What is the antibiotic (Abx) choice for otitis media?

From the Guidelines

For acute otitis media, the first-line antibiotic treatment is amoxicillin at a dose of 80-90 mg/kg/day divided twice daily for 5-10 days, as recommended by the most recent and highest quality study 1. This recommendation is based on the anticipated clinical response and the microbiologic flora likely to be present, with amoxicillin being generally effective against susceptible and intermediate resistant pneumococci, as well as being safe, inexpensive, and having an acceptable taste and narrow microbiologic spectrum 1. Some key points to consider when treating acute otitis media include:

• The choice of a first-line treatment should be based on the anticipated clinical response and the microbiologic flora likely to be present 1
• Amoxicillin is recommended as first-line therapy for AOM because it is generally effective when used in sufficient doses against susceptible and intermediate resistant pneumococci 1
• If the patient is allergic to amoxicillin and the allergic reaction is not a type I hypersensitivity reaction, the physician can prescribe cefdinir, cefpodoxime, or cefuroxime 1
• The optimal duration of therapy for patients with AOM is uncertain, but treatment for 5-10 days is commonly recommended 1
• For patients who have received antibiotics in the past 30 days, have concurrent conjunctivitis, or in areas with high prevalence of resistant organisms, amoxicillin-clavulanate may be preferred 1 It's also important to note that antibiotics are usually not needed in most cases of otitis media, and a strategy of watchful waiting could reduce unnecessary antibiotic use, unless the child is younger than 2 years with bilateral otitis media 1.

From the FDA Drug Label

CLINICAL STUDIES SECTION Pediatric Patients ... Acute Otitis Media ... azithromycin (10 mg/kg on Day 1 followed by 5 mg/kg on Days 2 to 5) was compared to amoxicillin/clavulanate potassium (4:1)

For the 553 patients who were evaluated for clinical efficacy, the clinical success rate (i. e., cure plus improvement) at the Day 11 visit was 88% for azithromycin and 88% for the control agent

In a non-comparative clinical and microbiologic trial performed in the United States, where significant rates of beta-lactamase producing organisms (35%) were found, 131 patients were evaluable for clinical efficacy. The combined clinical success rate (i.e., cure and improvement) at the Day 11 visit was 84% for azithromycin

The following presumptive bacterial/clinical cure outcomes (i.e., clinical success) were obtained from the evaluable group:

• S. pneumoniae: 61/74 (82%) at Day 11,40/56 (71%) at Day 30
• H. influenzae: 43/54 (80%) at Day 11,30/47 (64%) at Day 30
• M. catarrhalis: 28/35 (80%) at Day 11,19/26 (73%) at Day 30
• S pyogenes: 11/11 (100%) at Day 11,7/7 at Day 30

Azithromycin is a viable option for the treatment of otitis media, with clinical success rates comparable to amoxicillin/clavulanate potassium. The choice of antibiotic should be based on the specific circumstances of each patient, including the suspected or confirmed causative pathogen and the patient's medical history and allergies 2.

From the Research

Antibiotic Choice for Otitis Media

• The first-line antibiotic for otitis media is amoxicillin, with a recommended dose of 80-90 mg/kg/day 3, 4, 5.
• For patients who fail amoxicillin therapy, second-line options include:
  • High-dose amoxicillin/clavulanate (90 mg/kg/day based on the amoxicillin component) 3, 5.
  • Ceftriaxone 3, 5.
  • Other options such as trimethoprim-sulfamethoxazole, erythromycin-sulfisoxazole, cefaclor, cefuroxime axetil, and cefixime may also be considered 6.
• The choice of antibiotic should be based on factors such as:
  • In vitro activity against common pathogens, including drug-resistant Streptococcus pneumoniae 3, 4, 5.
  • Pharmacokinetics and pharmacodynamics 3.
  • Adverse event profile 7.
  • Palatability and cost 3, 5.
• Tympanocentesis may be useful for identifying the causative pathogen and guiding antibiotic therapy, especially in patients who have failed multiple courses of antibiotics 3, 5.