What is the recommended first‑line antibiotic regimen for acute otitis media in children and adults, including dosing, duration, and alternatives for penicillin‑allergic patients?

First-Line Antibiotic for Acute Otitis Media

High-dose amoxicillin (80–90 mg/kg/day divided into 2 doses) is the recommended first-line antibiotic for acute otitis media in both children and adults. 1, 2

Dosing and Duration by Age

Children Under 2 Years

• Amoxicillin 80–90 mg/kg/day divided twice daily for 10 days (maximum 2 g per dose) 2, 3
• The 10-day course is mandatory regardless of symptom severity in this age group 2

Children 2–5 Years

• 7-day course for mild-to-moderate disease 2, 3
• 10-day course for severe disease (moderate-to-severe otalgia, otalgia ≥48 hours, or fever ≥39°C) 2
• Dose remains 80–90 mg/kg/day divided twice daily 2, 3

Children ≥6 Years and Adults

• 5–7 day course for mild-to-moderate disease 2, 3
• 10-day course for severe presentations 2
• Adult dosing: 1.5–4 g/day 2

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate (90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate in 2 divided doses) as first-line when: 1, 2

• Amoxicillin use within the previous 30 days 1, 2
• Concurrent purulent conjunctivitis (suggests Haemophilus influenzae) 1, 2
• Daycare attendance or high local prevalence of β-lactamase-producing organisms 2

The 14:1 ratio formulation (amoxicillin to clavulanate) causes significantly less diarrhea than other preparations while maintaining efficacy 1, 2

Penicillin-Allergic Patients

Non-Severe (Non-IgE-Mediated) Allergy

Oral cephalosporins are the preferred alternatives, with cross-reactivity risk <0.1%: 1, 2

• Cefdinir 14 mg/kg/day once daily (first choice due to convenience) 1, 2
• Cefuroxime 30 mg/kg/day divided twice daily 1, 2
• Cefpodoxime 10 mg/kg/day divided twice daily 1, 2
• Ceftriaxone 50 mg IM/IV once daily for 1–3 days (if unable to take oral medication) 1, 2

Severe (IgE-Mediated) Allergy

Macrolides may be considered, but azithromycin should be avoided as first-line due to pneumococcal resistance exceeding 40% with bacterial failure rates of 20–25% 2, 3

Treatment Failure Protocol

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

First Failure (Initially on Amoxicillin)

• Switch to amoxicillin-clavulanate 90 mg/kg/day 1, 2

Second Failure (Amoxicillin-Clavulanate Fails)

• Ceftriaxone 50 mg/kg IM once daily for 3 consecutive days 1, 2
• A 3-day course is superior to a single-dose regimen 2

Multiple Failures

• Perform tympanocentesis with culture and susceptibility testing 1, 2
• Consider clindamycin 30–40 mg/kg/day in 3 divided doses with or without third-generation cephalosporin coverage for H. influenzae and M. catarrhalis 1, 2
• Consult infectious disease specialist for multidrug-resistant organisms 2

Critical Pitfalls to Avoid

Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures due to substantial pneumococcal resistance 2

Do not prescribe antibiotics for isolated tympanic membrane redness without middle ear effusion—this does not constitute acute otitis media 2

Antibiotics do not prevent complications: 33–81% of children who develop acute mastoiditis had received prior antibiotics 2

Persistent middle ear effusion after successful treatment is expected: 60–70% at 2 weeks, 40% at 1 month, and 10–25% at 3 months—this requires monitoring but not additional antibiotics unless it persists >3 months with hearing loss 1, 2

Pain Management

Initiate acetaminophen or ibuprofen immediately in all patients, regardless of antibiotic decision 2, 3

Analgesics provide relief within 24 hours, whereas antibiotics provide no symptomatic benefit during the first 24 hours 2

Pain management is the most critical non-antibiotic intervention and should continue throughout the acute phase 2