What medication is recommended for otitis media in pediatric and adult patients?

Medication for Otitis Media

For acute otitis media, amoxicillin at high doses (80-90 mg/kg/day in children; 1.5-4 g/day in adults) is the first-line antibiotic, with amoxicillin-clavulanate as the preferred second-line agent. 1, 2, 3

Pediatric Treatment Algorithm

Initial Antibiotic Selection by Age and Severity

Children <6 months:

• Immediate antibiotics required regardless of severity 3, 4
• High-dose amoxicillin 80-90 mg/kg/day divided into 2-3 doses for 10 days 3, 4

Children 6-23 months:

• Severe AOM (moderate-to-severe otalgia OR fever ≥39°C) or bilateral AOM: immediate antibiotics 3
• Non-severe unilateral AOM: observation acceptable with reliable 48-72 hour follow-up 3
• If antibiotics chosen: amoxicillin 80-90 mg/kg/day for 10 days 3

Children ≥2 years:

• Severe symptoms: immediate antibiotics, 7-10 day course 3
• Mild-moderate symptoms: observation acceptable with follow-up 3
• If antibiotics chosen: amoxicillin 80-90 mg/kg/day for 7 days (ages 2-5) or 5-7 days (ages ≥6) 3

When to Use Amoxicillin-Clavulanate Instead

Use amoxicillin-clavulanate 90 mg/kg/day (based on amoxicillin component) as first-line if: 3

• Amoxicillin received within previous 30 days
• Concurrent purulent conjunctivitis present
• Recurrent AOM unresponsive to amoxicillin
• Attends daycare (higher risk of beta-lactamase producers) 4

Treatment Failure Management

If symptoms worsen or fail to improve within 48-72 hours: 3, 4

• Reassess to confirm AOM diagnosis
• If initially on amoxicillin: switch to amoxicillin-clavulanate 90 mg/kg/day 3, 4
• If initially on amoxicillin-clavulanate: switch to ceftriaxone 50 mg/kg IM/IV daily for 3 days (maximum 1-2 grams) 3, 4
• Three-day ceftriaxone course superior to one-day regimen 3

Penicillin Allergy Alternatives

For non-type I hypersensitivity (non-severe allergy): 3

• Cefdinir 14 mg/kg/day in 1-2 divided doses
• Cefuroxime axetil 30 mg/kg/day in 2 divided doses
• Cefpodoxime 10 mg/kg/day in 2 divided doses
• Cross-reactivity with second/third-generation cephalosporins is negligible 3

For true type I IgE-mediated allergy: 3

• Macrolides (azithromycin) are safest but have lower efficacy against resistant organisms
• Azithromycin dosing: 30 mg/kg single dose OR 10 mg/kg day 1, then 5 mg/kg days 2-5 5

Adult Treatment Algorithm

First-Line Therapy

Amoxicillin-clavulanate is preferred over plain amoxicillin in adults due to higher rates of beta-lactamase-producing organisms (17-34% of H. influenzae, 100% of M. catarrhalis) 2

• Standard dose: 3 g/day amoxicillin component 2
• High-dose for risk factors: 2000 mg/125 mg twice daily 2

Risk factors requiring high-dose therapy: 2

• Antibiotic use within past month
• Age >65 years
• Moderate-to-severe symptoms
• Comorbid conditions or immunocompromised status
• Geographic regions with high penicillin-nonsusceptible S. pneumoniae rates

Treatment Duration in Adults

5-7 days is appropriate for uncomplicated cases 2

• Shorter courses have fewer side effects than traditional 10-day regimens 2
• Adults have different immune responses and lower treatment failure risk than young children 2

Treatment Failure in Adults

Reassess at 48-72 hours if symptoms persist or worsen: 2

• Consider respiratory fluoroquinolones (levofloxacin, moxifloxacin) or ceftriaxone 2
• Do not simply extend duration of failing antibiotic 2

Penicillin Allergy in Adults

For non-type I allergy: 2

• Cefdinir, cefuroxime (500 mg twice daily), or cefpodoxime 2, 3

For severe allergy: 2

• Respiratory fluoroquinolones (though avoid as first-line due to resistance concerns) 2

Pain Management (All Ages)

Pain control is mandatory and must be addressed immediately in every patient, regardless of antibiotic decision: 2, 3

• Acetaminophen or ibuprofen in age-appropriate doses 2, 3
• Continue throughout acute phase, especially first 24 hours 3
• Pain relief often occurs before antibiotics provide benefit 3

Critical Pitfalls to Avoid

Diagnostic errors: 2, 3

• Isolated tympanic membrane redness with normal landmarks does NOT indicate AOM 1, 2
• Do not confuse otitis media with effusion (OME) for acute AOM—OME does not require antibiotics 2, 3
• Proper pneumatic otoscopy with visualization of bulging, limited mobility, or distinct erythema is essential 2

Treatment errors: 2, 3

• NSAIDs at anti-inflammatory doses and corticosteroids have NOT demonstrated efficacy for AOM 2, 3
• Do NOT use macrolides or trimethoprim-sulfamethoxazole as first-line (>40% and 50% resistance rates respectively against S. pneumoniae) 2
• Do NOT use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures due to substantial resistance 3, 4
• Long-term prophylactic antibiotics are discouraged for recurrent AOM 3

Post-Treatment Follow-Up

Middle ear effusion commonly persists after successful treatment: 3

• 60-70% at 2 weeks, 40% at 1 month, 10-25% at 3 months 3
• This post-AOM effusion (OME) requires monitoring but NOT antibiotics unless persisting >3 months with hearing loss 3

Prevention Strategies

Modifiable risk factors: 3

• Encourage breastfeeding ≥6 months
• Reduce/eliminate pacifier use after 6 months
• Avoid supine bottle feeding
• Eliminate tobacco smoke exposure
• Minimize daycare attendance when possible

Immunizations: 3

• Pneumococcal conjugate vaccine (PCV-13) 3
• Annual influenza vaccination 3