How should acute otitis media be treated in an adult?

Treatment of Acute Otitis Media in Adults

Treat adults with acute otitis media using high-dose amoxicillin (1.5-4 g/day) for 5-10 days as first-line therapy, with immediate pain management using acetaminophen or ibuprofen regardless of antibiotic choice. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis requires all three elements 2:

• Acute onset of ear pain, fever, or hearing loss
• Middle ear effusion demonstrated by impaired tympanic membrane mobility on pneumatic otoscopy 3
• Signs of inflammation: bulging tympanic membrane, distinct erythema with bulging, or new otorrhea not from otitis externa 2

Critical pitfall: Isolated tympanic membrane redness with normal landmarks does NOT warrant antibiotic treatment 2. Bulging combined with reduced mobility are the most predictive findings 2.

Immediate Pain Management

Address pain immediately in every patient, as this is often the primary symptom requiring relief 1, 2:

• Acetaminophen or ibuprofen dosed appropriately 1, 2
• Pain relief typically occurs within 24 hours, whereas antibiotics provide no symptomatic benefit in the first 24 hours 1, 2
• Continue analgesics throughout the acute phase regardless of antibiotic decision 1

First-Line Antibiotic Selection

High-dose amoxicillin is the first-line antibiotic for most adults with acute otitis media 1, 2:

• Adult dosing: 1.5-4 g/day divided into 2-3 doses 2
• Rationale: effective against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (the three most common pathogens), safe, inexpensive, and narrow spectrum 1, 4

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate as first-line when 1, 2:

• Patient received amoxicillin within the previous 30 days
• Concurrent purulent conjunctivitis (suggests H. influenzae)
• High local prevalence of beta-lactamase-producing organisms 1

Penicillin Allergy Alternatives

For non-severe penicillin allergy (non-IgE-mediated) 1:

• Cefdinir, cefuroxime, or cefpodoxime (cross-reactivity with second/third-generation cephalosporins is lower than historically reported) 1

For severe penicillin allergy 5:

• Macrolides (though resistance is increasing) 5
• Fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) 5

Treatment Duration

Adults require 5-10 days of antibiotic therapy 2:

• 10 days is preferred for complete bacterial eradication 2
• The diagnosis and management are overall similar to children, though initial presentation may differ slightly 5

Treatment Failure Management

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

1. Confirm the diagnosis remains acute otitis media and exclude other causes 2
2. If initially treated with amoxicillin: Switch to amoxicillin-clavulanate 1, 2
3. If amoxicillin-clavulanate fails: Administer intramuscular ceftriaxone 50 mg/kg once daily for 3 days (a 3-day course is superior to single-dose) 1, 6

Critical pitfall: Do NOT use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures due to substantial resistance 1, 7

Post-Treatment Expectations

Middle ear effusion commonly persists after successful treatment 1, 2:

• 60-70% have effusion at 2 weeks 1, 2
• 40% at 1 month 1
• 10-25% at 3 months 1

This persistent effusion (otitis media with effusion) does NOT require antibiotics unless it persists beyond 3 months with hearing loss 1, 2. Routine follow-up is not necessary for uncomplicated cases that resolve clinically 2.

When Imaging is NOT Indicated

Imaging studies are NOT indicated for uncomplicated acute otitis media 5. The diagnosis is clinical, based on otoscopic findings and symptoms 5.

Imaging becomes necessary only in refractory cases when 5:

• Antibiotic treatment fails and infection persists
• Symptoms worsen or new symptoms arise (posterior auricular swelling, mastoid tenderness, headache, vertigo, neurological deficits)
• Complications are suspected (subperiosteal abscess, labyrinthitis, meningitis, intracranial abscess) 5

Key Clinical Pearls

• Antibiotics do NOT prevent complications: 33-81% of patients who develop acute mastoiditis had received prior antibiotics 1
• In most cases, acute otitis media resolves spontaneously with fewer patients requiring antibiotic treatment 5
• The bacteria involved in adults are the same as in children (S. pneumoniae, H. influenzae, M. catarrhalis), and therapeutic choices do not differ 5
• Avoid topical antibiotics for suppurative otitis media—these are contraindicated and only indicated for otitis externa or tube otorrhea 1