What is the recommended treatment for a patient with an ear infection, considering age and severity of symptoms?

Treatment for Ear Infection

Immediate Priority: Determine Type of Ear Infection

The treatment for ear infection depends critically on whether you are dealing with acute otitis externa (outer ear canal infection) versus acute otitis media (middle ear infection), as these require fundamentally different therapeutic approaches. 1, 2

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For Acute Otitis Externa (Swimmer's Ear)

First-Line Treatment

Topical antibiotic drops (with or without steroids) are the primary treatment for acute otitis externa in patients aged 2 years and older. 1

• Prescribe topical antimicrobial drops active against Pseudomonas aeruginosa and Staphylococcus aureus 1
• Antibiotic/steroid combination drops are significantly more effective than placebo (OR 11,95% CI 2.00-60.57) 3
• If tympanic membrane perforation is known or suspected, use only non-ototoxic preparations 1

Essential Adjunctive Measures

• Perform aural toilet (suction, dry mopping, or removal of obstructing cerumen) if ear canal is obstructed 1
• Place an ear canal wick if the canal is too swollen for drops to penetrate 1
• Prescribe analgesics based on pain severity (ibuprofen or acetaminophen) 1, 2

Reassessment Protocol

• Patients should show clinical improvement within 48-72 hours 1
• If no improvement by 48-72 hours: reassess diagnosis, check adherence, consider adding systemic antibiotics covering P. aeruginosa and S. aureus, or perform additional aural toilet 1
• Complete symptom resolution may take up to 2 weeks, but early improvement is expected 1

Common Pitfall

Do not prescribe oral antibiotics as initial therapy for uncomplicated acute otitis externa—topical treatment alone is effective 1, 3

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For Acute Otitis Media (Middle Ear Infection)

Step 1: Confirm Diagnosis

Three elements are required for AOM diagnosis: acute onset of symptoms, middle ear effusion, and signs of middle ear inflammation. 2, 4

• Use pneumatic otoscopy to confirm middle ear effusion 2
• Isolated tympanic membrane redness without bulging or effusion does NOT warrant antibiotics—reassess if symptoms persist beyond 3 days 1, 4

Step 2: Immediate Pain Management

Prescribe analgesics (ibuprofen or acetaminophen) immediately for all children with ear pain, as antibiotics provide no symptomatic benefit in the first 24 hours. 2, 4

• Pain relief should occur within 24 hours with analgesics 2
• Ibuprofen may be superior to acetaminophen for ear pain 4

Step 3: Antibiotic Decision Algorithm

Observation Without Immediate Antibiotics (Watchful Waiting)

Consider observation for 48-72 hours in children ≥6 months with:

• Non-severe symptoms (mild otalgia, temperature <39°C) 2
• Unilateral infection in children ≥2 years 2
• Reliable follow-up mechanism in place 2

Immediate Antibiotic Therapy Required For:

• Children <6 months (any AOM) 2
• Bilateral AOM in children <2 years 2
• Severe symptoms (moderate-to-severe otalgia, temperature ≥39°C) 2
• AOM with otorrhea 2
• Toxic appearance or signs of another bacterial infection 2

Step 4: Antibiotic Selection

First-line: Amoxicillin 80-90 mg/kg/day divided every 12 hours 2, 5

• Duration: 10 days for children <2 years; 5 days for children ≥2 years 1, 2
• This high dose (80-90 mg/kg/day) is essential for adequate coverage of resistant Streptococcus pneumoniae 2

Alternative agents (if penicillin allergy without type I hypersensitivity):

• Cefdinir, cefpodoxime, or cefuroxime 2, 4
• Amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil for suspected H. influenzae (e.g., concurrent purulent conjunctivitis) 1, 4

For penicillin allergy (type I hypersensitivity):

• Azithromycin may be considered, though less effective than beta-lactams 6

Step 5: Reassessment

If no improvement within 48-72 hours: 2, 4

• Confirm AOM diagnosis and exclude other causes 2
• If initially observed, start antibiotics 2
• If already on antibiotics, switch to alternative agent (e.g., amoxicillin-clavulanate if started on amoxicillin) 2
• Consider ENT referral if treatment failures persist 4

Critical Pitfalls to Avoid

• Do not underdose amoxicillin—use 80-90 mg/kg/day, not lower doses 2
• Do not withhold analgesics while waiting for antibiotics to work—pain relief requires separate medication 2, 4
• Do not prescribe antibiotics for isolated tympanic membrane redness without other AOM criteria 2, 4
• Do not use observation approach without ensuring reliable follow-up 2
• Even with appropriate antibiotics, 30% of children <2 years may have persistent symptoms at 3-7 days 2

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Special Considerations

Otitis Media with Effusion (OME)

Antibiotics are NOT indicated for OME unless it persists beyond 3 months 1, 7

• Refer to ENT specialist if prolonged course with hearing loss 1

Age-Specific Considerations

• Children <2 years have higher treatment failure rates and require longer antibiotic courses (10 days vs. 5 days) 1, 2
• The guideline for acute otitis externa applies only to patients ≥2 years 1