What is the treatment for acute otitis media (AOM)?

From the Guidelines

The first-line treatment for acute otitis media is amoxicillin at a dose of 80-90 mg/kg/day divided twice daily for 5-10 days, with the duration depending on age and severity. For children under 2 years or those with severe symptoms, a 10-day course is recommended, while older children with mild to moderate disease may be treated for 5-7 days. In patients with penicillin allergy, alternatives include azithromycin (10 mg/kg on day 1, then 5 mg/kg for 4 days) or clarithromycin (15 mg/kg/day divided twice daily for 10 days) 1.

Key Considerations

• The choice of antibiotic should be based on the anticipated clinical response and the microbiologic flora likely to be present, with amoxicillin being the recommended first-line therapy for AOM due to its effectiveness against susceptible and intermediate resistant pneumococci, as well as its safety, low cost, and acceptable taste 1.
• Pain management is essential and can include acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) 1.
• Antibiotic therapy is important because most cases are bacterial in origin, commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, with the high dose of amoxicillin specifically designed to overcome pneumococcal resistance 1.
• Patients should be reassessed if symptoms worsen or fail to improve within 48-72 hours of starting treatment, with consideration of alternative antibiotics such as amoxicillin-clavulanate for those who fail initial therapy or have recently been treated with antibiotics 1.

Additional Recommendations

• For patients who fail initial therapy or have recently been treated with antibiotics, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) is recommended to cover beta-lactamase producing organisms 1.
• The use of pneumatic otoscopy and tympanometry is recommended for the diagnosis of AOM, with a stringent definition of AOM including symptoms such as ear pain, fever, or respiratory symptoms, as well as signs such as bulging or new-onset otorrhea 1.
• Watchful waiting may be considered for children over 2 years with mild symptoms, but antibiotic therapy should be initiated if symptoms worsen or fail to improve within 48-72 hours 1.

From the FDA Drug Label

ACUTE BACTERIAL OTITIS MEDIA Caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase producing strains) or Moraxella catarrhalis (including beta-lactamase producing strains). NOTE: In one study lower clinical cure rates were observed with a single dose of ceftriaxone for injection compared to 10 days of oral therapy In a second study comparable cure rates were observed between single dose Ceftriaxone for Injection and the comparator.

Treatment for Acute Otitis Media: Ceftriaxone (IV) is indicated for the treatment of acute bacterial otitis media caused by susceptible organisms, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. However, the clinical cure rates with a single dose of ceftriaxone may be lower compared to 10 days of oral therapy, and the decision to use ceftriaxone should be balanced against the potential advantages of parenteral therapy 2.

• Key Points:
  • Ceftriaxone is effective against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
  • Single dose ceftriaxone may have lower clinical cure rates compared to 10 days of oral therapy.
  • The decision to use ceftriaxone should be based on the potential advantages of parenteral therapy.

From the Research

Treatment Options for Acute Otitis Media

• The first-line treatment for acute otitis media is high-dose amoxicillin (80 to 90 mg/kg/d divided twice daily) 3.
• For persistent or recurrent acute otitis media, guidelines recommend high-dose amoxicillin/clavulanate (90/6.4 mg/kg/d), cefdinir, cefprozil, cefpodoxime, cefuroxime, or ceftriaxone 3.
• Amoxicillin is also the first-line drug for otitis media, with effective second-line drugs including trimethoprim-sulfamethoxazole, erythromycin-sulfisoxazole, cefaclor, cefuroxime axetil, and cefixime 4.
• The pneumococcal conjugate vaccine should be administered to all children less than 2 years old and those at risk for recurrent AOM 5.

Pain Relief in Acute Otitis Media

• Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs (NSAIDs) are regarded as the cornerstone of AOM management for pain relief 6.
• Paracetamol may be more effective than placebo in relieving pain at 48 hours, with a number needed to treat for an additional beneficial outcome (NNTB) of 7 6.
• Ibuprofen may be more effective than placebo in relieving pain at 48 hours, with a NNTB of 6 6.
• The evidence is very uncertain about the effect of ibuprofen versus paracetamol in relieving short-term ear pain in children with AOM 6.

Antibiotic Therapy

• Antibiotics are recommended in children two years and younger, most commonly a 5-day course of amoxicillin (or a macrolide in patients allergic to penicillin) 7.
• The high prevalence of drug-resistant S. pneumoniae and beta-lactamase-producing organisms presents a clinical challenge for practitioners in the selection of empiric antimicrobial therapy 5.
• Pharmacokinetic/pharmacodynamic principles should be considered in addition to minimum inhibitory concentrations in selecting antibiotics for AOM 5.