What is the first line treatment for Acute Otitis Media (AOM)?

First-Line Treatment for Acute Otitis Media

Amoxicillin at high doses (80-90 mg/kg/day in two divided doses) is the first-line antibiotic treatment for acute otitis media when antibiotics are indicated. 1

When to Use Standard Amoxicillin

• Prescribe amoxicillin when the child has NOT received amoxicillin in the past 30 days 1
• Use amoxicillin when the child does NOT have concurrent purulent conjunctivitis 1
• Amoxicillin is appropriate when the child is NOT allergic to penicillin 1
• The high dose (80-90 mg/kg/day) is specifically designed to overcome intermediate and highly resistant pneumococcal strains 2

When to Use Enhanced Beta-Lactamase Coverage

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 when: 1

• The child received amoxicillin in the past 30 days 1
• Concurrent purulent conjunctivitis is present 1
• History of recurrent AOM unresponsive to amoxicillin 1
• Beta-lactamase-producing organisms (H. influenzae, M. catarrhalis) are the predominant cause of amoxicillin treatment failure, with 34% of H. influenzae isolates producing beta-lactamase 3, 4

Alternative First-Line Options for Penicillin Allergy

For non-type I penicillin allergy (non-anaphylactic): 1, 3, 2

• Cefdinir (14 mg/kg/day in 1-2 doses) 3, 5
• Cefuroxime (30 mg/kg/day in 2 divided doses) 3
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 3

For type I penicillin hypersensitivity (anaphylactic): 2, 5

• Azithromycin (10 mg/kg on day 1, then 5 mg/kg days 2-5) 2, 6, 5
• However, macrolides have significant limitations with bacterial failure rates of 20-25% due to increasing pneumococcal resistance 3, 2

Microbiology Driving Treatment Decisions

The three most common bacterial pathogens are: 1

• Streptococcus pneumoniae (most common historically, though H. influenzae became more common after PCV7 introduction) 1
• Nontypeable Haemophilus influenzae (now often the most frequently isolated pathogen) 1
• Moraxella catarrhalis 1

Bacteria and/or viruses can be detected in up to 96% of AOM cases using comprehensive testing 1

Treatment Duration

• 5-7 days for children ≥2 years with mild to moderate disease 2
• 10 days for children <2 years or those with severe symptoms 2
• 8 days in the absence of spontaneous perforation 7
• 10 days in case of perforation 7

Reassessment and Treatment Failure

Reassess the patient if symptoms worsen or fail to improve within 48-72 hours: 1

• Confirm the diagnosis of AOM 8, 2
• For patients initially on amoxicillin who fail, switch to amoxicillin-clavulanate 2
• For patients who fail amoxicillin-clavulanate, consider ceftriaxone (50 mg IM for 3 days) 8, 2

Pain Management

• Address pain immediately with oral analgesics (acetaminophen or ibuprofen) regardless of antibiotic decision 8, 3
• Pain management should be prioritized during the first 24 hours 3

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for isolated tympanic membrane redness with normal landmarks - this is not sufficient for AOM diagnosis 8, 2
• Avoid fluoroquinolones as first-line therapy due to resistance concerns and side effect profiles 8, 2
• Do not rely on macrolides as first-line agents unless there is documented type I penicillin allergy, due to increasing pneumococcal resistance 3, 2
• Beta-lactamase-producing H. influenzae (present in 34% of isolates) is the predominant cause of amoxicillin-alone treatment failure, which is why amoxicillin-clavulanate is preferred in specific circumstances 3, 4