What is the recommended treatment for otitis media?

Treatment of Acute Otitis Media

Immediate Management Decision

For children under 6 months, those with severe symptoms (moderate-to-severe otalgia >48 hours or fever ≥39°C/102.2°F), or bilateral AOM in children 6-23 months, prescribe antibiotics immediately. 1, 2 For children 6-23 months with unilateral, non-severe AOM, or children ≥24 months with non-severe AOM (bilateral or unilateral), observation with close follow-up is an acceptable alternative based on shared decision-making with parents. 1, 2

Observation requires a reliable mechanism to ensure follow-up within 48-72 hours and immediate antibiotic availability if symptoms worsen or fail to improve. 2

Pain Management

Address pain immediately in every patient, regardless of whether antibiotics are prescribed—this is paramount and should occur within the first 24 hours. 1, 2 Use acetaminophen or ibuprofen as first-line analgesics. 2 Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited. 2

First-Line Antibiotic Selection

Prescribe high-dose amoxicillin (80-90 mg/kg/day divided into 2 doses) as the first-line antibiotic for most patients with AOM. 1, 2, 3 This recommendation is based on amoxicillin's effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), excellent safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 2, 3

When to Use Amoxicillin-Clavulanate Instead

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 therapy in these specific situations: 1, 2, 4

• Child received amoxicillin within the previous 30 days
• Concurrent purulent conjunctivitis is present
• History of recurrent AOM unresponsive to amoxicillin
• Need for β-lactamase coverage (increasing prevalence of β-lactamase-producing H. influenzae and M. catarrhalis) 2

Penicillin-Allergic Patients

For patients with penicillin allergy, alternative antibiotics include: 2

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

Azithromycin (30 mg/kg as single dose or 10 mg/kg daily for 3 days) is an option but less preferred due to increasing resistance patterns. 5

Treatment Duration

The duration varies by age and severity: 2

• Children <2 years or those with severe symptoms: 10-day course
• Children 2-5 years with mild-to-moderate AOM: 7-day course is equally effective
• Children ≥6 years with mild-to-moderate symptoms: 5-7 day course

Treatment Failure Protocol

If symptoms worsen or fail to improve within 48-72 hours, reassess the patient to confirm AOM diagnosis and exclude other causes of illness. 1, 2, 3

Antibiotic Switching Algorithm:

• If initially on amoxicillin: Switch to amoxicillin-clavulanate 1, 2
• If initially on amoxicillin-clavulanate or patient fails second-line therapy: Consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days, with 3-day course superior to 1-day regimen) 2
• For multiple treatment failures: Consider tympanocentesis with culture and susceptibility testing 2

Post-Treatment Expectations

After successful antibiotic treatment, 60-70% of children have middle ear effusion at 2 weeks, decreasing to 40% at 1 month and 10-25% at 3 months. 2 This persistent effusion without acute symptoms is otitis media with effusion (OME), which requires monitoring but not antibiotics. 2

Prevention Strategies

Modifiable risk factors to address include: 2

• Encourage breastfeeding for at least 6 months
• Reduce or eliminate pacifier use after 6 months of age
• Avoid supine bottle feeding
• Minimize daycare attendance when possible
• Eliminate tobacco smoke exposure
• Ensure pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccination 1, 2

Long-term prophylactic antibiotics are discouraged for recurrent AOM. 1, 2

Critical Pitfalls to Avoid

• Do not misdiagnose OME as AOM—this leads to unnecessary antibiotic use. 3 AOM requires acute onset, middle ear effusion, AND signs of acute inflammation. 1, 3
• Do not use corticosteroids (systemic or intranasal) for routine AOM treatment—current evidence does not support their effectiveness. 2
• Do not assume antibiotics prevent complications—33-81% of acute mastoiditis patients had received prior antibiotics. 2
• Do not use ototoxic topical preparations when tympanic membrane integrity is uncertain or perforation is present. 2

Recurrent AOM Considerations

For children with recurrent AOM despite medical management, consider tympanostomy tube placement, which reduces recurrence rates (failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy). 2