What is the management of acute suppurative otitis media?

Management of Acute Suppurative Otitis Media

Initial Treatment Decision

High-dose amoxicillin (80-90 mg/kg/day divided in 2 doses) is the first-line antibiotic for acute suppurative otitis media in most patients, combined with immediate pain management using acetaminophen or ibuprofen. 1

Age-Based Antibiotic Indications

• All children <6 months: Immediate antibiotics required 1
• Children 6-23 months with severe AOM or bilateral disease: Immediate antibiotics 1
• Children 6-23 months with unilateral, non-severe disease: Observation option acceptable if reliable 48-72 hour follow-up ensured 1
• Children ≥24 months with non-severe disease: Observation option acceptable with reliable follow-up 1
• Adults with AOM: Immediate antibiotics typically required due to higher likelihood of bacterial etiology 2

Defining Severe Disease

Severe symptoms include: 1

• Temperature ≥39°C (102.2°F)
• Moderate to severe otalgia
• Otalgia lasting ≥48 hours
• Otorrhea (spontaneous tympanic membrane perforation)

Pain Management (Critical First Step)

Address pain immediately in every patient, regardless of antibiotic decision. 1

• Acetaminophen or ibuprofen should be initiated within the first 24 hours 3
• NSAIDs during the acute phase significantly reduce pain compared to placebo 1
• Avoid topical antibiotics - these are contraindicated in suppurative otitis media and only indicated for otitis externa or tube otorrhea 1
• Never use ototoxic topical preparations when tympanic membrane integrity is uncertain 1

First-Line Antibiotic Selection

Standard First-Line: High-Dose Amoxicillin

• Pediatric dosing: 80-90 mg/kg/day divided in 2 doses 3, 1
• Adult dosing: 1.5-4 g/day 1
• Rationale: Effectiveness against common pathogens (S. pneumoniae, H. influenzae, M. catarrhalis), safety profile, low cost, acceptable taste, narrow microbiologic spectrum 3, 1
• High-dose achieves middle ear fluid levels exceeding MIC for intermediately resistant S. pneumoniae and many highly resistant strains 3

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate, 14:1 ratio, divided in 2 doses) as first-line when: 3, 1

• Patient received amoxicillin in previous 30 days
• Concurrent purulent conjunctivitis present
• Coverage needed for β-lactamase-producing H. influenzae and M. catarrhalis
• Adults: Amoxicillin-clavulanate is preferred first-line due to higher prevalence of β-lactamase-producing organisms 2

Penicillin Allergy Alternatives

For non-type I hypersensitivity (non-severe allergy): 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
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported 1

For type I hypersensitivity (severe allergy): 2

• Erythromycin-sulfafurazole
• Avoid fluoroquinolones as first-line due to resistance concerns and side effects 2

Treatment Duration

• Children <2 years and those with severe symptoms: 10-day course 1
• Children 2-5 years with mild-to-moderate AOM: 7-day course equally effective 1
• Children ≥6 years with mild-to-moderate symptoms: 5-7 day course 1, 4
• Adults: 8-10 days for most cases, 5 days acceptable for uncomplicated cases 2

Complete the full antibiotic course even if symptoms resolve to ensure bacterial eradication and prevent treatment failure (21% with inadequate treatment vs. 5% with complete treatment). 4

Management of Treatment Failure

Defining Treatment Failure

Reassess if: 1, 4, 2

• Symptoms worsen or fail to improve within 48-72 hours
• Persistent fever beyond 48-72 hours
• Continued severe ear pain
• Persistent irritability and sleep disruption
• Note: Symptom worsening in first 24 hours is normal and does not indicate failure 4

Second-Line Therapy Algorithm

If initial amoxicillin fails: 1

1. Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component)

If amoxicillin-clavulanate fails: 1 2. Intramuscular ceftriaxone 50 mg/kg/day for 1-3 days 3. Three-day course superior to 1-day regimen 1

For multiple treatment failures: 1

• Consider tympanocentesis with culture and susceptibility testing to guide therapy

Post-Treatment Middle Ear Effusion

Persistent middle ear effusion after clinical resolution is NOT an indication for continued or restarted antibiotics. 1, 4

• 60-70% of children have effusion at 2 weeks post-treatment 1, 4
• 40% at 1 month 1, 4
• 10-25% at 3 months 1, 4
• This represents otitis media with effusion (OME), not active AOM - requires monitoring only 1, 4

Role of Tympanocentesis/Paracentesis

Consider tympanocentesis for: 1, 5, 6

• Multiple antibiotic treatment failures
• Need to identify causative pathogen and antibiotic susceptibilities
• Severe cases requiring drainage of the tympanum
• Diagnostic uncertainty in complicated cases

Prevention Strategies

Immunizations

• Pneumococcal conjugate vaccine (PCV-13): All children, reduces multidrug-resistant pneumococcal disease 3, 1
• Annual influenza vaccination: Recommended for AOM prevention 1

Modifiable Risk Factors

• Encourage breastfeeding for ≥6 months 1
• Reduce/eliminate pacifier use after 6 months of age 1
• Avoid supine bottle feeding 1
• Minimize daycare attendance when possible 1
• Eliminate tobacco smoke exposure 1

What NOT to Do

• Do not use long-term prophylactic antibiotics for recurrent AOM 1
• Do not use corticosteroids (including prednisone) - current evidence does not support effectiveness 1

Recurrent AOM Considerations

For children with recurrent episodes despite optimal medical management: 1

• Consider tympanostomy tube placement
• Failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy
• Note: Antibiotics do not eliminate risk of complications like acute mastoiditis (33-81% of mastoiditis patients had received prior antibiotics) 1

Critical Pitfalls to Avoid

• Do not confuse OME with active AOM - isolated redness without bulging or effusion does not warrant antibiotics 2
• Do not rely solely on clinical history - proper otoscopic examination with visualization of bulging, limited mobility, or distinct erythema is essential 2
• Do not stop antibiotics prematurely when symptoms improve - this risks recurrence and promotes resistance 4
• Do not use topical antibiotics or ototoxic preparations in suppurative otitis media 1