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

Treatment of Acute Otitis Media (Ear Infection)

High-dose amoxicillin (80-90 mg/kg/day divided into 2 doses) is the first-line antibiotic treatment for most children and adults with acute otitis media. 1, 2

Initial Management Decision

The decision to use antibiotics immediately versus observation depends on age and severity:

• Immediate antibiotics are indicated for: 1, 2

  • All children under 6 months of age
  • Children 6-23 months with bilateral AOM or severe symptoms
  • Children of any age with severe AOM (high fever >39°C, moderate-to-severe otalgia, or symptoms lasting ≥48 hours)
  • Adults with severe symptoms
  • Any patient when reliable follow-up cannot be ensured

• Observation without immediate antibiotics is appropriate for: 3, 1

  • Children ≥2 years with mild-to-moderate, unilateral symptoms
  • Requires mechanism to ensure follow-up within 48-72 hours
  • Must have immediate antibiotic initiation available if symptoms worsen or fail to improve

Pain Management

Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed. 3, 1 Acetaminophen or ibuprofen should be given, especially during the first 24 hours. 1

First-Line Antibiotic Selection

Amoxicillin at 80-90 mg/kg/day (divided into 2 doses) for children or 1.5-4 g/day for adults is the preferred initial antibiotic due to its effectiveness against Streptococcus pneumoniae, safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 3, 1, 2

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate in 2 divided doses) as first-line when: 1, 2

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

Penicillin Allergy Alternatives

For patients with penicillin allergy, alternative antibiotics include: 1

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

Important caveat: 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

Treatment Duration

Treatment duration varies by age and severity: 1

• Children <2 years: 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 days (though 10-day course is standard)

Management of Treatment Failure

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

Treatment failure algorithm: 3, 1

1. If initially treated with amoxicillin → switch to amoxicillin-clavulanate
2. If initially treated with amoxicillin-clavulanate → consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days; a 3-day course is superior to 1-day)
3. For multiple treatment failures → consider tympanocentesis with culture and susceptibility testing

Critical pitfall: Trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole are NOT appropriate for treatment failures due to substantial pneumococcal resistance. 3 Azithromycin should NOT be used as a switch from amoxicillin for treatment failure and should be reserved only for patients with true penicillin allergy who cannot tolerate cephalosporins. 2

Special Considerations

Beta-lactamase-producing organisms (H. influenzae, M. catarrhalis) are the predominant pathogens in amoxicillin treatment failures, occurring in approximately 34-62% of cases. 4 This explains why amoxicillin-clavulanate or cephalosporins are appropriate second-line agents.

For recurrent AOM (not acute treatment): 1, 2

• Address modifiable risk factors: encourage breastfeeding ≥6 months, reduce/eliminate pacifier use after 6 months, avoid supine bottle feeding, minimize daycare exposure when possible, eliminate tobacco smoke exposure
• Ensure pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccination
• Long-term prophylactic antibiotics are discouraged
• Consider tympanostomy tube placement for frequent recurrences

Distinguishing AOM from Otitis Media with Effusion (OME)

OME (middle ear effusion without acute symptoms) does NOT warrant antibiotic therapy. 3, 2 After successful AOM treatment, 60-70% of children have persistent middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months—this is OME and requires monitoring but not antibiotics. 3, 1