Otitis%20media%20-%20acute%20(pediatric) Treatment

• Depending on the diagnostic certainty, patient’s age, illness severity and assurance of follow-up, selected patients may be treated with observation without antibiotic therapy
  • Placebo-controlled trials have shown that most patients improve without adverse consequences without antimicrobial therapy
• An antibiotic prescription may be given to the guardian if patient’s symptoms worsen within 2-3 days or anytime during the observation period

• <6 months old, with acute otitis media, regardless if with mild, moderate or severe symptoms
• ≥6 months old, with either unilateral or bilateral acute otitis media (AOM), presenting with severe illness
  • Severe illness is considered if otalgia is moderate to severe for >48 hours or if fever ≥39°C (102.2°F)
• ≥6 months old, with AOM, with otorrhea
• 6-23 months old, with bilateral AOM, presenting with mild otalgia for <48 hours and fever <39°C, no otorrhea
• 6-23 months old, with unilateral AOM, and presenting with non-severe illness (mild otalgia for <48 hours and fever <39°C), no otorrhea
• >2 years old with severe bilateral AOM
• ≥2 years old, with unilateral or bilateral AOM, with non-severe illness (mild otalgia for <48 hours and fever <39°C)
• Recurrent otitis media

• ≥2 years old, with unilateral or bilateral uncomplicated AOM, with confirmed diagnosis, and presenting with non-severe illness (no otorrhea)
• Back-up antibiotics may be considered for those with worsening symptoms or if no improvement is seen within 3 days

• Children previously treated with Amoxicillin within the last 30 days OR diagnosed with concurrent purulent conjunctivitis or with a history of recurrent AOM unresponsive to Amoxicillin, should be given antibiotics with beta-lactamase coverage
• Shift to other antibiotics if child’s symptoms worsen or disease is unresponsive within 48-72 hours of treatment

Analgesics

• Eg Paracetamol (Acetaminophen), Ibuprofen
• Considered the mainstay of pain relief for acute otitis media (AOM)
• Effective analgesia for mild-moderate pain

Topical Agents

• Eg Benzocaine, Lidocaine, Procaine
• May provide temporary relief in patients >5 years old

• May help reduce the risk of hearing loss and eardrum perforation

• Amoxicillin at sufficient doses is still considered the 1st-line agent for AOM
• Recommended for pediatric patients without history of antibiotic intake within the last 30 days prior to administration of Amoxicillin
  • Child should be concurrent purulent conjunctivitis-free and without history of allergy to Penicillin
• It is effective against most of the bacteria which cause AOM including susceptible and intermediate-resistant pneumococci
• In areas where Penicillin-resistant pneumococci are common, high-dose Amoxicillin should be given

• High doses of Amoxicillin combined with Clavulanic acid are recommended for patients who fail standard Amoxicillin therapy or in those who present with severe or recurrent illness
• This combination will provide coverage for beta-lactamase producing organisms (eg H influenzae and M catarrhalis) along with Penicillin-resistant/nonsusceptible S pneumoniae

• Effective against beta-lactamase producing bacterial strains (eg S pneumoniae, H influenzae and M catarrhalis)
• Indicated for treatment of infections resistant to single therapy with beta-lactam or cephalosporins

• May be considered in patients unable to take oral medications or if with treatment failure after 1st-line therapy
• Treatment x 3 days is also recommended in patients who have failed Amoxicillin/clavulanic acid therapy and those with type I allergy to Penicillin
• Has superior efficacy to S pneumoniae compared with alternative oral antibiotics

• Cefdinir, Cefixime, Cefpodoxime, Cefprozil and Cefuroxime are the preferred agents because of their effectiveness against drug-resistant S pneumoniae, H influenzae and M catarrhalis
• Cefdinir, Cefpodoxime and Cefuroxime are highly unlikely to develop cross-reactivity to Penicillin
• These agents may be considered in patients with non-type 1 hypersensitivity reaction to Penicillin

• May be given to patients with type I allergy to Penicillin and those refractory to advanced antibiotic therapy
• May be considered in a patient who has persistent AOM after previous complete antibiotic therapy and in whom tympanocentesis is not possible for Gram stain and culture
• Clindamycin may be effective against Penicillin-resistant pneumococcal infection not responding to other treatment
• Clindamycin is not active against H influenzae or M catarrhalis and should not be used if these organisms are suspected

• Co-trimoxazole may be considered in patients with type 1 allergy to Penicillin
• Used less frequently due to local S pneumoniae resistance patterns

• Eg Azithromycin, Clarithromycin, Erythromycin
• May be given to patients with type 1 allergy to Penicillin and those refractory to advanced antibiotic therapy
• Less efficacy against S pneumoniae and H influenzae compared to Penicillin
  • Drug resistance to pneumococcus should be checked
• Depending on local resistance patterns, may be preferred over Co-trimoxazole

• Optimal duration of antimicrobial therapy in AOM patients is uncertain; should depend on patient's age and disease severity

• Continue antibiotics x 10 days

• Continue antibiotics x 7 days

• Continue antibiotics x 5-7 days

• Application of warm or cold compress on the affected ear may help alleviate pain