What is the appropriate duration of antibiotic therapy for uncomplicated acute otitis media in a 5‑year‑old boy with left ear pain?

Treatment Duration for Acute Otitis Media in a 5-Year-Old

A 5-year-old boy with uncomplicated acute otitis media should receive a 7-day course of high-dose amoxicillin (80–90 mg/kg/day divided twice daily) if symptoms are mild-to-moderate, or a full 10-day course if symptoms are severe. 1

Defining Severity to Determine Duration

The treatment duration hinges on symptom severity at presentation:

• Severe symptoms include moderate-to-severe otalgia, ear pain persisting ≥48 hours, or fever ≥39°C (102.2°F). 1
• Mild-to-moderate symptoms are everything else—mild ear pain of recent onset and low-grade or absent fever. 1

For this 5-year-old with mild-to-moderate disease, the American Academy of Pediatrics explicitly recommends 7 days of antibiotic therapy, which is equally effective as 10 days in this age group. 1 This shorter duration reduces unnecessary antibiotic exposure without compromising clinical outcomes. 1

If the child presents with severe symptoms, extend treatment to the full 10-day course. 1, 2 The 10-day regimen remains standard for severe presentations across all pediatric age groups. 1

First-Line Antibiotic Selection

• High-dose amoxicillin (80–90 mg/kg/day divided into two doses) is the first-line agent for most children with acute otitis media, including this 5-year-old. 1, 3
• This dosing achieves middle ear fluid concentrations adequate to overcome penicillin-resistant Streptococcus pneumoniae, the most common pathogen. 1

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin + 6.4 mg/kg/day of clavulanate in two divided doses) if: 1, 3

• The child received amoxicillin within the past 30 days. 1
• Concurrent purulent conjunctivitis is present (suggesting Haemophilus influenzae). 1
• The child attends daycare or lives in an area with high prevalence of beta-lactamase-producing organisms. 1

Immediate Pain Management

• Initiate weight-based acetaminophen or ibuprofen immediately for all children with ear pain, regardless of antibiotic use. 1, 3
• Analgesics provide relief within 24 hours, whereas antibiotics offer no symptomatic benefit in the first 24 hours. 1
• Continue pain medication throughout the acute phase, as 30% of children younger than 2 years still have pain after 3–7 days of antibiotic therapy. 1

Reassessment Protocol

• Re-evaluate at 48–72 hours if symptoms worsen or fail to improve. 1, 3
• If amoxicillin fails, switch to amoxicillin-clavulanate. 1, 3
• If amoxicillin-clavulanate fails, administer intramuscular ceftriaxone 50 mg/kg once daily for 3 consecutive days (superior to a single-dose regimen). 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, 2
• This post-treatment effusion (otitis media with effusion) requires monitoring but not additional antibiotics unless it persists beyond 3 months with documented hearing loss. 1, 2

Critical Pitfalls to Avoid

• Do not use azithromycin as first-line therapy—pneumococcal macrolide resistance exceeds 40% in the United States, with bacterial failure rates of 20–25%. 1, 4
• Do not prescribe antibiotics for isolated tympanic membrane redness without middle ear effusion—this does not constitute acute otitis media. 1
• Complete the full prescribed course even if symptoms resolve early—premature discontinuation risks recurrence and promotes resistance. 2
• Routine follow-up visits are not necessary for uncomplicated cases that resolve clinically, though reassessment is warranted for children with recurrent infections or developmental delays. 3