Acute Otitis Media: Comprehensive Evaluation and Management
Diagnostic Criteria
Diagnose acute otitis media only when all three elements are present: acute onset of symptoms, middle ear effusion documented by pneumatic otoscopy, and signs of middle ear inflammation. 1, 2
- Moderate to severe bulging of the tympanic membrane or new otorrhea (not from otitis externa) establishes the diagnosis definitively 1
- Mild bulging plus recent onset ear pain (less than 48 hours) or intense erythema also meets diagnostic criteria 1
- Pneumatic otoscopy is essential—impaired tympanic membrane mobility confirms middle ear effusion 2, 3
- Isolated redness without effusion does not constitute AOM and should not be treated with antibiotics 2
Severe vs. Non-Severe Classification
Severe AOM is defined by any of the following 1, 2, 4:
- Moderate-to-severe otalgia
- Otalgia lasting ≥48 hours
- Temperature ≥39°C (102.2°F)
Immediate Pain Management
Initiate weight-based acetaminophen or ibuprofen immediately for every patient with ear pain, regardless of antibiotic decision. 1, 2, 4
- Analgesics provide relief within 24 hours, whereas antibiotics offer no symptomatic benefit in the first 24 hours 2
- Continue pain medication throughout the acute phase—30% of children under 2 years still have pain after 3–7 days of antibiotic therapy 2
Antibiotic vs. Observation Decision Algorithm
Children <6 Months
Always prescribe antibiotics immediately 2, 4
Children 6–23 Months
| Presentation | Management | Citation |
|---|---|---|
| Severe AOM (any laterality) | Immediate antibiotics | [1,2,4] |
| Bilateral non-severe AOM | Immediate antibiotics | [1,2,4] |
| Unilateral non-severe AOM | Either antibiotics OR observation with close follow-up (shared decision-making) | [1,2,4] |
Children ≥24 Months
| Presentation | Management | Citation |
|---|---|---|
| Severe AOM | Immediate antibiotics | [1,2,4] |
| Non-severe AOM (any laterality) | Either antibiotics OR observation with close follow-up (shared decision-making) | [1,2,4] |
Adults
Immediate antibiotics for severe symptoms; observation appropriate for non-severe presentations with reliable follow-up 2
Observation ("Watchful Waiting") Requirements
When choosing observation over immediate antibiotics, all of the following must be in place 2, 4:
- Reliable follow-up mechanism within 48–72 hours (scheduled visit or phone contact) 2
- Safety-net antibiotic prescription provided to family, to be filled only if symptoms worsen or fail to improve 2
- Shared decision-making with caregivers who understand the plan 2
- Immediate antibiotic initiation if the child worsens or shows no improvement at 48–72 hours 2, 4
Approximately 66% of children in observation cohorts complete the illness without requiring antibiotics 2
First-Line Antibiotic Selection
Standard First-Line: High-Dose Amoxicillin
Prescribe amoxicillin 80–90 mg/kg/day divided twice daily (maximum 2 g per dose) when the child has not received amoxicillin in the past 30 days, has no concurrent purulent conjunctivitis, and is not penicillin-allergic. 1, 2, 4
- Achieves middle ear concentrations adequate to overcome penicillin-resistant S. pneumoniae, H. influenzae, and M. catarrhalis 2
- Offers excellent safety, low cost, acceptable taste, and narrow microbiologic spectrum 1, 2
When to Use Amoxicillin-Clavulanate Instead
Switch to amoxicillin-clavulanate (90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate, divided twice daily) as first-line when any of the following apply 1, 2, 4:
- Amoxicillin use within the past 30 days 1, 2, 4
- Concurrent purulent conjunctivitis (suggests β-lactamase-producing H. influenzae) 1, 2, 4
- History of recurrent AOM unresponsive to amoxicillin 1, 2
- Attendance at daycare or high local prevalence of β-lactamase-producing organisms 2, 5
Twice-daily dosing of amoxicillin-clavulanate causes significantly less diarrhea than three-times-daily dosing with equivalent efficacy 2
Penicillin-Allergic Patients
Non-Severe (Non-IgE-Mediated) Allergy
Cross-reactivity between penicillins and second/third-generation cephalosporins is only 0.1%, making these agents safe alternatives 2, 4
Recommended oral cephalosporins (in order of preference) 2, 4:
