What is the recommended treatment for a patient with acute otitis media (ear infection)?

Treatment of Acute Otitis Media (Ear Infection)

For acute otitis media in adults and children over 2 years, amoxicillin at high doses (80-90 mg/kg/day in children, standard adult dosing) is the first-line antibiotic when treatment is indicated, with pain management being an essential component regardless of antibiotic use. 1, 2

Diagnosis Confirmation

Before treating, confirm the diagnosis requires three essential elements 1, 2:

• Acute onset of signs and symptoms (within 48 hours)
• Presence of middle ear effusion (documented by pneumatic otoscopy, tympanometry, or visualization)
• Signs of middle ear inflammation (moderate to severe bulging of tympanic membrane, new onset otorrhea not from external canal, or mild bulging with recent ear pain/intense erythema)

Critical pitfall: Do not confuse otitis media with effusion (OME) for acute otitis media—isolated middle ear fluid without acute inflammation does not require antibiotics. 2 Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotic therapy. 2

Pain Management (Essential First Step)

Initiate analgesics immediately for all patients with AOM, regardless of whether antibiotics are prescribed 1, 2:

• Acetaminophen or ibuprofen at appropriate doses
• Pain relief is a primary treatment goal, not a peripheral concern

Antibiotic Decision Algorithm

For Children 6 Months to 23 Months:

• Bilateral AOM (any severity): Prescribe antibiotics 1
• Unilateral AOM with severe symptoms (moderate-severe otalgia >48 hours OR temperature ≥39°C): Prescribe antibiotics 1
• Unilateral AOM without severe symptoms: Either prescribe antibiotics OR offer observation with close 48-72 hour follow-up based on shared decision-making 1

For Children ≥24 Months and Adults:

• Severe symptoms (moderate-severe otalgia >48 hours OR temperature ≥39°C): Prescribe antibiotics 1
• Non-severe symptoms: Either prescribe antibiotics OR offer observation with close 48-72 hour follow-up 1, 2

Note: Adults typically require antibiotic therapy due to higher likelihood of bacterial etiology compared to children. 2

First-Line Antibiotic Selection

Standard First-Line (No Recent Antibiotic Use):

Amoxicillin is the drug of choice 1, 2:

• Children: 80-90 mg/kg/day divided twice daily 1, 3
• Adults: Standard dosing (typically 500 mg three times daily or 875 mg twice daily)
• Use when patient has NOT received amoxicillin in past 30 days, has no concurrent purulent conjunctivitis, and is not penicillin-allergic 1

When to Use Amoxicillin-Clavulanate Instead:

Prescribe amoxicillin-clavulanate (90 mg/kg/day based on amoxicillin component) as first-line when 1, 2:

• Patient received amoxicillin in the past 30 days
• Concurrent purulent conjunctivitis is present
• History of recurrent AOM unresponsive to amoxicillin
• Adults with moderate disease or recent antibiotic exposure: Consider high-dose formulation (2000 mg/125 mg twice daily) 2

Rationale: Beta-lactamase-producing Haemophilus influenzae (17-34% of strains) and Moraxella catarrhalis (100% of strains) are the primary causes of amoxicillin treatment failure. 2, 3 High-dose amoxicillin achieves 92% eradication of S. pneumoniae, 84% eradication of beta-lactamase-negative H. influenzae, but only 62% eradication of beta-lactamase-positive H. influenzae. 3

Penicillin Allergy Alternatives

Non-Type I (Non-Severe) Allergy:

• Cefdinir, cefpodoxime, or cefuroxime 2

Type I (Severe) Allergy:

• Azithromycin: 30 mg/kg as single dose (children with otitis media) OR 10 mg/kg day 1, then 5 mg/kg days 2-5 4
• Alternative: Erythromycin-sulfisoxazole 2, 5

Important caveat: Azithromycin has lower efficacy than beta-lactams for AOM and should be reserved for true penicillin allergies. 5

Treatment Duration

• Children <2 years: 10 days 1, 2
• Children ≥2 years with uncomplicated cases: 5-7 days acceptable 1, 2
• Adults: 5-7 days for uncomplicated cases 2

Management of Treatment Failure

Reassess within 48-72 hours if symptoms worsen or fail to improve 1, 2:

Definition of Treatment Failure:

• Worsening condition
• Persistence of symptoms beyond 48 hours after antibiotic initiation
• Recurrence within 4 days of treatment discontinuation 2

Second-Line Options:

If initial therapy was amoxicillin 1, 2:

• Switch to amoxicillin-clavulanate (90 mg/kg/day)
• Alternative: Ceftriaxone 50 mg/kg IM for 3 days 2

If initial therapy was amoxicillin-clavulanate:

• Consider ceftriaxone or respiratory fluoroquinolones (adults only: levofloxacin, moxifloxacin) 2

Common Pitfalls to Avoid

• Do not use oral antibiotics for acute otitis externa (swimmer's ear)—this is a different condition requiring topical therapy 1
• Do not rely on NSAIDs or corticosteroids as primary therapy—they have not demonstrated efficacy for AOM treatment 2
• Avoid fluoroquinolones as first-line due to resistance concerns and side effects 2
• Do not prescribe antibiotics for isolated tympanic membrane erythema without other diagnostic criteria 2

Prevention Strategies

• Pneumococcal conjugate vaccination (PCV13) 2
• Annual influenza vaccination 2
• Smoking cessation in household 2
• Treatment of underlying allergies 2