What is the treatment for otitis media?

Treatment of Otitis Media

Immediate Management Decision

For acute otitis media (AOM), immediate antibiotic therapy with high-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is indicated for all children under 6 months, children 6-23 months with severe symptoms or bilateral disease, and any child ≥24 months with severe symptoms, while observation without immediate antibiotics is appropriate for children ≥6 months with non-severe unilateral disease when reliable follow-up can be ensured. 1, 2

Pain Management (Critical First Step)

• Pain control must be addressed immediately in every patient, regardless of whether antibiotics are prescribed. 1, 2
• Analgesics (acetaminophen or ibuprofen) should be initiated within the first 24 hours and continued as long as needed. 1
• Pain relief often occurs before antibiotics provide benefit, as antibiotics do not provide 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

Antibiotic Selection Algorithm

First-Line Therapy

Amoxicillin at 80-90 mg/kg/day divided into two doses is the first-line antibiotic for most patients with AOM. 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

When to Use Amoxicillin-Clavulanate Instead

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 therapy when: 1, 2

• The 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 patients with penicillin allergy, use: 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

Treatment Duration by Age

The duration of antibiotic therapy 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

Observation Without Immediate Antibiotics

Observation is appropriate for children 6-23 months with non-severe unilateral AOM and children ≥24 months with non-severe AOM, provided a mechanism exists to ensure follow-up within 48-72 hours. 1, 2

Requirements for Observation Strategy

• Joint decision-making with parents/caregivers 2
• Reliable follow-up mechanism within 48-72 hours 1
• Immediate antibiotic initiation if symptoms worsen or fail to improve 1
• Pain management must still be provided 1, 2

Common Pitfall to Avoid

Watchful waiting may be associated with transient worsening of the child's condition, prolongation of symptoms, and increased parental work absences (mean 2.1 vs 1.2 days). 3 However, delayed initiation does not worsen overall recovery as measured by improvement during treatment. 3

Treatment Failure Management

If symptoms worsen or fail to improve within 48-72 hours, reassess to confirm AOM diagnosis and exclude other causes. 1, 2

Second-Line Therapy Algorithm

• If initially observed without antibiotics: Start amoxicillin 1, 2
• If initially treated with amoxicillin: Switch to amoxicillin-clavulanate 1, 2
• If failing amoxicillin-clavulanate: Consider intramuscular ceftriaxone (50 mg/kg/day for 1-3 days) 1
• A 3-day course of ceftriaxone is superior to a 1-day regimen for AOM unresponsive to initial antibiotics 1

Multiple Treatment Failures

For children with multiple treatment failures, tympanocentesis with culture and susceptibility testing should be considered. 1 The choice of antibiotic should consider local resistance patterns, with increasing prevalence of beta-lactamase-producing organisms. 1

Post-Treatment Follow-Up

After successful antibiotic treatment: 1

• 60-70% of children have middle ear effusion at 2 weeks
• 40% at 1 month
• 10-25% at 3 months

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

Otitis Media with Effusion (OME) Management

For OME, watchful waiting for 3 months with age-appropriate hearing testing is recommended, as antibiotics, decongestants, and nasal steroids are ineffective and not recommended. 1, 4

Surgical Intervention for OME

Tympanostomy tube placement should be considered for: 1

• Bilateral OME persisting >3 months
• Hearing loss
• Significant effect on child's well-being

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

Prevention Strategies

Modifiable risk factors to address include: 1, 2

• Encourage breastfeeding for at least 6 months
• Reduce or eliminate pacifier use after 6 months of age
• Avoid supine bottle feeding
• Eliminate tobacco smoke exposure
• Minimize daycare attendance patterns when possible
• Pneumococcal conjugate vaccination (PCV-13) and annual influenza vaccination 1, 2

Long-term prophylactic antibiotics are discouraged for recurrent AOM. 1

Critical Pitfall: Antibiotics Don't Prevent All Complications

Antibiotics administered for AOM do not eliminate the risk of complications like acute mastoiditis, as 33-81% of mastoiditis patients had received prior antibiotics. 1 This underscores the importance of proper diagnosis and follow-up regardless of antibiotic use.