What is the management and treatment of otitis media?

Management and Treatment of Acute Otitis Media

Diagnosis Requirements

Acute otitis media (AOM) requires three essential elements: acute onset of symptoms, presence of middle ear effusion (demonstrated by bulging tympanic membrane, limited/absent mobility, air-fluid level, or otorrhea), and signs of middle ear inflammation (distinct erythema or otalgia). 1, 2

• Proper visualization with pneumatic otoscopy is critical—bulging combined with color changes and reduced mobility are the most predictive findings 1
• Common pitfall: Do not diagnose AOM based on isolated tympanic membrane redness with normal landmarks, as this does not warrant antibiotic treatment 3
• Distinguish AOM from otitis media with effusion (OME), which presents with middle ear fluid but no acute inflammatory signs and does not require antibiotics 1, 4

Pain Management (First Priority)

Immediately address pain in every patient with AOM, regardless of antibiotic decision, using acetaminophen or ibuprofen—this is a strong recommendation and should be initiated within the first 24 hours. 1, 5, 3

• Pain relief often occurs before antibiotics provide benefit, as antibiotics do not provide symptomatic relief in the first 24 hours 5
• Even after 3-7 days of antibiotic therapy, 30% of children younger than 2 years may have persistent pain or fever 5

Initial Management Decision: Observation vs. Immediate Antibiotics

Immediate Antibiotics Required For:

• All children <6 months of age 5, 2
• Children 6-23 months with severe AOM or bilateral AOM 5, 2
• Children of any age with severe symptoms (moderate-to-severe otalgia, otalgia >48 hours, temperature ≥39°C) 1, 5
• Patients with otorrhea 2
• When follow-up cannot be ensured 5, 2

Observation Option (48-72 hours) Appropriate For:

• Children 6-23 months with non-severe unilateral AOM and uncertain diagnosis 1, 5
• Children ≥2 years with non-severe symptoms 1, 5, 2
• Observation requires a mechanism to ensure follow-up within 48-72 hours and immediate antibiotic initiation if symptoms worsen or fail to improve 5, 2

First-Line Antibiotic Selection

High-dose amoxicillin (80-90 mg/kg/day divided into two doses for children; 1.5-4 g/day for adults) is the first-line antibiotic for most patients with AOM. 1, 5, 3, 2

• Amoxicillin is recommended because it is effective against susceptible and intermediate-resistant pneumococci, safe, inexpensive, has acceptable taste, and narrow microbiologic spectrum 1
• High-dose amoxicillin achieves middle ear fluid levels exceeding the minimum inhibitory concentration for intermediately resistant S. pneumoniae and many highly resistant serotypes 1

Switch to Amoxicillin-Clavulanate as First-Line When:

• Patient received amoxicillin in the previous 30 days 5, 3, 2
• Concurrent purulent conjunctivitis present 5, 3, 2
• Coverage needed for β-lactamase-producing organisms (H. influenzae, M. catarrhalis) 1, 5, 3

Dosing for amoxicillin-clavulanate: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate (14:1 ratio) in 2 divided doses for children; 500 mg three times daily or 875 mg twice daily for adults 1, 3

• This formulation is less likely to cause diarrhea than other amoxicillin-clavulanate preparations 1

Penicillin Allergy Alternatives

For Non-Type I Hypersensitivity:

• Cefdinir 14 mg/kg/day in 1-2 doses (children) or 300 mg twice daily (adults) 1, 5, 3
• Cefuroxime axetil 30 mg/kg/day in 2 doses (children) or 250-500 mg twice daily (adults) 1, 5, 3
• Cefpodoxime 10 mg/kg/day in 2 doses (children) or 200 mg twice daily (adults) 1, 5, 3
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported 5

For Type I Hypersensitivity:

• Consider macrolides only as last resort given 20-25% bacterial failure rates 3
• Avoid fluoroquinolones as first-line therapy due to antimicrobial resistance concerns and adverse effect profiles 3

