Otitis%20media%20-%20acute%20(pediatric) Treatment
Principles of Therapy
- 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
Pharmacotherapy
Symptomatic Therapy
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
Non-Pharmacological Therapy
Pain Management
- Application of warm or cold compress on the affected ear may help alleviate pain