Sandbox aom

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Moubarak, M.D. [2]

Overview

Acute otitis media (AOM) usually follows a viral upper respiratory tract infection leading to Eustachian tube dysfunction with impaired clearance and pressure regulation of the middle ear. Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without otorrhea or children older than 2 years with unilateral or bilateral AOM without otorrhea. Antibiotics covering common bacterial pathogens (e.g., Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae) have been used with success in selected patients to accelerate the recovery and lower the risk of tympanic membrane perforations and contralateral AOM episodes. High-dose amoxicillin (90 mg/kg/day) remains the drug of choice for initial antibiotic therapy; amoxicillin-clavulanate or ceftriaxone should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours.

Medical Therapy

Initial management of uncomplicated AOM with high certainty of diagnosis

Clinical Practice Guideline from the American Academy of Pediatrics

Age	AOM With Otorrhea	AOM With Severe Symptoms†	Bilateral AOM Without Otorrhea	Unilateral AOM Without Otorrhea
6 mo to 2 y	Antibiotic therapy	Antibiotic therapy	Antibiotic therapy	Antibiotic therapy or additional observation
≥ 2 y	Antibiotic therapy	Antibiotic therapy	Antibiotic therapy or additional observation	Antibiotic therapy or additional observation

^† A toxic-appearing child, persistent otalgia more than 48 h, temperature ≥39°C (102.2°F) in the past 48 h, or if there is uncertain access to follow-up after the visit.

Observation

Due to the self-limited nature of most episodes of AOM (particularly in children 2 years and older), initial observation is advisable for selected patients if close follow-up can be ensured and rescue antibiotics administered for persistent or worsening symptoms in 48 to 72 hours.

Antibiotic Therapy

The rationale for antibiotic therapy in children with AOM is based on a high prevalence of bacteria from tympanocentesis cultures. A significant benefit of immediate antibiotic therapy is evident in bilateral AOM, AOM with severe symptoms, AOM with otorrhea, or Streptococcus pneumoniae infection.

When a decision to treat with antibiotics has been made, amoxicillin should be used if all of the following criteria are fulfilled:

• The patient has not received amoxicillin in the past 30 days.
• The patient does not have concurrent purulent conjunctivitis.
• The patient is not allergic to penicillin.

Additional β-lactamase coverage should be considered if any of the following criteria is fulfilled:

• The patient has received amoxicillin in the past 30 days.
• The patient has concurrent purulent conjunctivitis.
• The patient has a history of recurrent AOM unresponsive to amoxicillin.

High-dose amoxicillin is recommended as the first-line treatment in most patients.

Antibiotics Used in the Treatment of Otitis Media Preferred Regimen ▸ Amoxicillin 80 to 90 mg per kg per day, given orally in two divided doses Recurrent or persistent acute otitis media, those used amoxicillin, or antibiotics within the previous month, or with concurrent purulent conjunctivitis ▸ Amoxicillin-clavulanate 90 mg of amoxicillin per kg per day; 6.4 mg of clavulanate per kg per day, given orally in two divided doses For patients with penicillin allergy ▸ Azithromycin 30 mg per kg, given orally one dose For recurrent acute otitis media ▸ Azithromycin 20 mg per kg once daily, given orally x 3 days For penicillin allergy type 1 hypersensitivity ▸ Azithromycin 5 to 10 mg per kg once daily, given orally x 5 days For patients with penicillin allergy excluding type 1 hypersensitivity ▸ Cefdinir 14 mg per kg per day, given orally in one or two doses OR ▸ Cefpodoxime 30 mg per kg once daily, given orally OR ▸ Ceftriaxone 50 mg per kg once daily, IM or IV. One dose for initial episode of otitis media, three doses for recurrent infections OR ▸ Cefuroxime 30 mg per kg per day, given orally in two divided doses OR ▸ Clarithromycin 15 mg per kg per day, given orally in three divided doses OR ▸ Clindamycin 30 to 40 mg per kg per day, given orally in four divided doses

Topical agents ▸ ciprofloxacin/dexamethasone 3 drops twice daily OR ▸ Ofloxacin 5 drops twice daily (10 drops in patients older than 12 years) OR ▸ Hydrocortisone/neomycin/polymyxin B 4 drops three to four times daily

Analgesics ▸ Acetaminophen 15 mg per kg every six hours OR ▸ Ibuprofen 10 mg per kg every six hours OR ▸ Antipyrine/benzocaine 2 to 4 drops three to four times daily