Initiate Appropriate Treatment
Key Points:
- It is recommended that children with low risk be treated with a wait-and-see approach.
- If antibiotic treatment is necessary, it is recommended that amoxicillin be the initial treatment.
Treatment Options for Acute Otitis Media
Watch and Wait
Low-risk children six months to two years without severe disease and an uncertain diagnosis should be treated with oral and topical analgesics and may be observed for 48 to 72 hours. If symptoms do not resolve or are worse, child should be rechecked and/or antibiotics prescribed. Parents may be provided with a prescription at the initial visit and advised to wait 48 hours, filling the prescription only if symptoms worsen or do not improve [A]. Clinicians must be available to communicate with parents regarding child's symptoms during the observation time. The opportunity to share decision-making for treatment can lead to higher parental satisfaction
[A].
Low-risk children are defined as otherwise healthy, do not attend day care, and have had no prior ear infections within the last month.
Severe disease is defined as fever greater than or equal to 39 degrees Celsius in the past 24 hours and moderate to severe otalgia. A diagnosis of acute otitis media meets any of the following criteria: sudden onset of symptoms, signs of middle-ear effusion, and signs and symptoms of middle-ear inflammation [R].
Antibiotic Treatment
When antibiotics are necessary, the drug used for initial treatment is amoxicillin. Reasons for using amoxicillin include safety, effectiveness, well tolerated and reasonably priced [M].
Low-dose amoxicillin (40 mg/kg/day) may be used if low risk (greater than two years, no day care, and no antibiotics for the past three months) and high dose (80 mg/kg/day) may be used if not low risk or for resistant acute otitis media if the lower dose was used initially [R]./p>
Indications for using another medication include:
- Failure to respond to initial treatment drug (resistant or persistent acute otitis media)
- History of lack of response to initial treatment drug (failure of medication on at least two occasions in the current respiratory season)
- Hypersensitivity to initial treatment medications
- Presence of resistant organism determined by culture
- Coexisting illness requiring a different medication
Other recommended treatment medications include (check the health plan formulary listing for currently available medications):
- Amoxicillin/clavulanate potassium
- Cefuroxime axetil
- Ceftriaxone sodium: prescribe one dose for new onset otitis media and a three-day course for a truly resistant pattern of otitis media or if oral treatment cannot be given
- Cefprozil
- Loracarbef
- Cefdinir
- Cefixime
- Cefpodoxime proxetil
Other treatment medications that are currently used but are not as strongly supported in the literature are listed below. These medications are not recommended when the patient has failed a course of amoxicillin.
- Trimethoprim sulfa
- Clarithromycin
- Erythromycin ethylsuccinate and sulfisoxazole acetyl
- Azithromycin
Several studies have shown that a single dose of ceftriaxone 50 mg/kg is equivalent to a 10-day course of oral antibiotics for new cases of acute otitis media. No further doses of oral antibiotic are needed following ceftriaxone. This should be reserved for special cases to prevent the more widespread emergence of resistant organisms. This treatment is indicated primarily for patients with compliance problems similar to intramuscular (IM) penicillin in streptococcal pharyngitis.
For persistent acute otitis media, a daily dose of ceftriaxone for three to five days is also an option and does not need additional oral antibiotics. This would be an option prior to referral to an ear, nose and throat physician for persistent acute otitis media if the patient failed on several second-line antibiotics [A, D].
Treatment of Resistant Acute Otitis Media
Resistant acute otitis media is defined as persistence of moderately severe symptoms (pain and fever) after three to five days of antibiotic therapy with findings of continued pressure and inflammation (bulging) behind the tympanic membrane. A second antibiotic should be chosen; the alternative first-line medication may be an appropriate choice. (Referral to ear, nose and throat specialist may be indicated if significant pain and fever continue for four to five days on the second medication or if complications of otitis media occur.)
The Drug-Resistant-Streptococcus pneumoniae (DRSP) Therapeutic Working Group, convened by the Centers for Disease Control and Prevention, has stated the following. Agents selected for alternative therapy for true clinical treatment failures should meet two criteria: they should be effective against beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis and they should be effective against S. pneumoniae including most drug-resistant-Streptococcus pneumoniae [A, M].
Treatment of Persistent Acute Otitis Media
Persistent acute otitis media is defined as continued findings of acute otitis media present within six days of finishing a course of antibiotics. A second course of therapy with a different antibiotic is indicated for persistent acute otitis media [R].
Research has shown that only 20% to 30% of ear infections require treatment with antibiotics. In Britain and the Netherlands, antibiotics are currently used much less frequently for acute otitis media, and patients are often treated symptomatically. The traditional approach in the United States is to treat acute ear infections since there is currently no predictor of those infections that will self-resolve [R, C].
Observation may be considered if there are mild symptoms and findings on exam. Parents should be carefully instructed to watch for escalating symptoms. These options should be discussed fully with the parent and/or patient; observation requires that they be comfortable with the plan and capable of the required observation and follow-up
[M].