Sandbox:Otitis media medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]; Shanshan Cen, M.D. [3]; Mohamed Moubarak, M.D. [4]; Luke Rusowicz-Orazem, B.S.

Overview

The mainstay of therapy for acute otitis media (AOM) is antimicrobial therapy. High-dose Amoxicillin is the drug of choice for initial antibiotic therapy; high-dose Amoxicillin-Clavulanate or intramuscular Ceftriaxone should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours. Antimicrobial agents 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. . The optimal duration of antibiotics remains uncertain: a 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively. 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. Otalgia is generally managed with Acetaminophen, Ibuprofen, or narcotic analgesics with Codeine.

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.

Rationale for Antibiotic Therapy Choice

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 most evident in bilateral AOM, AOM with severe symptotms, AOM with otorrhea, or Streptococcus pneumoniae infection. Antibiotic therapy is recommended in the following settings:

• AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours, or temperature 39°C [102.2°F] or higher)
• Bilateral AOM in children younger than 24 months without severe signs or symptoms

When a decision to treat with antibiotics has been made, high-dose amoxicillin is recommended 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.

Duration of Therapy

• Standard 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms.
• In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively.

Antibiotic Regimens

Initial (Immediate or Delayed) Antibiotic Treatment

• Preferred Regimen
  • Amoxicillin 80–90 mg/kg/d bid OR Amoxicillin 90 mg/kg/d with Clavulanate 6.4 mg/kg/d
• Alternative Regimen (if allergic to penicillin)
  • Cefdinir 14 mg/kg/d qd or bid OR Cefuroxime 30 mg/kg/d bid OR Cefpodoxime 10 mg/kg/d bid OR Ceftriaxone 50 mg/kg IM/IV qd

After Failure of Initial Antibiotic Treatment

• Preferred Regimen
  • Amoxicillin 90 mg/kg/d with Clavulanate 6.4 mg/kg/d OR Ceftriaxone 50 mg/kg IM/IV qd
• Alternative Regimen
  • Clindamycin 30–40 mg/kg/d tid ± 3° Cephalosporin ± Tympanocentesis

Pain Management

Episodes of AOM are commonly associated with otalgia, managed by the following:

• Acetaminophen
• Ibuprofen
• Narcotic
• Codeine
  • Should be used with caution in the treatment of severe otalgia due to the risk of respiratory depression, altered mental status, gastrointestinal upset, and constipation.

Antimicrobial regimens

• Acute otitis media

• 1. Causative pathogens

• Streptococcus pneumoniae
• Hemophilus influenzae
• Moraxella catarrhalis
• Polymicrobial
• Viral

• 2. Empiric antimicrobial therapy

• Preferred regimen: Amoxicillin 40–90 mg/kg/day PO q12h OR Amoxicillin-Clavulanate 90/6.4 mg/kg/day PO q12h
• Alternative regimen: Cefdinir 14 mg/kg/day PO q12 or q24h OR Cefuroxime 30 mg/kg/day PO q12h OR Cefpodoxime 10 mg/kg/day PO q12h OR Ceftriaxone 50 mg/kg/day IM or IV q24h
• Note: Amoxicillin-Clavulanate may be considered in patients with recent Amoxicillin intake or concomitant conjunctivitis. Alternative regimens should be considered in patients with Penicillin allergies. Re-evaluate after 2-3 days for treatment response.

• 3. Special considerations

• 3.1 Acute otitis media post-treatment failure (48-72 hours)

• Preferred regimen: Amoxicillin-Clavulanate 90/6.4 mg/kg/day PO q12h OR Ceftriaxone 50 mg/kg/day IM or IV q24h
• Alternative regimen: Clindamycin 30–40 mg/kg/day PO q8h ± (Cefdinir 14 mg/kg/day PO q12 or q24h OR Cefuroxime 30 mg/kg/day PO q12h OR Cefpodoxime 10 mg/kg/day PO q12h OR Ceftriaxone 50 mg/kg/day IM or IV q24h)

• 3.2 Acute otitis media post-intubation

• Preferred regimen: Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q12h OR Imipenem 0.5 g IV q6h OR Meropenem 500 mg IV q8h OR Piperacillin-Tazobactam 4–6 g IV q4–6h OR Ticarcillin-Clavulanate 3 g IV q4h OR Ciprofloxacin 400 mg IV q12h OR Ciprofloxacin 750 mg PO q12h