Treatment of Acute Otitis Media
High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the first-line antibiotic for most children and adults with acute otitis media, but immediate antibiotics are not always necessary—children ≥2 years with mild-to-moderate symptoms and reliable follow-up can be managed with watchful waiting. 1
Initial Management Decision: Antibiotics vs. Observation
The decision to start immediate antibiotics depends on age, symptom severity, and laterality:
Immediate antibiotics are required for: 1
- All children <6 months of age
- Children 6-23 months with severe AOM or bilateral non-severe AOM
- Adults with severe symptoms
- Any patient when follow-up cannot be ensured
Observation without immediate antibiotics is appropriate for: 1, 2
- Children 6-23 months with non-severe unilateral AOM
- Children ≥24 months with non-severe AOM
When choosing observation, you must establish a mechanism to ensure follow-up within 48-72 hours and provide immediate antibiotic initiation if symptoms worsen or fail to improve. 1
Pain Management: The Non-Negotiable First Step
Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed. 1 This is critical because:
- Antibiotics provide no symptomatic relief in the first 24 hours 1
- Even after 3-7 days of antibiotic therapy, 30% of children younger than 2 years may have persistent pain or fever 1
- Analgesics such as acetaminophen or ibuprofen should be initiated within the first 24 hours and continued as long as needed 1
First-Line Antibiotic Selection
High-dose amoxicillin is the preferred first-line agent due to its effectiveness against common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 1, 2
Dosing: 1
- Pediatric: 80-90 mg/kg/day in 2 divided doses
- Adult: 1.5-4 g/day
Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) as first-line when: 1, 2
- Patient received amoxicillin in the previous 30 days
- Concurrent purulent conjunctivitis is present
- Coverage for beta-lactamase-producing organisms is needed (particularly H. influenzae and M. catarrhalis)
The FDA label confirms that amoxicillin-clavulanate 45/6.4 mg/kg/day divided every 12 hours demonstrated 87% clinical efficacy at end of therapy for acute otitis media, with significantly lower diarrhea rates (14%) compared to every 8-hour dosing (34%). 3
Penicillin-Allergic Patients
For patients with penicillin allergy, 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)
Important caveat: 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
Treatment Duration
The duration of antibiotic therapy is age and severity-dependent: 1, 2
- Children <2 years or severe symptoms: 10-day course
- Children 2-5 years with mild-to-moderate AOM: 7-day course (equally effective as 10 days)
- Children ≥6 years with mild-to-moderate AOM: 5-7 day course
Management of Treatment Failure
If symptoms worsen or fail to improve within 48-72 hours of initial treatment: 1, 2
- Reassess the patient to confirm AOM diagnosis
- Switch to amoxicillin-clavulanate if initially treated with amoxicillin
- If already on amoxicillin-clavulanate, consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days)
- A 3-day course of ceftriaxone is superior to a 1-day regimen for AOM unresponsive to initial antibiotics 1
For children with multiple treatment failures: Consider tympanostomy tube placement and tympanocentesis with culture and susceptibility testing. 1, 2 The choice of antibiotic should account for local resistance patterns, particularly the increasing prevalence of beta-lactamase producing organisms. 1
Critical Pitfalls to Avoid
Do not use corticosteroids: The American Academy of Pediatrics explicitly recommends against routine use of corticosteroids (including prednisone) in treating acute otitis media, as current evidence does not support their effectiveness. 1
Antibiotics do not eliminate complication risk: 33-81% of patients who develop acute mastoiditis had received prior antibiotics, so maintain vigilance for complications even with appropriate treatment. 1
Distinguish AOM from otitis media with effusion (OME): 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 This persistent effusion without clinical symptoms is OME and requires monitoring but not antibiotics. 1, 2
Special Consideration: AOM with PE Tube in Place
Topical fluoroquinolone antibiotics (ofloxacin or ciprofloxacin) are first-line therapy for acute tube otorrhea when a functioning PE tube is present. 4 Oral antibiotics are generally unnecessary when the tube is functioning and allowing drainage. 4
Oral antibiotics may be warranted when: 4
- Systemic symptoms present (high fever, severe illness, signs of mastoiditis)
- Failure of topical therapy after 48-72 hours
- Concurrent AOM in the contralateral ear without a tube
Never use aminoglycoside-containing drops when a PE tube is present due to ototoxicity risk with direct middle ear access. 4
Prevention Strategies
Risk reduction strategies include: 1, 2
- Breastfeeding for at least 6 months
- Pneumococcal conjugate vaccines (PCV-13) and annual influenza vaccination
- Avoiding tobacco smoke exposure
- Reducing or eliminating pacifier use after 6 months of age
- Avoiding supine bottle feeding
- Minimizing daycare attendance when possible
Long-term prophylactic antibiotics are discouraged for recurrent AOM. 1 For recurrent cases, consider tympanostomy tube placement, which has failure rates of 21% for tubes alone and 16% for tubes with adenoidectomy. 1