What is the treatment for an ear infection (otitis media)?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg/day divided twice daily) is the first-line antibiotic for acute otitis media in most patients, with treatment decisions guided by age, symptom severity, and laterality of infection. 1, 2

Initial Management Decision

The approach to treating acute otitis media depends critically on patient age and clinical presentation:

• Children <6 months: Immediate antibiotic therapy is mandatory regardless of symptom severity 1, 2
• Children 6-23 months: Immediate antibiotics for severe AOM or bilateral disease; observation acceptable for unilateral, non-severe cases with reliable follow-up 1, 2
• Children ≥2 years: Observation without immediate antibiotics is appropriate for mild-to-moderate symptoms when follow-up within 48-72 hours can be ensured 3, 1, 2
• Adults: Immediate antibiotics for severe symptoms; observation may be considered for mild cases 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

Analgesics (acetaminophen or ibuprofen) must be initiated immediately in every patient, regardless of antibiotic decision, as antibiotics provide no symptomatic relief in the first 24 hours. 1 Pain relief should continue as long as needed, with 30% of children younger than 2 years experiencing persistent pain or fever even after 3-7 days of antibiotic therapy. 1

First-Line Antibiotic Selection

Amoxicillin at 80-90 mg/kg/day divided into 2 doses is the preferred initial antibiotic due to its effectiveness against common pathogens (S. pneumoniae, H. influenzae, M. catarrhalis), safety profile, low cost, and narrow microbiologic spectrum. 1, 2

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 (suggests H. influenzae)
• Coverage for beta-lactamase-producing organisms is needed

High-dose amoxicillin achieves bacteriologic eradication in 92% of S. pneumoniae cases and 84% of beta-lactamase-negative H. influenzae, though only 62% of beta-lactamase-positive H. influenzae are eradicated. 4

Penicillin Allergy Alternatives

For patients with penicillin allergy, appropriate alternatives 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 non-severe penicillin allergy. 1

Critical pitfall: Azithromycin should NOT be used as a substitute for amoxicillin in treatment failure and should be reserved only for patients with true penicillin allergy who cannot tolerate cephalosporins, as resistance rates are substantial. 3, 2

Treatment Duration

Treatment duration varies by age and severity: 1

• 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 symptoms: 5-7 day course

Management of Treatment Failure

If symptoms worsen or fail to improve within 48-72 hours, reassess to confirm AOM diagnosis and switch antibiotics: 3, 1, 2

• If initially on amoxicillin: Switch to amoxicillin-clavulanate 3, 1
• If initially on amoxicillin-clavulanate or oral third-generation cephalosporins: Use intramuscular ceftriaxone (50 mg/kg/day) 3, 1
• For ceftriaxone: A 3-day course is superior to a 1-day regimen for treatment-resistant AOM 3, 1

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

Multiple Treatment Failures

For children with repeated treatment failures: 3, 1

• Tympanocentesis with culture and antibiotic susceptibility testing should be strongly considered
• Clindamycin may be used (with or without coverage for H. influenzae and M. catarrhalis using cefdinir, cefixime, or cefuroxime)
• For multidrug-resistant S. pneumoniae serotype 19A unresponsive to clindamycin, consultation with pediatric infectious disease and otolaryngology is warranted before considering levofloxacin or linezolid (neither FDA-approved for AOM)

Important caveat: Trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole have substantial resistance rates and are not appropriate for treatment failures. 3

Post-Treatment Follow-Up

Routine follow-up visits at 10-14 days are not necessary for all children with uncomplicated AOM. 3 However, middle ear effusion (otitis media with effusion) is common after successful treatment:

• 60-70% at 2 weeks
• 40% at 1 month
• 10-25% at 3 months 3, 1

Otitis media with effusion (OME) without acute symptoms requires monitoring but NOT antibiotics. 3, 1, 2 This distinction is critical to avoid unnecessary antibiotic use.

Prevention Strategies

For recurrent AOM, evidence-based prevention includes: 1, 2

• Pneumococcal conjugate vaccine (PCV-13)
• Annual influenza vaccination
• Breastfeeding for at least 6 months
• Reducing/eliminating pacifier use after 6 months
• Avoiding supine bottle feeding
• Eliminating tobacco smoke exposure
• Minimizing daycare attendance when possible

Long-term prophylactic antibiotics are discouraged for recurrent AOM. 1, 2 For children with persistent recurrent infections despite risk reduction, tympanostomy tube placement should be considered. 1

Common Diagnostic Pitfall

Over-diagnosis of AOM occurs in 40-80% of patients. 2 Isolated redness of the tympanic membrane with normal landmarks is NOT an indication for antibiotics; the child should be reassessed only if symptoms persist beyond 3 days. 3 Proper diagnosis requires middle ear effusion with signs of acute inflammation and acute onset of symptoms. 1, 2