Otitis Media Acute Treatment

Aka: Otitis Media Acute Treatment, Acute Otitis Media Management

1. See Also
   1. Acute Otitis Media
   2. Otitis Media Diagnosis
   3. Observation Protocol for Acute Otitis Media Management
   4. Otitis Media Acute Treatment
   5. Otitis Media Prophylaxis
   6. Otalgia
2. Precautions: Pitfalls
   1. Antihistamines and Decongestants are not useful
   2. Antibiotic dosages are often too low
   3. Most Otitis Media cases over age 2 years resolve without antibiotics
   4. Alert patient families that child may have fever and Ear Pain for 48-72 hours despite antibiotics
      1. However, return for Vomiting, high fever, Headache, pain over mastoid bone
3. Risk factors: Treatment Failure
   1. Otitis Media within the last month
   2. Antibiotic within the last month
   3. Day Care attendance
   4. Bilateral Otitis Media
   5. Age less than 2 years old
   6. Age at first Otitis Media less than 6 months old
   7. Over 3 episodes Acute Otitis Media in last 6 months
   8. Beta-Lactamase producing H. Influenzae or M. catarrhalis
4. Management: General
   1. Treat Otalgia with Acetaminophen and Ibuprofen
   2. No FDA approved topical anesthetics are available as of 2019
      1. With an intact drum, some providers use topical Lidocaine 0.5% or other Lidocaine preparations
      2. Mösges (2010) Arzneimittelforschung 60(7):427-31 +PMID: 20712132 [PubMed]
   3. Recheck ear exam in 3 months to confirm clearance of middle ear effusion (see below)
5. Protocol: Observation Protocol
   1. See Observation Protocol for Acute Otitis Media Management
   2. Strongly consider observation <48 hours of symptoms
      1. Age over 2 years OR
      2. Age 6-24 months if no severe symptoms
   3. Antibiotics have few benefits beyond Placebo for ages 2-12 years old with middle ear infection
      1. Otitis Media Diagnosis is highly inaccurate
         1. Asher (2005) Acta Pediatr 94(4): 423-8 [PubMed]
      2. No significant reduction in pain at 24 hours and 2 weeks compared with Placebo
         1. Antibiotics are also associated with adverse effects (Diarrhea, Vomiting, rash)
         2. Venekamp (2015) Cochrane Database Syst Rev (6):CD000219 [PubMed]
      3. Initial antibiotics (versus observation, expectant management) does not reduce Otitis Media complication rates
         1. No difference in Tympanometry at 4 weeks
         2. Marginal difference in Tympanic Membrane Perforation (NNT 33 with antibiotics)
         3. No difference in Otitis Media recurrence
         4. No proven reduction in Mastoiditis
         5. Grossman (2016) Pediatr Infect Dis 25(2): 162-5 [PubMed]
6. Protocol: No Penicillin or Cephalosporin allergy
   1. Antibiotic duration
      1. Age under 2 years: 10 day course
      2. Age 2 to 5 years: 7 day course
      3. Age >5 years: 5 day course (if severe symptoms, use 7 day course)
   2. First Line
      1. Amoxicillin 80-90 mg/kg/day PO divided twice daily for 10 days
         1. Dose up to 1000 mg three times daily
      2. If Penicillin Allergy
         1. Use Cefdinir (Omnicef) or Azithromycin (higher Antibiotic Resistance rates)
         2. May consider other Cephalosporins from second-line list below
            1. Move to third-line therapy if persistent severe findings after 48-72 hours of antibiotics
         3. If unable to use Cephalosporins (due to allergy)
            1. Use alternative agents as shown below (e.g. Azithromycin)
      3. Indications for moving to second-line treatment
         1. Persistent symptoms with bulging, erythematous TM after 48-72 hours on first-line treatment
         2. Antibiotics in last 30 days
         3. Concurrent Otitis Media with purulent Conjunctivitis
   3. Second Line (10 day course)
      1. Amoxicillin with clavulanate (Augmentin) 90 mg/kg/day divided twice daily for 10 days (preferred)
         1. Dose up to 2000/125 mg of XR orally twice daily
      2. Cefdinir (Omnicef) 14 mg/kg/day divided one to two times daily for 10 days (preferred in Penicillin allergic)
         1. Dose up to 300 mg every 12 hours or 600 mg every 24 hours
      3. Cefuroxime (Zinacef, Ceftin) 30 mg/kg/day divided twice daily (up to 500 mg twice daily) for 10 days
