What is the treatment for otitis media?

Treatment of Acute Otitis Media

Initial Management Decision: Antibiotics vs. Observation

For children under 6 months of age, immediate antibiotic therapy is mandatory regardless of symptom severity. 1

For older children, the decision depends on age and severity:

• Children 6-23 months: Immediate antibiotics for severe AOM or bilateral non-severe AOM; observation acceptable for unilateral non-severe AOM 1
• Children ≥24 months: Observation without immediate antibiotics is appropriate for non-severe AOM with reliable follow-up within 48-72 hours 1, 2
• Adults: Immediate antibiotics for severe symptoms 1

Observation requires a mechanism to ensure follow-up and immediate antibiotic initiation if symptoms worsen or fail to improve within 48-72 hours. 1

Pain Management

Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed, especially during the first 24 hours. 1, 2 Acetaminophen or ibuprofen should be used for analgesia. 1 Topical analgesics may provide relief within 10-30 minutes, though evidence quality is limited. 1

First-Line Antibiotic Selection

High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses for children; 1.5-4 g/day for adults) is the first-line antibiotic for most patients with acute otitis media. 1, 2 This recommendation is based on its effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 1, 3

When to Use Amoxicillin-Clavulanate Instead

Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) should be used as first-line therapy in these specific situations: 1, 2

• Patient received amoxicillin in the previous 30 days
• Concurrent purulent conjunctivitis is present
• Coverage for beta-lactamase-producing organisms is needed

Penicillin Allergy Alternatives

For penicillin-allergic patients, alternative antibiotics include: 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)
• Ceftriaxone (50 mg IM or IV per day for 1-3 days)

Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these cephalosporins generally safe for patients with non-severe penicillin allergy. 1

Note: While azithromycin is FDA-approved for acute otitis media in children at doses of 30 mg/kg as a single dose, 10 mg/kg once daily for 3 days, or 10 mg/kg on Day 1 followed by 5 mg/kg/day on Days 2-5 4, it is not mentioned in current American Academy of Pediatrics guidelines as a preferred agent, likely due to concerns about resistance patterns and the preference for beta-lactam antibiotics.

Treatment Duration

Treatment duration should be tailored to age and severity: 1, 2

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

Treatment Failure Management

If symptoms worsen or fail to improve within 48-72 hours of initial treatment, reassess to confirm the diagnosis and switch antibiotics. 1, 2

The escalation pathway is: 1

1. If initially on amoxicillin → switch to amoxicillin-clavulanate
2. If failing amoxicillin-clavulanate → consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days)
3. A 3-day course of ceftriaxone is superior to a 1-day regimen for AOM unresponsive to initial antibiotics 1

Critical Pitfall

The predominant pathogens in treatment failure are beta-lactamase-producing organisms, particularly H. influenzae and M. catarrhalis. 1, 3 This explains why amoxicillin-clavulanate or ceftriaxone are the appropriate second-line choices.

Multiple Treatment Failures

For children with multiple treatment failures, tympanostomy tube placement with culture and susceptibility testing should be considered. 1, 2 This allows targeted antibiotic therapy based on actual pathogen identification.

Post-Treatment Follow-Up

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. 1 The presence of middle ear effusion without clinical symptoms after AOM resolution is defined as otitis media with effusion (OME) and requires monitoring but not antibiotics. 1 Watchful waiting for 3 months with age-appropriate hearing testing is recommended for OME. 1

Recurrent AOM Management

For recurrent AOM, consider tympanostomy tube placement, which reduces recurrence rates with failure rates of 21% for tubes alone and 16% for tubes with adenoidectomy. 1, 2 Long-term prophylactic antibiotics are discouraged. 1

Prevention Strategies

Risk reduction strategies include: 1, 2

• Breastfeeding for at least 6 months
• Avoiding tobacco smoke exposure
• Reducing or eliminating pacifier use after 6 months of age
• Minimizing daycare attendance when possible
• Pneumococcal conjugate vaccination (PCV-13)
• Annual influenza vaccination

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 Topical antibiotics are contraindicated for acute otitis media and should only be used for otitis externa or tube otorrhea. 1