What is the treatment for an ear infection (otitis media)?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day divided twice daily) is the first-line antibiotic treatment for acute otitis media in most patients, with immediate treatment indicated for children under 6 months, bilateral disease in children 6-23 months, or severe symptoms at any age. 1, 2

Initial Management Decision

The approach to treating otitis media depends critically on patient age, symptom severity, and laterality:

Immediate antibiotic therapy is indicated for:

• All children under 6 months of age 1
• Children 6-23 months with bilateral AOM or severe symptoms 1
• Children of any age with severe symptoms (high fever >39°C, moderate-to-severe otalgia) 3, 1
• Adults with severe symptoms 1

Observation without immediate antibiotics is appropriate for:

• Children ≥2 years with mild-to-moderate, unilateral AOM 1, 2
• Children 6-23 months with non-severe unilateral AOM 1
• This requires reliable follow-up within 48-72 hours and immediate antibiotic initiation if symptoms worsen or fail to improve 1

Pain management must be addressed immediately in every patient, regardless of antibiotic decision, using acetaminophen or ibuprofen. 1

First-Line Antibiotic Selection

Amoxicillin at high doses (80-90 mg/kg/day in children; 1.5-4 g/day in adults) divided into 2 daily doses 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 spectrum. 3, 1

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses) as first-line when:

• Patient received amoxicillin within the previous 30 days 1
• Concurrent purulent conjunctivitis is present (suggests H. influenzae) 3, 1
• Coverage for beta-lactamase-producing organisms is needed 1

Penicillin Allergy Alternatives

For patients with penicillin allergy, appropriate alternatives include:

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

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

Azithromycin should NOT be used as a substitute for treatment failure and is reserved only for patients with true penicillin allergy who cannot tolerate cephalosporins, due to high pneumococcal resistance rates. 2, 4

Treatment Duration

Duration varies by age and severity:

• Children <2 years: 10-day course 1
• Children 2-5 years with mild-to-moderate AOM: 7-day course 1
• Children ≥6 years with mild-to-moderate symptoms: 5-7 days 3, 1

Management of Treatment Failure

If symptoms worsen or fail to improve within 48-72 hours, reassess to confirm AOM diagnosis and consider treatment failure. 3, 1

For patients initially treated with amoxicillin who fail:

• Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) 3, 1

For patients who fail amoxicillin-clavulanate or oral third-generation cephalosporins:

• Intramuscular ceftriaxone (50 mg/kg/day for 3 days is superior to 1-day regimen) 3, 1

For multiple treatment failures:

• Tympanocentesis with culture and susceptibility testing should be strongly considered 3, 1
• Consultation with otolaryngology and infectious disease specialists may be warranted before using unconventional agents like levofloxacin or linezolid 3

The predominant pathogens in treatment failure are beta-lactamase-producing organisms, particularly H. influenzae. 5

Critical Pitfalls to Avoid

Do not prescribe antibiotics for:

• Isolated redness of tympanic membrane with normal landmarks 3
• Otitis media with effusion (OME) - middle ear effusion without acute symptoms 3, 1, 2
• Inability to visualize the tympanic membrane due to cerumen - refer to ENT instead 3

Trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole are NOT appropriate for treatment failure due to substantial pneumococcal resistance. 3

Antibiotics do not eliminate the risk of complications like acute mastoiditis, as 33-81% of mastoiditis patients had received prior antibiotics. 1

Follow-Up Considerations

After successful treatment, middle ear effusion (OME) is common and expected:

• 60-70% of children have MEE at 2 weeks post-treatment 3, 1
• 40% at 1 month 3, 1
• 10-25% at 3 months 3, 1

OME requires monitoring but NOT antibiotic therapy unless it persists beyond 3 months with hearing loss or developmental concerns. 3, 1

Prevention Strategies for Recurrent AOM

Evidence-based prevention measures include:

• Pneumococcal conjugate vaccine (PCV-13) 1
• Annual influenza vaccination 1
• Breastfeeding for at least 6 months 1
• Eliminating tobacco smoke exposure 1
• Reducing/eliminating pacifier use after 6 months of age 1
• Avoiding supine bottle feeding 1

Long-term prophylactic antibiotics are discouraged for recurrent AOM. 1

For truly recurrent AOM (≥3 episodes in 6 months or ≥4 in 12 months), consider tympanostomy tube placement, which has failure rates of 21% for tubes alone and 16% for tubes with adenoidectomy. 1