What is the treatment for otitis media (middle ear infection) and otitis externa (swimmer's ear)?

Treatment of Ear Infections

Acute Otitis Media (Middle Ear Infection)

For children with acute otitis media, symptomatic pain management is mandatory, while antibiotic therapy should be initiated immediately for children under 2 years or those with severe disease (moderate-to-severe otalgia or fever ≥39°C), but watchful waiting for 48-72 hours is appropriate for children ≥2 years with mild symptoms and reliable follow-up. 1

Initial Antibiotic Selection

• Amoxicillin at high-dose (80-90 mg/kg/day) is the first-line antibiotic for uncomplicated AOM in patients without penicillin allergy 1, 2
• This dosing provides adequate coverage against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

When Antibiotics Are Mandatory

• All children <2 years of age regardless of severity 1, 3
• Any child with severe AOM (fever ≥39°C or moderate-to-severe otalgia) 1
• Bilateral AOM in children 6-23 months 1
• AOM with otorrhea (ear discharge) 1

Watchful Waiting Criteria

• Children ≥2 years with nonsevere AOM (mild otalgia and fever <39°C) can be observed for 48-72 hours without immediate antibiotics if reliable follow-up is ensured 1
• Antibiotics reduce pain at 2-3 days (number needed to treat: 20) but also cause adverse effects (number needed to harm: 14) 1

Treatment Failures (No Improvement After 48-72 Hours)

If the child fails initial amoxicillin therapy, escalate to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component). 1

For persistent failure after amoxicillin-clavulanate:

• Intramuscular ceftriaxone (50 mg/kg) for 3 days is superior to single-dose therapy 1
• Consider tympanocentesis for culture and susceptibility testing when multiple antibiotics have failed 1
• Trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole are NOT appropriate due to high resistance rates (20-30% for H. influenzae, 50-70% for M. catarrhalis) 1

Pain Management

Analgesic treatment must be provided to all children with ear pain, as this is a primary treatment goal alongside infection resolution 1, 4

Special Populations

Children with tympanostomy tubes and AOM require topical ofloxacin (5 drops twice daily for 10 days in children 1-12 years) rather than oral antibiotics 5

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Otitis Externa (Swimmer's Ear)

Topical antibiotic-corticosteroid eardrops are the primary treatment for otitis externa, with oral antibiotics reserved only for extension beyond the ear canal or in immunocompromised/diabetic patients. 1, 6

First-Line Treatment

• Topical antibiotic preparations (with or without corticosteroids) are highly effective and superior to oral antibiotics 1, 6
• All FDA-approved topical preparations for otitis externa show equivalent efficacy 1
• Ofloxacin otic solution 0.3% is one option: 5 drops (0.25 mL) once daily for 7 days in children 6 months-13 years, or 10 drops (0.5 mL) once daily for 7 days in patients ≥13 years 5

Critical Safety Consideration

When tympanic membrane perforation is known or suspected (including presence of tympanostomy tubes), prescribe ONLY non-ototoxic topical preparations to prevent iatrogenic hearing loss 1

When Oral Antibiotics Are Indicated

• Infection extends beyond the external auditory canal 1, 6
• Poorly controlled diabetes mellitus 1, 6
• Immunosuppression 1, 6
• Necrotizing (malignant) otitis externa, which requires prolonged systemic antibiotics and can be life-threatening 1, 6

Adjunctive Measures

• Cleansing of the external auditory canal is essential 6
• Analgesics for pain control 6
• Corticosteroid preparations reduce swelling, erythema, and secretions 6

Treatment Failure

Reassess patients who fail to respond within 48-72 hours to confirm the diagnosis and exclude other causes, including necrotizing otitis externa in high-risk patients 1

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Key Clinical Pitfalls

• Do not prescribe oral antibiotics for uncomplicated otitis externa—topical therapy is more effective and avoids systemic side effects 1, 6
• Avoid ototoxic eardrops (aminoglycosides) when the tympanic membrane integrity is uncertain 1
• Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures in AOM due to high resistance rates 1
• Middle ear effusion persists in 60-70% of children at 2 weeks post-AOM treatment—this is otitis media with effusion (OME), not treatment failure, and does not require continued antibiotics 1