How should acute otitis media be managed in infants, children, and adults regarding antibiotic selection, dosing, duration, and observation based on severity, age, and risk factors such as penicillin allergy?

Acute Otitis Media Treatment

High-dose amoxicillin (80–90 mg/kg/day divided twice daily) is the first-line antibiotic for acute otitis media in most patients, with immediate treatment mandatory for all infants under 6 months, children 6–23 months with bilateral or severe disease, and any patient with severe symptoms (moderate-to-severe otalgia or fever ≥39°C). 1, 2

Immediate Pain Management (Mandatory for All Patients)

• Initiate acetaminophen or ibuprofen immediately in all patients regardless of antibiotic decision, as antibiotics provide no symptomatic relief in the first 24 hours and approximately 30% of children under 2 years still have pain or fever after 3–7 days of antibiotic therapy. 1, 2
• Continue analgesics throughout the acute phase, particularly during the first 24–48 hours when pain is most severe. 1

Diagnostic Confirmation

• Confirm diagnosis with pneumatic otoscopy demonstrating all three required criteria: (1) acute onset of symptoms, (2) middle-ear effusion (impaired tympanic membrane mobility, bulging, or air-fluid level), and (3) signs of middle-ear inflammation (moderate-to-severe bulging or new otorrhea). 1, 2
• Isolated tympanic membrane redness without bulging or effusion does not constitute AOM and should not be treated with antibiotics. 1, 3

Treatment Algorithm by Age and Severity

Infants < 6 Months

• Immediate antibiotics are mandatory for all infants under 6 months regardless of severity, due to higher complication risk and difficulty monitoring clinical progress. 1, 2, 3
• Prescribe high-dose amoxicillin 80–90 mg/kg/day divided into 2–3 doses for 10 days. 1, 2, 3

Children 6–23 Months

• Immediate antibiotics required for bilateral AOM (regardless of severity) or any AOM with severe symptoms (moderate-to-severe otalgia or fever ≥39°C). 1, 2
• Observation acceptable for unilateral non-severe AOM only if reliable 48–72 hour follow-up is guaranteed; provide safety-net prescription to fill if symptoms worsen or fail to improve. 1, 2

Children 2–5 Years

• Immediate antibiotics required for severe symptoms (moderate-to-severe otalgia, otalgia ≥48 hours, or fever ≥39°C). 1, 2
• Observation acceptable for non-severe unilateral or bilateral AOM with reliable 48–72 hour follow-up. 1, 2

Children ≥6 Years and Adults

• Immediate antibiotics required for severe symptoms (moderate-to-severe otalgia or fever ≥39°C). 1, 2
• Observation acceptable for non-severe disease with reliable 48–72 hour follow-up. 1, 2

First-Line Antibiotic Selection

Standard First-Line: Amoxicillin

• High-dose amoxicillin 80–90 mg/kg/day divided twice daily (maximum 2 g per dose) achieves middle-ear fluid concentrations adequate to overcome penicillin-resistant Streptococcus pneumoniae (approximately 35% of isolates) and covers beta-lactamase-negative Haemophilus influenzae and Moraxella catarrhalis. 1, 2, 4
• This dosing achieves approximately 92% eradication of S. pneumoniae and 84% eradication of beta-lactamase-negative H. influenzae. 1

When to Use Amoxicillin-Clavulanate First-Line

Switch to amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day + clavulanate 6.4 mg/kg/day divided twice daily) when any of the following are present: 1, 2, 5

• Amoxicillin use within the preceding 30 days
• Concurrent purulent conjunctivitis (suggests H. influenzae infection)
• Daycare attendance or high local prevalence of beta-lactamase-producing organisms
• History of recurrent AOM unresponsive to amoxicillin

Twice-daily dosing of amoxicillin-clavulanate causes significantly less diarrhea than three-times-daily dosing while maintaining equivalent efficacy. 1, 2

Penicillin Allergy Alternatives

Non-Severe (Non-IgE-Mediated) Penicillin Allergy

Cross-reactivity between penicillins and second/third-generation cephalosporins is approximately 0.1%, far lower than the historically cited 10%, making these agents generally safe. 1, 2

