly critical during the first 24 hours 1, 2
• Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited 1

First-Line Antibiotic Selection

High-dose amoxicillin is the first-line antibiotic for most patients: 3, 1, 2, 4

Pediatric dosing: 80-90 mg/kg/day divided into 2 doses 1, 2

Adult dosing: 1.5-4 g/day 4

Amoxicillin is preferred due to its effectiveness against the most common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), excellent safety profile, low cost, acceptable taste in children, and narrow microbiologic spectrum. 1, 4

Use amoxicillin-clavulanate instead of amoxicillin as first-line when: 3, 1, 2

• Patient received amoxicillin in the previous 30 days (children) or 4-6 weeks (adults)
• Concurrent purulent conjunctivitis is present
• Coverage for beta-lactamase-producing organisms is needed

Pediatric dosing: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses 1

Adult dosing: 1.75-4 g/250 mg per day 4

Penicillin Allergy Alternatives

For patients with penicillin allergy, use: 1, 2, 4

• Cefdinir (14 mg/kg/day in 1-2 doses for children)
• Cefuroxime (30 mg/kg/day in 2 doses for children)
• Cefpodoxime (10 mg/kg/day in 2 doses for children)
• Ceftriaxone (50 mg IM or IV per day for 1-3 days)

Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these cephalosporins generally safe for non-severe penicillin allergies. 1

Macrolides (azithromycin, clarithromycin) and trimethoprim-sulfamethoxazole have bacteriologic failure rates of 20-25% and should be reserved for situations where cephalosporins cannot be used. 4

Treatment Duration

Antibiotic duration varies by age and severity: 1

• Children <2 years or those with severe symptoms: 10-day course
• Children 2-5 years with mild-to-moderate AOM: 7-day course
• Children ≥6 years with mild-to-moderate symptoms: 5-7 day course (though 10 days is standard)

Management of Treatment Failure

If symptoms worsen or fail to improve within 48-72 hours: 1, 2, 4

1. Reassess to confirm AOM diagnosis and exclude other causes
2. If initially observed without antibiotics: Start amoxicillin
3. If initially treated with amoxicillin: Switch to amoxicillin-clavulanate
4. If initially treated with amoxicillin-clavulanate: Consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 1

A 3-day course of ceftriaxone is superior to a 1-day regimen for AOM unresponsive to initial antibiotics. 1, 5

For children with multiple treatment failures: Consider tympanocentesis with culture and susceptibility testing. 1

Otitis Media with Effusion (OME)

OME requires a fundamentally different approach than AOM: 3

• Watchful waiting is recommended initially for 3 months with age-appropriate hearing testing 3
• Medical treatment (antibiotics, decongestants, nasal steroids) is discouraged 3
• Surgical intervention (tympanostomy tubes) is recommended for selected cases with: 3
  • Bilateral disease persisting >3 months
  • Hearing loss (>25-40 dB HL in better ear, varies by guideline)
  • Significant effect on child's well-being, behavior, or development
• Parent involvement in decision-making is essential 3

After successful AOM treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months—this is OME, not treatment failure, and requires monitoring but not antibiotics. 1

Prevention Strategies for Recurrent AOM

Modifiable risk factor reduction: 3, 1, 2

• Encourage breastfeeding for ≥6 months
• Reduce or eliminate pacifier use after 6 months of age
• Avoid supine bottle feeding
• Eliminate tobacco smoke exposure
• Minimize daycare attendance patterns when possible

Immunization: 3, 1, 2

• Pneumococcal conjugate vaccines (PCV-13)
• Annual influenza vaccination

Long-term prophylactic antibiotics are discouraged for recurrent AOM. 3

For recurrent AOM despite risk factor modification: Consider tympanostomy tube placement, which reduces recurrence rates (failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy). 1

Critical 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 ototoxic topical preparations when tympanic membrane integrity is uncertain 1
• Do not use corticosteroids for routine AOM treatment—current evidence does not support their effectiveness 1
• Recognize that antibiotics do not eliminate mastoiditis risk—33-81% of mastoiditis patients had received prior antibiotics 1
• Ensure accurate diagnosis with proper tympanic membrane visualization and confirmation of middle ear inflammation before treating 4
• Avoid respiratory fluoroquinolones for milder disease to prevent resistance 4