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.[1] 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.[2] 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[3]
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.[4]

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[5][6]
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

References

  1. Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
  2. Venekamp, Roderick P.; Sanders, Sharon; Glasziou, Paul P.; Del Mar, Chris B.; Rovers, Maroeska M. (2013). "Antibiotics for acute otitis media in children". The Cochrane Database of Systematic Reviews. 1: –000219. doi:10.1002/14651858.CD000219.pub3. ISSN 1469-493X. PMID 23440776.
  3. Siddiq, Somiah; Grainger, Joe; Prentice, Philippa (2014-11-12). "The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013". Archives of Disease in Childhood. Education and Practice Edition. doi:10.1136/archdischild-2013-305550. ISSN 1743-0593. PMID 25395494.
  4. Rovers, Maroeska M.; Glasziou, Paul; Appelman, Cees L.; Burke, Peter; McCormick, David P.; Damoiseaux, Roger A.; Gaboury, Isabelle; Little, Paul; Hoes, Arno W. (2006-10-21). "Antibiotics for acute otitis media: a meta-analysis with individual patient data". Lancet. 368 (9545): 1429–1435. doi:10.1016/S0140-6736(06)69606-2. ISSN 1474-547X. PMID 17055944.
  5. Ramakrishnan K, Sparks RA, Berryhill WE (2007). "Diagnosis and treatment of otitis media". Am Fam Physician. 76 (11): 1650–8. PMID 18092706.
  6. Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.