What is the treatment for otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line antibiotic for most patients with acute otitis media, but immediate pain management is mandatory for all patients regardless of antibiotic decision. 1

Initial Management Decision: Antibiotics vs. Observation

Immediate antibiotics are required for:

• All children <6 months of age 1
• Children 6-23 months with severe AOM or bilateral non-severe AOM 1
• Children with severe symptoms (moderate-to-severe otalgia, otalgia >48 hours, or temperature ≥39°C) 1
• When follow-up cannot be ensured 1

Observation without immediate antibiotics is appropriate for:

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

Pain Management (Critical First Step)

Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed, especially during the first 24 hours. 1, 2

• Use acetaminophen or ibuprofen 1
• Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited 1

First-Line Antibiotic Selection

Amoxicillin 80-90 mg/kg/day in 2 divided doses is first-line for most patients due to effectiveness against common pathogens (S. pneumoniae, H. influenzae, M. catarrhalis), safety, low cost, acceptable taste, and narrow microbiologic spectrum. 1, 2

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

• Patient received amoxicillin in the previous 30 days 1
• Concurrent purulent conjunctivitis is present 1
• Coverage for beta-lactamase-producing organisms (especially H. influenzae and M. catarrhalis) is needed 1

Penicillin-Allergic Patients

For non-severe penicillin allergy, use second/third-generation cephalosporins (cross-reactivity is lower than historically reported): 1

• 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 per day for 1-3 days 1

Treatment Duration

Duration depends on age and severity: 1, 2

• Children <2 years and those with severe symptoms: 10-day course 1, 2
• Children 2-5 years with mild-to-moderate AOM: 7-day course (equally effective) 1, 2
• Children ≥6 years with mild-to-moderate symptoms: 10-day course 1

Treatment Failure Management

If symptoms worsen or fail to improve within 48-72 hours:

• Reassess to confirm AOM diagnosis 1, 2
• Switch to amoxicillin-clavulanate if initial treatment was amoxicillin 1, 2
• If already on amoxicillin-clavulanate, use intramuscular ceftriaxone 50 mg/kg/day for 1-3 days 1
• A 3-day course of ceftriaxone is superior to a 1-day regimen for AOM unresponsive to initial antibiotics 1, 3

Common pitfall: The predominant pathogens in treatment failure are beta-lactamase-producing organisms, particularly H. influenzae. 4

Multiple Treatment Failures

For children with multiple treatment failures, consider tympanostomy tube placement with culture and susceptibility testing. 1, 2

Post-Treatment Middle Ear Effusion

After successful antibiotic treatment, middle ear effusion is common and expected: 1

• 60-70% of children have effusion at 2 weeks 1
• 40% at 1 month 1
• 10-25% at 3 months 1

This is defined as otitis media with effusion (OME) and requires monitoring but NOT antibiotics. 1, 2

Special Case: AOM with PE Tube in Place

Topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin) are first-line for acute tube otorrhea when a functioning PE tube is present. 5

• Oral antibiotics are generally unnecessary when the tube is functioning and allowing drainage 5
• Never use aminoglycoside-containing drops when a PE tube is present due to ototoxicity 5
• Consider oral antibiotics only for systemic symptoms (high fever, severe illness, mastoiditis signs) or failure of topical therapy after 48-72 hours 5

Prevention Strategies

Modifiable risk factors to address: 1, 2

• Encourage breastfeeding for at least 6 months 1
• Reduce or eliminate pacifier use after 6 months of age 1
• Avoid supine bottle feeding 1
• Eliminate tobacco smoke exposure 1, 2
• Minimize daycare attendance when possible 1

Vaccination: 1, 2

• Pneumococcal conjugate vaccine (PCV-13) 1, 2
• Annual influenza vaccination 1

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

What NOT to Do

Corticosteroids (including prednisone) should NOT be routinely used in the treatment of acute otitis media as current evidence does not support their effectiveness. 1

Critical pitfall: Antibiotics do not eliminate the risk of complications like acute mastoiditis—33-81% of mastoiditis patients had received prior antibiotics. 1