What is the recommended treatment for a typical child or adult presenting with acute otitis media—ear pain, fever, hearing changes, and a red inflamed tympanic membrane—assuming no drug allergies, immunodeficiency, or chronic ear disease?

Treatment of Acute Otitis Media with Red Inflamed Eardrum

Symptomatic management of ear pain and fever is mandatory for all patients, and high-dose amoxicillin (80–90 mg/kg/day in children, 1.5–4 g/day in adults) is the first-line antibiotic when treatment is indicated. 1

Immediate Pain Management

• Administer acetaminophen or ibuprofen immediately for all patients with ear pain, regardless of whether antibiotics are prescribed, as analgesics provide relief within the first 24 hours whereas antibiotics provide no symptomatic benefit during this period. 1, 2
• Continue pain medication throughout the acute phase, as approximately 30% of children younger than 2 years still experience pain or fever after 3–7 days of antibiotic therapy. 1

Diagnostic Confirmation

• Confirm the diagnosis requires all three elements: acute onset of symptoms (ear pain, fever, irritability), presence of middle ear effusion documented by impaired tympanic membrane mobility or bulging on pneumatic otoscopy, and signs of middle ear inflammation (moderate-to-severe bulging or new otorrhea). 1, 3
• Isolated redness of the tympanic membrane without effusion does not constitute acute otitis media and should not be treated with antibiotics. 1

Antibiotic Decision Algorithm

Children < 6 Months

• Immediate antibiotics are mandatory regardless of severity due to higher complication risk and difficulty monitoring clinical progress. 1, 4
• Prescribe high-dose amoxicillin 80–90 mg/kg/day divided twice or three times daily for 10 days. 1, 4

Children 6–23 Months

• Immediate antibiotics required for severe AOM (moderate-to-severe otalgia, otalgia ≥48 hours, or fever ≥39°C) or bilateral AOM. 1
• Observation without immediate antibiotics is appropriate for non-severe unilateral AOM only if reliable follow-up within 48–72 hours can be ensured. 1

Children ≥2 Years

• Immediate antibiotics required for severe AOM (criteria above). 1
• Observation with safety-net prescription is appropriate for non-severe AOM (unilateral or bilateral) with reliable follow-up. 1
• Treatment duration: 7 days for mild-moderate disease in children 2–5 years; 10 days for severe disease or children <2 years. 1

Adults

• Amoxicillin-clavulanate is the preferred first-line agent for adults, dosed for 5 days. 5
• Alternative first-line options include cefuroxime-axetil or cefpodoxime-proxetil. 5

First-Line Antibiotic Selection

• High-dose amoxicillin (80–90 mg/kg/day in children, maximum 2 g per dose; 1.5–4 g/day in adults) divided twice daily is the first-line treatment for most patients. 1
• This high dose achieves middle ear fluid concentrations adequate to overcome penicillin-resistant Streptococcus pneumoniae, which accounts for approximately 35% of isolates. 1

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate (90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate in two divided doses) when any of the following are present: 1

• Amoxicillin use within the previous 30 days
• Concurrent purulent conjunctivitis (suggests Haemophilus influenzae)
• Recurrent AOM unresponsive to amoxicillin
• Daycare attendance or high local prevalence of beta-lactamase-producing organisms

The twice-daily dosing of amoxicillin-clavulanate results in significantly less diarrhea (14% vs. 34%) compared with three-times-daily dosing while maintaining equivalent efficacy. 6

Penicillin-Allergic Patients

• For non-severe (non-IgE-mediated) penicillin allergy, use cefdinir 14 mg/kg/day once daily (preferred for convenience), cefuroxime 30 mg/kg/day divided twice daily, or cefpodoxime 10 mg/kg/day divided twice daily. 1
• Cross-reactivity between penicillins and second- or third-generation cephalosporins is negligible (approximately 0.1%), far lower than the historically cited 10%. 1
• Do not use azithromycin as first-line therapy because pneumococcal macrolide resistance exceeds 40% in the United States, with bacterial failure rates of 20–25%. 1

Treatment Failure Management

• Re-evaluate at 48–72 hours if symptoms worsen or fail to improve. 1
• If initially observed without antibiotics, start high-dose amoxicillin. 1
• If amoxicillin fails, switch to amoxicillin-clavulanate (90 mg/kg/day). 1
• If amoxicillin-clavulanate fails, administer intramuscular ceftriaxone 50 mg/kg once daily for three consecutive days (superior to single-dose regimen). 1
• Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures due to substantial pneumococcal resistance. 1

Post-Treatment Expectations

• Middle ear effusion persists in 60–70% of children at 2 weeks after successful treatment, declining to 40% at 1 month and 10–25% at 3 months. 1
• This post-AOM effusion (otitis media with effusion) requires monitoring but not additional antibiotics unless it persists >3 months with hearing loss. 1

Critical Pitfalls to Avoid

• Antibiotics do not prevent complications: 33–81% of children who develop acute mastoiditis had received prior antibiotics. 1
• Do not prescribe antibiotics for otitis media with effusion (fluid without acute symptoms). 1
• Ensure adequate visualization of the tympanic membrane before prescribing antibiotics. 5
• Do not use topical antibiotics for acute otitis media; these are contraindicated and only indicated for otitis externa or tube otorrhea. 1