What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

First-line treatment for acute otitis media is high-dose amoxicillin (80-90 mg/kg/day in children, 1.5-4 g/day in adults) combined with immediate pain management using acetaminophen or ibuprofen, with amoxicillin-clavulanate reserved for specific high-risk scenarios. 1, 2, 3

Immediate Pain Management

• Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed. 1, 2, 3
• Oral analgesics (acetaminophen or ibuprofen) should be initiated during the first 24 hours, as pain can be severe and significantly impacts quality of life. 1, 2
• Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited. 3

Antibiotic Selection Algorithm

First-Line Therapy: High-Dose Amoxicillin

• High-dose amoxicillin (80-90 mg/kg/day divided into two doses for children; 1.5-4 g/day for adults) is the preferred first-line agent due to its effectiveness against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, combined with excellent safety profile, low cost, and narrow microbiologic spectrum. 2, 3
• This dosing achieves bacteriologic eradication in 92% of S. pneumoniae cases and 84% of beta-lactamase-negative H. influenzae cases. 4

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses for children; 875 mg/125 mg every 12 hours for adults) as first-line therapy when: 1, 2, 3

• Patient received amoxicillin in the previous 30 days
• Concurrent purulent conjunctivitis is present
• Coverage for beta-lactamase-producing organisms is needed (particularly H. influenzae and M. catarrhalis)
• Patient is an adult (amoxicillin-clavulanate is preferred first-line for adults due to higher likelihood of beta-lactamase producers) 1

Penicillin Allergy Alternatives

• For non-type I penicillin allergy: cefdinir (14 mg/kg/day), cefpodoxime (10 mg/kg/day), or cefuroxime (30 mg/kg/day) are recommended alternatives. 2, 3
• For type I hypersensitivity: erythromycin-sulfafurazole or azithromycin can be considered, though cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported. 1, 3

Treatment Duration

• Children <2 years and those with severe symptoms: 10-day course 2, 3
• Children 2-5 years with mild-to-moderate AOM: 7-day course is equally effective 2, 3
• Children ≥6 years with mild-to-moderate symptoms: 5-7 day course 2
• Adults: 5-7 day course for uncomplicated cases, with 8-10 days for most cases based on pediatric evidence 1, 2

Observation Without Immediate Antibiotics (Watchful Waiting)

Observation for 48-72 hours is appropriate for: 2, 3

• Children ≥2 years with non-severe, unilateral AOM
• Children ≥2 years with mild symptoms and uncertain diagnosis
• Otherwise healthy children with reliable follow-up mechanism

Immediate antibiotics are mandatory for: 2, 3

• All children <6 months of age
• Children 6-23 months with severe AOM or bilateral AOM
• Adults with AOM (higher likelihood of bacterial etiology)
• Patients with severe symptoms (moderate-to-severe otalgia, fever ≥39°C)
• When reliable follow-up cannot be ensured

Management of Treatment Failure

Treatment failure is defined as: 1

• Worsening of symptoms
• Persistence of symptoms beyond 48-72 hours after antibiotic initiation
• Recurrence of symptoms within 4 days of treatment discontinuation

When treatment failure occurs: 1, 2, 3

• Reassess to confirm AOM diagnosis (distinguish from otitis media with effusion)
• Switch to amoxicillin-clavulanate if initial therapy was amoxicillin 2, 3
• Switch to intramuscular ceftriaxone (50 mg/kg/day for 3 days) if amoxicillin-clavulanate fails 1, 3
• A 3-day course of ceftriaxone is superior to a 1-day regimen for AOM unresponsive to initial antibiotics 3
• Consider tympanocentesis with culture and susceptibility testing for multiple treatment failures 3

Critical Pitfalls to Avoid

• Do not confuse persistent middle ear effusion (otitis media with effusion) with active AOM. After successful treatment, 60-70% of children have middle ear effusion at 2 weeks, 40% at 1 month, and 10-25% at 3 months—this does NOT require antibiotics. 2, 3
• Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotic therapy. Proper diagnosis requires acute onset, middle ear effusion, AND signs of middle ear inflammation. 1, 2
• Avoid fluoroquinolones as first-line therapy due to antimicrobial resistance concerns and side effects. 1
• NSAIDs at anti-inflammatory doses and corticosteroids have not demonstrated efficacy for AOM treatment and should not be routinely used. 1, 3
• Do not use topical antibiotics for AOM—these are contraindicated and only indicated for otitis externa or tube otorrhea. 3
• Complete the full antibiotic course even if symptoms resolve to ensure bacterial eradication and prevent treatment failure (21% failure rate with incomplete treatment versus 5% with complete treatment). 2

Prevention Strategies

• Pneumococcal conjugate vaccination (PCV-13) and annual influenza vaccination 2, 3
• Smoking cessation and eliminating tobacco smoke exposure 1, 3
• Breastfeeding for at least 6 months 3
• Reducing or eliminating pacifier use after 6 months of age 3
• Avoiding supine bottle feeding 3
• Treating underlying allergies 1