Treatment Duration

Treatment duration depends on age and severity: 1, 5, 2

• Children <2 years and those with severe symptoms: 10 days 1, 5, 2
• Children 2-5 years with mild-to-moderate AOM: 7 days 1, 5, 2
• Children ≥6 years with mild-to-moderate AOM: 5-7 days 5, 2
• Adults: 5-10 days, with 10 days preferred for complete eradication 3

Complete the full antibiotic course even if symptoms resolve to ensure bacterial eradication and prevent treatment failure. 2

• Stopping antibiotics prematurely risks recurrence (21% treatment failure with inadequate treatment vs. 5% with complete treatment) 2

Treatment Failure Management

Treatment failure is defined as symptoms worsening at any point, persisting beyond 48-72 hours after starting antibiotics, or recurring within 4 days of completing treatment. 3, 2

Reassessment at 48-72 Hours:

• Confirm AOM diagnosis and exclude other causes 1, 3
• Symptom worsening in the first 24 hours is normal and does not indicate treatment failure 2
• After 24-48 hours, symptoms should begin improving 2

Second-Line Treatment Options:

If initially treated with amoxicillin, switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate). 1, 5, 2

If amoxicillin-clavulanate fails, use ceftriaxone 50 mg/kg IM or IV daily for 1-3 days. 1, 5, 6

• A 3-day course of ceftriaxone is superior to a 1-day regimen for AOM unresponsive to initial antibiotics 5
• Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole when amoxicillin fails, as resistance to these agents is substantial 1

For Multiple Treatment Failures:

Perform tympanocentesis with Gram stain, culture, and antibiotic susceptibility testing. 1, 5

• If tympanocentesis unavailable, consider clindamycin with or without coverage for H. influenzae and M. catarrhalis (cefdinir, cefixime, or cefuroxime) 1
• For multidrug-resistant S. pneumoniae serotype 19A unresponsive to clindamycin, consider levofloxacin or linezolid (not FDA-approved for AOM; consult infectious disease specialist) 1

Post-Treatment Follow-Up and Middle Ear Effusion

Persistent middle ear effusion (MEE) after clinical resolution is common and NOT an indication to continue or restart antibiotics. 1, 5, 2

• 60-70% of children have MEE at 2 weeks post-treatment, 40% at 1 month, and 10-25% at 3 months 1, 5, 2
• Do not confuse persistent MEE (otitis media with effusion/OME) with active AOM—OME requires monitoring but not antibiotics 1, 5, 2
• Routine follow-up is not necessary for uncomplicated AOM that resolves clinically 1, 2
• Reassess children with cognitive or developmental delays to ensure MEE resolves, as transient hearing loss may affect development 1

Prevention Strategies

Modifiable risk factors to address: 5

• Encourage breastfeeding for at least 6 months 5
• Reduce or eliminate pacifier use after 6 months of age 5
• Avoid supine bottle feeding 5
• Eliminate tobacco smoke exposure 5
• Minimize daycare attendance patterns when possible 5

Immunization recommendations: 5, 2

• Ensure up-to-date pneumococcal conjugate vaccines (PCV-13) 5, 2
• Annual influenza vaccination 5, 2

Recurrent AOM Management

For recurrent AOM, consider tympanostomy tube placement, which reduces recurrence rates (failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy). 5

• Long-term prophylactic antibiotics are discouraged for recurrent AOM 5
• Antibiotic prophylaxis provides modest benefit only while being given, with no longer-lasting benefit after cessation 1

Critical Pitfalls to Avoid

• Antibiotics do not eliminate the risk of complications like acute mastoiditis—33-81% of mastoiditis patients had received prior antibiotics 5
• Never use topical antibiotics for suppurative otitis media—these are contraindicated and only indicated for otitis externa or tube otorrhea 5
• Avoid ototoxic topical preparations when tympanic membrane integrity is uncertain 5
• Corticosteroids should not be routinely used in the treatment of AOM, as current evidence does not support their effectiveness 5