Preferred oral options in order: 1, 2, 6, 7

• Cefdinir 14 mg/kg/day once daily (preferred for convenience)
• Cefuroxime 30 mg/kg/day divided twice daily
• Cefpodoxime 10 mg/kg/day divided twice daily

Severe (IgE-Mediated) Penicillin Allergy

• Azithromycin may be used, but recognize that pneumococcal macrolide resistance exceeds 40% in the United States with bacterial failure rates of 20–25%. 1
• Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole due to substantial pneumococcal resistance. 1, 2

Treatment Duration

• Children < 2 years: 10 days for all episodes regardless of severity. 1, 2
• Children 2–5 years: 7 days for mild-moderate symptoms; 10 days for severe symptoms. 1, 2
• Children ≥6 years: 5–7 days for mild-moderate symptoms; 10 days for severe symptoms. 1, 2

Management of Treatment Failure

Reassess at 48–72 hours if symptoms worsen or fail to improve; confirm diagnosis with proper tympanic membrane visualization. 1, 2

Escalation Algorithm

1. If initial amoxicillin fails: Switch to amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day). 1, 2

2. If amoxicillin-clavulanate fails: Administer intramuscular ceftriaxone 50 mg/kg once daily (maximum 1–2 g) for 3 consecutive days (superior to 1-day regimen). 1, 2

3. After multiple failures: Consider tympanocentesis with culture and susceptibility testing; if unavailable, use clindamycin with or without coverage for H. influenzae and M. catarrhalis. 1, 2

4. For multidrug-resistant S. pneumoniae serotype 19A: Levofloxacin or linezolid may be used only after infectious disease and otolaryngology specialist consultation. 1, 2

Post-Treatment Expectations and Follow-Up

• Middle-ear effusion persists in 60–70% of children at 2 weeks, 40% at 1 month, and 10–25% at 3 months after successful therapy; this represents otitis media with effusion (OME), not treatment failure. 1, 2
• Do not prescribe antibiotics for post-AOM effusion unless it persists >3 months with documented hearing loss. 1, 2
• Routine follow-up visits are not necessary for all children; consider reassessment for infants <6 months, children with severe initial presentations, recurrent AOM, developmental delays, or when parents request it. 2

Recurrent AOM Management

Recurrent AOM is defined as ≥3 episodes in 6 months or ≥4 episodes in 12 months with at least one episode in the preceding 6 months. 1, 2

Prevention Strategies

• Administer pneumococcal conjugate vaccine (PCV-13) and annual influenza vaccination. 1, 2, 8
• Encourage exclusive breastfeeding for at least 6 months. 1, 2, 8
• Limit pacifier use after 6 months of age. 1, 2
• Avoid supine bottle feeding. 1, 2
• Eliminate tobacco smoke exposure. 1, 2
• Reduce daycare attendance when feasible. 1, 2

Surgical Intervention

• Tympanostomy tubes should be considered for children meeting recurrent AOM criteria; failure rates are approximately 21% for tubes alone and 16% for tubes combined with adenoidectomy. 1, 2
• Long-term prophylactic antibiotics are not recommended because modest benefit does not outweigh antimicrobial resistance risk. 1, 2

Critical Pitfalls to Avoid

• Antibiotics do not prevent complications: 33–81% of children who develop acute mastoiditis had received antibiotics previously. 1
• Do not use topical antibiotics for AOM; they are reserved for otitis externa or tympanostomy tube otorrhea. 1, 2
• Do not use systemic corticosteroids for AOM; evidence shows no benefit. 1, 2
• Do not substitute two 250 mg/125 mg amoxicillin-clavulanate tablets for one 500 mg/125 mg tablet, as they contain the same amount of clavulanate (125 mg) but different amoxicillin doses. 5
• Azithromycin should not be used first-line due to pneumococcal macrolide resistance exceeding 40% with bacterial failure rates of 20–25%. 1