      4. Cefprozil (Cefzil) 30 mg/kg/day divided twice daily (up to 500 mg twice daily) for 10 days
      5. Cefpodoxime (Vantin) 10 mg/kg divided twice daily (up to 200 mg twice daily) for 10 days
   4. Third Line
      1. Strongly consider Tympanocentesis for Bacterial culture
      2. Ceftriaxone (Rocephin) 50 mg/kg IM daily for 3 days
      3. Clindamycin 30-40 mg/kg/day divided four times daily for 10 days
         1. Fails to cover HaemophilusInfluenzae
7. Protocol: Agents if Penicillin and Cephalosporin Allergy
   1. Consider Tympanocentesis
   2. Clindamycin (Cleocin) 30-40 mg/kg/day (max 1800 mg) divided four times daily for 10 days
   3. Macrolide antibiotics (High Bacterial resistance rate)
      1. Erythromycin
      2. Clarithromycin (Biaxin) 15 mg/kg/day divided twice daily for 10 days
      3. Azithromycin (Zithromax)
         1. One dose of Azithromycin XR (Zmax) at 30 mg/kg (up to 1500 mg) or
         2. Three days of Azithromycin at 20 mg/kg/day once daily (up to 500 mg/day) or
            1. This high dose approached Augmentin efficacy in one study
            2. Arrieta (2003) Antimicrob Agents Chemother 47:3179 [PubMed]
         3. Azithromycin 10 mg/kg (max: 500 mg) day 1, then 5 mg/kg/day (max 250 mg) for 5 days
   4. Fluoroquinolones (avoid under age 16 years)
      1. Levofloxacin (Levaquin) 20 mg/kg/day divided twice daily up to 750 mg every 24 hours
      2. Moxifloxacin (Avelox) 400 mg orally every 24 hours
8. Protocol: Topical agents if patent Tympanostomy Tubes
   1. See Tympanostomy Tube
   2. Do not use Cipro HC Otic (not sterile)
   3. Avoid all cortisporin products (including suspension)
   4. Combinations with steroid result in faster resolution but are much more expensive
   5. Ofloxacin 0.3% (Floxin Otic) 5 drops (10 drops if over age 12) twice daily for 7 days
   6. Ciprofloxacin ophthalmic (ciloxan drops) 4 drops twice daily for 7 days
   7. Ciprofloxacin 0.3% with Dexamethasone 0.1% (Ciprodex) 4 drops in ear twice daily for 7-10 days
   8. Ciprofloxacin 0.3% with Fluocinolone Acetonide 0.025% (Otovel) 0.25 ml vial in ear twice daily for 7 days
9. Follow-up: Persistent Middle Ear Effusion (Otitis Media with Effusion)
   1. Natural course
      1. At 2 weeks: 70% have persistent effusion
      2. At 4 weeks: 40%
      3. At 2 months: 20%
      4. At 3 months: 10%
   2. Persistent effusion at 3 months
      1. See Otitis Media with Effusion
      2. Consider otolaryngology Consultation (including consideration for Tympanostomy Tube)
      3. If Tympanostomy Tubes not placed, recheck effusion every 3 months
10. Precautions: Higher risk populations
    1. Infants under 8 weeks of age
       1. Associated with increased complications from Otitis Media
       2. Otitis Media in age <8 weeks may be complicated by Sepsis, Meningitis, Mastoiditis
       3. All febrile infants under 4 weeks undergo Neonatal Sepsis evaluation (regardless of Otitis Media presense)
          1. Infants <2 weeks commonly have GBS, Gram Negative Bacteria and Chlamydia trachomatis in middle ear
    2. Adults with recurrent otitits media (>2 episodes/year) or persistent Otitis Media (>6 weeks)
       1. Consider mechanical obstruction
       2. Consider naspharyngeal mass (especially blocking the eustachian tube)
11. Prevention
    1. Prevnar 13Vaccine
    2. Influenza Vaccine
    3. Breast Feeding
    4. Avoid Tobacco smoke exposure
    5. Avoid propped bottles
    6. Reduce or eliminate Pacifier use in age >6 months old
12. References
    1. (2019) Sanford Guide, accessed on IOS 11/19/2019
    2. (2016) Presc Lett 23(12): 68
    3. Aronovitz (2000) Clin Ther 22:29-39 [PubMed]
    4. Culpepper (1997) JAMA 278:1643-5 [PubMed]
    5. Del Mar (1997) BMJ 314:1526-9 [PubMed]
    6. Dowell (1998) Am Fam Physician 58:1113-23 [PubMed]
    7. Gaddey (2019) Am Fam Physician 100(6): 350-6 [PubMed]
    8. Harmes (2013) Am Fam Physician 88(7):435-40 [PubMed]
    9. Hoppe (1998) Am J Health Syst Pharm 55:1881-97 [PubMed]
    10. Lieberthal (2013) Pediatrics 131(3): e964-99 [PubMed]
    11. Pichichero (2000) Ann Otol Rhinol Laryngol 109:2-10 [PubMed]
    12. Pichichero (2000) Am Fam Physician 61(8):2410-6 [PubMed]