What is the treatment for middle ear infection?

Treatment of Middle Ear Infection (Acute Otitis Media)

High-dose amoxicillin (80-90 mg/kg/day) is the first-line antibiotic for treating acute otitis media in patients without penicillin allergy, with treatment continued for a minimum of 48-72 hours beyond symptom resolution. 1, 2

Initial Antibiotic Selection

First-Line Therapy

• Amoxicillin 80-90 mg/kg/day remains the standard first-line treatment because it provides effective coverage against the three major pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1
• The FDA-approved dosing requires treatment continuation for 48-72 hours beyond clinical improvement or documented bacterial eradication. 2
• Standard-dose amoxicillin alone is increasingly inadequate because 20-30% of H. influenzae strains and 50-70% of M. catarrhalis strains now produce β-lactamase enzymes that inactivate the antibiotic. 1, 3

Second-Line Therapy for Treatment Failure or Recurrent Infections

• High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in two divided doses for 10 days) should be used when patients fail initial therapy after 48-72 hours or have recurrent infections. 3, 4
• Alternative β-lactamase-stable agents include second- or third-generation cephalosporins (cefuroxime axetil 30 mg/kg/day, cefdinir 14 mg/kg/day) or trimethoprim-sulfamethoxazole. 1, 3
• For severe treatment failures, ceftriaxone may require up to three injections to optimize clinical success. 4

Penicillin-Allergic Patients

• Cefdinir (14 mg/kg/day in 1-2 doses) is recommended because cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported. 3
• Azithromycin (10 mg/kg/day for 3 days or 30 mg/kg as a single dose) demonstrated 83-89% clinical success rates in pediatric trials, though it is less effective than amoxicillin-clavulanate against resistant organisms. 5

Pain Management

Pain assessment and adequate analgesia are essential components of treatment, as middle ear pain can be severe due to proximity of the highly sensitive periosteum to the inflamed ear canal. 1

• Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) should be administered at adequate doses for mild to moderate pain. 1
• NSAIDs administered during the acute phase significantly reduce pain compared to placebo. 1
• For severe pain unresponsive to NSAIDs alone, fixed combinations with opioids (oxycodone or hydrocodone with acetaminophen/ibuprofen) may be necessary. 1
• Parenteral analgesia is rarely required but should be considered when oral medications fail to provide timely relief. 1

Expected Clinical Response and Monitoring

• Clinical improvement should occur within 48-72 hours of initiating appropriate antimicrobial therapy. 1, 3
• Effective antibiotics sterilize middle ear fluid of bacterial pathogens in >80% of infected ears within 72 hours. 1, 3
• Middle ear effusion may persist for weeks to months after acute symptoms resolve, even when sterile, and does not require continued antibiotic therapy. 1

Special Circumstances

Tympanostomy Tubes or Tympanic Membrane Perforation

• When drainage is visible through tubes or perforation, topical antibiotic eardrops (ofloxacin or ciprofloxacin-dexamethasone) applied twice daily for up to 10 days are the best treatment. 1
• Non-ototoxic topical preparations must be used when the tympanic membrane is not intact. 1
• Oral antibiotics are unnecessary for most ear infections with functioning tubes unless the child is systemically ill. 1

Recurrent Acute Otitis Media

• Chemoprophylaxis with low-dose penicillin, sulfonamide, or erythromycin demonstrates 60-90% protective efficacy in children with truly recurrent infections (≥3 episodes in 6 months or ≥4 episodes in 12 months). 1, 3
• Tympanostomy tube placement should be considered for children with recurrent infections and abnormal ear examination at clinic evaluation. 6

Fungal Otitis (Otomycosis)

• Suspect fungal infection if patients fail to respond to initial topical antibiotic therapy. 1
• Management requires debridement plus topical antifungal therapy; topical antibiotics are contraindicated as they promote further fungal overgrowth. 1

Critical Pitfalls to Avoid

• Do not use standard-dose amoxicillin for recurrent infections due to high prevalence of resistant organisms in this population. 1, 3
• Do not discontinue antibiotics prematurely—a full 10-day course is essential for recurrent infections to ensure complete pathogen eradication. 3, 4
• Do not prescribe antibiotics, decongestants, or nasal steroids for otitis media with effusion (middle ear fluid without acute symptoms), as they do not hasten clearance and are not recommended. 7
• Approximately one-third of children with bacterial acute otitis media improve without antibacterial treatment, but appropriate antimicrobial therapy accelerates resolution within 48-72 hours. 1