What are the appropriate antibiotics (abx) for treating otitis media (ear infections)?

From the Guidelines

Amoxicillin is the recommended first-line treatment for acute otitis media at a dose of 80-90 mg/kg/day. This recommendation is based on the most recent and highest quality study available, which suggests that amoxicillin is effective against susceptible and intermediate resistant pneumococci, and has a narrow microbiologic spectrum, making it a safe and inexpensive option 1.

Key Considerations

• The choice of antibiotic should be based on the anticipated clinical response and the microbiologic flora likely to be present.
• Amoxicillin-clavulanic acid is recommended as a second-choice option for patients who do not respond to amoxicillin or have a penicillin allergy.
• The optimal duration of therapy for patients with AOM is uncertain, but typical courses range from 5-10 days.
• Pain management with acetaminophen or ibuprofen is important regardless of antibiotic use.
• Completing the full course of antibiotics is essential to prevent recurrence and antibiotic resistance.

Alternatives and Special Considerations

• For patients with penicillin allergy, cefdinir, cefpodoxime, or cefuroxime may be considered as alternative options.
• Topical antibiotic drops like ciprofloxacin-dexamethasone or ofloxacin are preferred for otitis externa (swimmer's ear).
• Systemic antibiotics are generally unnecessary for uncomplicated external ear infections.
• A strategy of watchful waiting could reduce unnecessary antibiotic use, especially in children over 2 years with mild symptoms 1.

From the FDA Drug Label

14.2 Acute Bacterial Otitis Media and Diarrhea in Pediatric Patients One U.S./Canadian clinical trial was conducted which compared 45/6. 4 mg/kg/day (divided every 12 hours) of amoxicillin and clavulanate potassium for 10 days versus 40/10 mg/kg/day (divided every 8 hours) of amoxicillin and clavulanate potassium for 10 days in the treatment of acute otitis media. The clinical efficacy rates at the end of therapy visit (defined as 2 to 4 days after the completion of therapy) and at the follow-up visit (defined as 22 to 28 days post-completion of therapy) were comparable for the 2 treatment groups, with the following cure rates obtained for the evaluable patients: At end of therapy, 87% (n = 265) and 82% (n = 260) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively. At follow-up, 67% (n = 249) and 69% (n = 243) for 45 mg/kg/day every 12 hours and 40 mg/kg/day every 8 hours, respectively.

• Amoxicillin-clavulanate is used for the treatment of acute bacterial otitis media, with cure rates of 87% at the end of therapy and 67% at follow-up for the every 12 hours regimen, and 82% at the end of therapy and 69% at follow-up for the every 8 hours regimen 2.
• Azithromycin is also used for the treatment of acute otitis media, with clinical success rates of 88% at the Day 11 visit and 73% at the Day 30 visit 3.
• The choice of antibiotic should be based on the severity of the infection, the patient's medical history, and the likelihood of resistance to certain antibiotics.
• It is essential to consult a healthcare professional for proper diagnosis and treatment of ear infections.

From the Research

Antibiotics for Ear Infections

• The first-line treatment for acute otitis media (AOM) is high-dose amoxicillin (80-90 mg/kg/d) 4, 5.
• For patients who are allergic to amoxicillin or have failed first-line treatment, alternative options include:
  • High-dose amoxicillin/clavulanate (90/6.4 mg/kg/d) 4, 5
  • Cefdinir, cefprozil, cefpodoxime, cefuroxime, or ceftriaxone 4
• Clarithromycin is also a safe and effective option for the treatment of AOM in children, with a lower incidence of gastrointestinal side effects compared to amoxicillin/clavulanate 6, 7.
• The choice of antibiotic should be based on the severity of the infection, the patient's medical history, and the local prevalence of resistant pathogens 8.

Considerations for Treatment

• The prevalence of drug-resistant Streptococcus pneumoniae (NSSP) and beta-lactamase-producing organisms should be considered when selecting empiric antimicrobial therapy 4, 5.
• Pharmacokinetic/pharmacodynamic principles should be considered in addition to minimum inhibitory concentrations when selecting antibiotics for AOM 5.
• The use of high-dose amoxicillin may not be necessary in communities with a low prevalence of NSSP 8.