What is the recommended treatment for otitis media?

Treatment of Otitis Media

High-dose amoxicillin (80-90 mg/kg/day in children; 3 g/day in adults) is the first-line antibiotic for acute otitis media, with immediate pain control using acetaminophen or ibuprofen as an essential component of initial management regardless of antibiotic use. 1

Diagnosis Confirmation Before Treatment

• Proper diagnosis requires three essential elements: acute onset of symptoms, presence of middle ear effusion (confirmed by pneumatic otoscopy or tympanometry), and signs of middle ear inflammation such as bulging tympanic membrane, limited mobility, or distinct erythema 1, 2
• Do not confuse otitis media with effusion (OME) for acute otitis media—OME presents with middle ear fluid without acute inflammation and does NOT require antibiotics 1, 3
• Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotic therapy 4

Pain Management (First Priority)

• Address pain immediately during the first 24 hours using oral acetaminophen or ibuprofen, regardless of whether antibiotics are prescribed 1
• This is a strong recommendation that applies universally to all patients with AOM 1

First-Line Antibiotic Therapy

For Children

• High-dose amoxicillin at 80-90 mg/kg/day divided into two daily doses is the first-line choice due to effectiveness against susceptible and intermediate-resistant Streptococcus pneumoniae (the most common pathogen), excellent safety profile, low cost, and narrow spectrum 1, 2
• This high-dose regimen achieves 92% eradication of S. pneumoniae (including penicillin-nonsusceptible strains with amoxicillin MIC ≤2.0 μg/mL), 84% eradication of beta-lactamase-negative H. influenzae, and 62% eradication of beta-lactamase-positive H. influenzae 3, 5

For Adults

• Amoxicillin-clavulanate (3 g/day amoxicillin component) is preferred as first-line therapy in adults because it provides coverage against beta-lactamase-producing organisms (H. influenzae and M. catarrhalis), which are more common causes of treatment failure in adults 4, 3, 6
• Plain amoxicillin at 3 g/day is acceptable if beta-lactamase-producing organisms are not suspected 4

Observation Without Immediate Antibiotics (Select Pediatric Cases Only)

• Consider observation without immediate antibiotics for otherwise healthy children aged 6 months to 2 years with non-severe illness and uncertain diagnosis, or children ≥2 years without severe symptoms or with uncertain diagnosis, only if assured follow-up within 48-72 hours is possible 1
• This approach is NOT established for adults—do not delay appropriate antibiotic therapy in adult AOM 3

When to Use Amoxicillin-Clavulanate as First-Line

Use high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in children; standard adult dosing) as first-line therapy in these specific situations:

• Patient received amoxicillin within the previous 30 days 1, 6
• Concurrent purulent conjunctivitis is present 1, 6
• Recurrent AOM unresponsive to amoxicillin 3
• When coverage for β-lactamase-producing organisms (H. influenzae, M. catarrhalis) is specifically needed 1, 6

The rationale is that 17-34% of H. influenzae and 100% of M. catarrhalis produce beta-lactamase, rendering plain amoxicillin ineffective 6, 5

Penicillin Allergy Alternatives

Non-Type I Hypersensitivity (Non-Severe Allergy)

• Cefdinir (14 mg/kg/day in 1-2 doses), cefuroxime (30 mg/kg/day in 2 divided doses), or cefpodoxime (10 mg/kg/day in 2 divided doses) are acceptable alternatives 1, 6
• These second-generation cephalosporins provide excellent coverage against S. pneumoniae, H. influenzae, and M. catarrhalis 6

Type I Hypersensitivity (Severe/Anaphylactic Allergy)

• Azithromycin (30 mg/kg as single dose for otitis media, or 10 mg/kg day 1 then 5 mg/kg days 2-5) or clarithromycin are fallback options 1, 7
• Important caveat: Macrolides have bacterial failure rates of 20-25% due to increasing pneumococcal resistance, so use only when necessary 6
• For children under 3 years with severe penicillin allergy, hospitalization for parenteral therapy is preferable 4

Treatment Duration

• 10 days for children <2 years and those with severe symptoms 1
• 7 days for children 2-5 years with mild-to-moderate disease 1
• 5-7 days for children ≥6 years and adults with mild-to-moderate disease 1, 3

Management of Treatment Failure

Definition of Treatment Failure

• Worsening condition, persistence of symptoms beyond 48-72 hours after antibiotic initiation, or recurrence of symptoms within 4 days of treatment discontinuation 3

Reassessment at 48-72 Hours

• If no improvement or worsening occurs, reassess to confirm AOM diagnosis and exclude other causes of illness 1, 3
• Patients may worsen slightly initially but should stabilize within the first 24 hours and begin improving during the second 24-hour period 6

Second-Line Therapy Algorithm

• If initially observed without antibiotics: Start high-dose amoxicillin 1
• If initially treated with amoxicillin: Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day amoxicillin component with 6.4 mg/kg/day clavulanate) 1, 6
• If amoxicillin-clavulanate fails: Consider ceftriaxone 50 mg/kg IM or IV daily for 3 days 1, 3

The predominant pathogens isolated from children with AOM failing high-dose amoxicillin therapy are beta-lactamase-producing organisms, which justifies the escalation to amoxicillin-clavulanate 5

Common Bacterial Pathogens

The three most common bacterial pathogens are:

• Streptococcus pneumoniae (most common, greatest risk at any age) 4, 1, 2
• Haemophilus influenzae (nontypeable strains) 1, 2
• Moraxella catarrhalis 1, 2

Beta-lactamase production occurs in 20-30% of H. influenzae and 50-70% of M. catarrhalis, which is the primary mechanism of treatment failure with plain amoxicillin 1, 6

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for otitis media with effusion (OME)—middle ear fluid without acute inflammation does not require antibiotics 1, 3
• Do not rely on NSAIDs at anti-inflammatory doses or corticosteroids as primary therapy, as they have not demonstrated efficacy for AOM treatment 3
• Do not use fluoroquinolones as first-line therapy due to resistance concerns and side effect profiles 3, 6
• Do not use cefixime in children under 5 years as it lacks adequate coverage 4
• Avoid relying on macrolides as first-line agents unless there is documented type I penicillin allergy, due to high pneumococcal resistance rates 6

Prevention Strategies

• Ensure pneumococcal conjugate vaccine (PCV) is up-to-date 1
• Consider annual influenza vaccination 1
• Address modifiable risk factors including smoke exposure, daycare attendance, and treating underlying allergies 1, 3
• Smoking cessation counseling for household members 3