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Otitis Media Acute Treatment
Aka: Otitis Media Acute Treatment, Acute Otitis Media Management
- See Also
- Acute Otitis Media
- Otitis Media Diagnosis
- Observation Protocol for Acute Otitis Media Management
- Otitis Media Acute Treatment
- Otitis Media Prophylaxis
- Pitfalls
- Antihistamines and Decongestants are not useful
- Antibiotic dosages are often too low
- Risk factors: Treatment Failure
- Otitis Media within the last month
- Antibiotic within the last month
- Day Care attendance
- Bilateral Otitis Media
- Age less than 2 years old
- Age at first Otitis Media less than 6 months old
- Over 3 episodes Acute Otitis Media in last 6 months
- Protocol: Observation Protocol
- See Observation Protocol for Acute Otitis Media Management
- Strongly consider observation <48 hours of symptoms
- Age over 2 years OR
- Age 6-24 months if no severe symptoms
- Protocol: No Penicillin or Cephalosporin allergy
- Antibiotic duration
- Age under 2 years: 10 day course
- Age 2 to 5 years: 7 day course
- Age >5 years: 5 day course (if severe symptoms, use 7 day course)
- First Line
- Amoxicillin 80-90 mg/kg/day PO divided twice daily for 10 days
- If Penicillin Allergy
- Use Cephalosporins from second-line list below
- Move to third-line therapy if persistent symptoms and signs after 48-72 hours of antibiotics
- If unable to use Cephalosporins (due to allergy)
- Use alternative agents as shown below
- Indications for moving to second-line treatment
- Persistent symptoms with bulging, erythematous TM after 48-72 hours on first-line treatment
- Amoxicillin in last 30 days
- Concurrent Otitis Media with Conjunctivitis
- Second Line (10 day course)
- Amoxicillin with clavulanate (Augmentin) 90 mg/kg/day divided twice daily for 10 days
- Cefuroxime (Zinacef, Ceftin) 30 mg/kg/day divided twice daily for 10 days
- Cefprozil (Cefzil) 30 mg/kg/day divided twice daily for 10 days
- Cefdinir (Omnicef) 14 mg/kg/day divided one to two times daily fo 10 days
- Cefpodoxime (Vantin) 10 mg/kg divided twice daily for 10 days
- Third Line
- Strongly consider Tympanocentesis for Bacterial culture
- Ceftriaxone (Rocephin) 50 mg/kg IM daily for 3 days
- Clindamycin 30-40 mg/kg/day divided four times daily for 10 days
- Protocol: Agents if Penicillin and Cephalosporin Allergy
- Consider Tympanocentesis
- Clindamycin (Cleocin) 30-40 mg/kg/day (max 1800 mg) divided four times daily for 10 days
- Macrolide antibiotics (High Bacterial resistance rate)
- Erythromycin
- Clarithromycin (Biaxin) 15 mg/kg/day divided twice daily for 10 days
- Azithromycin (Zithromax)
- One dose of Azithromycin XR (Zmax) at 30 mg/kg (up to 1500 mg) or
- Three days of Azithromycin at 20 mg/kg/day once daily (up to 500 mg/day) or
- This high dose approached Augmentin efficacy in one study
- Arrieta (2003) Antimicrob Agents Chemother 47:3179 [PubMed]
- Azithromycin 10 mg/kg (max: 500 mg) day 1, then 5 mg/kg/day (max 250 mg) for 5 days
- Fluoroquinolones (avoid under age 16 years)
- Levofloxacin (Levaquin)
- Moxifloxacin (Avelox)
- Protocol: Topical agents if patent Tympanostomy Tubes
- Ciprofloxacin with Hydrocortisone (Cipro HC Otic) 3 drops twice daily for 7-10 days
- Ofloxacin (Floxin Otic) 5 drops (10 drops if over age 12) twice daily for 7-10 days
- Follow-up: Persistent Middle Ear Effusion (Otitis Media with Effusion)
- Natural course
- At 2 weeks: 70% have persistent effusion
- At 4 weeks: 40%
- At 2 months: 20%
- At 3 months: 10%
- Persistent effusion at 3 months
- See Otitis Media with Effusion
- Consider otolaryngology Consultation (including consideration for Tympanostomy Tube)
- If Tympanostomy Tubes not placed, recheck effusion every 3 months
- Precautions: Higher risk populations
- Infants under 8 weeks of age
- Associated with increased complications from Otitis Media
- All febrile infants under 4 weeks undergo Neonatal Sepsis evaluation (regardless of Otitis Media presense)
- Adults with recurrent otitits media (>2 episodes/year) or persistent Otitis Media (>6 weeks)
- Consider mechanical obstruction
- Consider naspharyngeal mass (especially blocking the eustachian tube)
- References
- (2016) Presc Lett 23(12): 68
- Aronovitz (2000) Clin Ther 22:29-39 [PubMed]
- Culpepper (1997) JAMA 278:1643-5 [PubMed]
- Del Mar (1997) BMJ 314:1526-9 [PubMed]
- Dowell (1998) Am Fam Physician 58:1113-23 [PubMed]
- Harmes (2013) Am Fam Physician 88(7):435-40 [PubMed]
- Hoppe (1998) Am J Health Syst Pharm 55:1881-97 [PubMed]
- Lieberthal (2013) Pediatrics 131(3): e964-99 [PubMed]
- Pichichero (2000) Ann Otol Rhinol Laryngol 109:2-10 [PubMed]
- Pichichero (2000) Am Fam Physician 61(8):2410-6 [PubMed]