| Agent | Dose | Frequency | Notes |
|---|---|---|---|
| Cefdinir | 14 mg/kg/day | Once daily (preferred) | First-choice for convenience [2,4] |
| Cefuroxime | 30 mg/kg/day | Divided BID | [2,4] |
| Cefpodoxime | 10 mg/kg/day | Divided BID | [2,4] |
Severe IgE-Mediated Allergy
- Consider azithromycin only as a last resort—pneumococcal macrolide resistance exceeds 40% in the United States, with bacterial failure rates of 20–25% 2
- Ceftriaxone 50 mg/kg IM once daily for 1–3 days is an alternative 1, 2
Antibiotic Duration
| Age Group | Severity | Duration | Citation |
|---|---|---|---|
| <2 years | Any | 10 days | [2,4] |
| 2–5 years | Mild-moderate | 7 days | [1,2,4] |
| 2–5 years | Severe | 10 days | [2,4] |
| ≥6 years | Mild-moderate | 5–7 days | [2,4] |
| ≥6 years | Severe | 10 days | [2] |
Treatment Failure Management
Reassess at 48–72 hours if symptoms worsen or fail to improve 1, 2, 4
Escalation Algorithm
- If initially observed → Start high-dose amoxicillin 2, 4
- If amoxicillin fails → Switch to amoxicillin-clavulanate (90 mg/kg/day + 6.4 mg/kg/day clavulanate, divided BID) 1, 2, 4
- If amoxicillin-clavulanate fails → Administer ceftriaxone 50 mg/kg IM once daily for 3 consecutive days (superior to single-dose regimen) 1, 2, 4
- After multiple failures → Consider tympanocentesis with culture and susceptibility testing 1, 2
- If tympanocentesis unavailable → Use clindamycin with adjunctive coverage for H. influenzae and M. catarrhalis (e.g., cefdinir, cefuroxime) 2
- For multidrug-resistant S. pneumoniae serotype 19A → Levofloxacin or linezolid only after infectious disease and otolaryngology consultation 2
Critical Pitfalls
- Do NOT use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures—resistance is substantial 2
- Do NOT use azithromycin as first-line—macrolide resistance exceeds 40% 2
- Antibiotics do NOT prevent complications: 33–81% of children who develop acute mastoiditis had received prior antibiotics 2
Otitis Media with Effusion (OME)
Middle ear effusion without acute symptoms requires monitoring but NOT antibiotics 2, 6, 3
Expected Post-Treatment Course
- 60–70% of children have middle ear effusion at 2 weeks after successful AOM treatment 1, 2
- 40% at 1 month, 10–25% at 3 months 1, 2
- This post-AOM effusion is normal and does not require antibiotics 2, 6
Management of OME
- Watchful waiting for 3 months from diagnosis 2, 6, 3
- Age-appropriate hearing testing if effusion persists ≥3 months 2, 6
- Do NOT prescribe antibiotics, decongestants, antihistamines, or nasal steroids—they are ineffective 2, 3
- Consider tympanostomy tubes for bilateral OME persisting >3 months with documented hearing loss or significant effect on child's well-being 2, 6
Recurrent AOM
Recurrent AOM is defined as ≥3 episodes in 6 months OR ≥4 episodes in 12 months (with ≥1 episode in the preceding 6 months) 2
Prevention Strategies
- Pneumococcal conjugate vaccine (PCV-13) 1, 2
- Annual influenza vaccination 1, 2
- Breastfeeding for ≥6 months 1, 2
- Reduce or eliminate pacifier use after 6 months 2
- Avoid supine bottle feeding 2
- Eliminate tobacco smoke exposure 1, 2
- Minimize daycare attendance when possible 2
Surgical Intervention
- Consider tympanostomy tubes for children meeting recurrent AOM criteria 2
- Failure rates: 21% for tubes alone, 16% for tubes with adenoidectomy 2
- Adenoidectomy benefit is age-dependent and controversial 2
- Long-term prophylactic antibiotics are NOT recommended—modest benefit does not justify resistance risks 1, 2
Follow-Up Recommendations
- Routine follow-up is NOT necessary for all children 2
- Consider reassessment for:
Special Considerations
Tympanostomy Tube Otorrhea
Use topical antibiotics (e.g., ciprofloxacin-dexamethasone) rather than oral antibiotics for acute tube otorrhea 2
Distinguishing Otitis Externa from AOM
- Persistent ear drainage with external ear erythema and swelling suggests otitis externa, not AOM treatment failure 2
- Do NOT use topical antibiotics for AOM—they are contraindicated and only indicated for otitis externa or tube otorrhea 2
- Avoid ototoxic topical preparations when tympanic membrane integrity is uncertain 2