What is the recommended treatment for acute otitis media?

Treatment of Acute Otitis Media

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 treatment for acute otitis media when antibiotics are indicated, but immediate pain management with acetaminophen or ibuprofen must be addressed in every patient regardless of antibiotic decision. 1, 2

Initial Management Decision: Observation vs. Immediate Antibiotics

The decision to prescribe antibiotics immediately versus observation depends on age, symptom severity, and laterality:

Immediate antibiotics are required for: 1, 2

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

Observation without immediate antibiotics is appropriate for: 1, 3, 2

• Children 6-23 months with non-severe unilateral AOM
• Children ≥24 months with non-severe AOM
• Requires a mechanism to ensure follow-up within 48-72 hours and immediate antibiotic initiation if symptoms worsen or fail to improve

Pain Management (Critical First Step)

Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed. 1, 3, 2 This is paramount because:

• Antibiotics provide no symptomatic relief in the first 24 hours 1
• Even after 3-7 days of antibiotics, 30% of children <2 years may have persistent pain or fever 1
• Pain relief often occurs before antibiotics provide benefit 3

Recommended analgesics: 1, 2

• Acetaminophen or ibuprofen
• Continue as long as needed, especially during the first 24 hours
• Ibuprofen may be more effective than placebo in relieving pain at 48 hours (NNTB 6) 1

First-Line Antibiotic Selection

Amoxicillin is recommended because it is effective against susceptible and intermediate-resistant pneumococci, safe, inexpensive, has acceptable taste, and narrow microbiologic spectrum. 2

Dosing: 1, 2

• Children: 80-90 mg/kg/day divided into two doses
• Adults: 1.5-4 g/day

Use amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) instead of amoxicillin as first-line when: 1, 3

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

Penicillin Allergy Alternatives

For non-severe penicillin allergy: 1, 3

• 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 generally safe options. 1

Note: Azithromycin is FDA-approved for acute otitis media at 30 mg/kg as a single dose, or 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, but is not recommended as first-line by current guidelines due to increasing resistance patterns.

Treatment Duration

Duration depends on age and severity: 1, 2

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

Treatment Failure Management

Treatment failure is defined as: 2

• Symptoms worsening at any point
• Symptoms persisting beyond 48-72 hours after starting antibiotics
• Symptoms recurring within 4 days of completing treatment

If treatment failure occurs: 1, 3, 2

• Reassess at 48-72 hours to confirm AOM diagnosis and exclude other causes
• If initially managed with observation: begin antibiotics
• If initially treated with amoxicillin: switch to amoxicillin-clavulanate
• If failing amoxicillin-clavulanate: consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days, with 3-day course superior to 1-day regimen) 1

For multiple treatment failures: 1

• Consider tympanocentesis with culture and susceptibility testing

Critical Pitfalls to Avoid

Do not diagnose AOM based on isolated tympanic membrane redness with normal landmarks - this does not warrant antibiotic treatment. 2 Proper diagnosis requires three elements: acute onset, middle ear effusion, and signs of middle ear inflammation. 2

Do not use topical antibiotics for AOM - these are contraindicated and only indicated for otitis externa or tube otorrhea. 1

Do not prescribe antibiotics for persistent middle ear effusion after clinical resolution - 60-70% of children have middle ear effusion at 2 weeks post-treatment, decreasing to 40% at 1 month and 10-25% at 3 months. 1, 2 This is otitis media with effusion (OME) and requires monitoring but not antibiotics.

Antibiotics do not eliminate the risk of complications - 33-81% of mastoiditis patients had received prior antibiotics. 1

Prevention Strategies

Modifiable risk factors to address: 1, 3, 2

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

Immunization: 1, 3, 2

• Pneumococcal conjugate vaccines (PCV-13)
• Annual influenza vaccination

Long-term prophylactic antibiotics are discouraged for recurrent AOM. 3

Recurrent AOM Considerations

For recurrent AOM, consider tympanostomy tube placement, which can reduce recurrence rates (failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy). 1