Guidelines for the Diagnosis and Treatment of Acute Otitis Media

Guidelines for the Diagnosis and Treatment of Acute Otitis Media

Illness Severity	Diagnostic Criteria	Treatment Recommendations
Mild to moderate	>2 yrs or 6 mo to 2 yrs without middle-ear effusion	Observation alone (deferring antibiotic therapy for 48-72 h and limiting management to symptom relief)
	<6 mo; or 6 mo to 2 yrs with middle-ear effusion (fluid in the middle ear, evidenced by decreased TM mobility, air/fluid level behind TM, bulging TM, purulent otorrhea) and acute onset of signs and symptoms of middle-ear inflammation, including fever, otalgia, decreased hearing, tinnitus, vertigo, erythematous TM; or >2 yrs with bilateral disease, TM perforation, high fever, immunocompromise, emesis	Initial therapy^a Amoxicillin, 80-90 mg/kg qd (up to 2 g) PO in divided doses (bid or tid); or Cefdinir, 14 mg/kg qd PO in 1 dose or divided doses (bid); or Cefuroxime, 30 mg/kg qd PO in divided doses (bid); or Azithromycin, 10 mg/kg qd PO on day 1 followed by 5 mg/kg qd PO for 4 d Exposure to antibiotics within 30 d or recent treatment failure^a,b: Amoxicillin, 90 mg/kg qd (up to 2 g) PO in divided doses (bid), plus clavulanate, 6.4 mg/kg qd PO in divided doses (bid); or Ceftriaxone, 50 mg/kg IV/IM qd for 3 d; or Clindamycin, 30-40 mg/kg qd PO in divided doses (tid)
Severe	As above, with temperature ≥39.0°C (102°F); or Moderate to severe otalgia	Initial therapy^a Amoxicillin, 90 mg/kg qd (up to 2 g) PO in divided doses (bid), plus clavulanate, 6.4 mg/kg qd PO in divided doses (bid); or Ceftriaxone, 50 mg/kg IV/IM qd for 3 d Exposure to antibiotics within 30 d or recent treatment failure^a,b Ceftriaxone, 50 mg/kg IV/IM qd for 3 d; or Clindamycin, 30-40 mg/kg qd PO in divided doses (tid); or Consider tympanocentesis with culture

Illness Severity

Diagnostic Criteria

Treatment Recommendations

Mild to moderate

>2 yrs or 6 mo to 2 yrs without middle-ear effusion

Observation alone (deferring antibiotic therapy for 48-72 h and limiting management to symptom relief)

<6 mo; or

6 mo to 2 yrs with middle-ear effusion (fluid in the middle ear, evidenced by decreased TM mobility, air/fluid level behind TM, bulging TM, purulent otorrhea) and acute onset of signs and symptoms of middle-ear inflammation, including fever, otalgia, decreased hearing, tinnitus, vertigo, erythematous TM; or

>2 yrs with bilateral disease, TM perforation, high fever, immunocompromise, emesis

Initial therapy^a

Amoxicillin, 80-90 mg/kg qd (up to 2 g) PO in divided doses (bid or tid); or

Cefdinir, 14 mg/kg qd PO in 1 dose or divided doses (bid); or

Cefuroxime, 30 mg/kg qd PO in divided doses (bid); or

Azithromycin, 10 mg/kg qd PO on day 1 followed by 5 mg/kg qd PO for 4 d

Exposure to antibiotics within 30 d or recent treatment failure^a,b:

Amoxicillin, 90 mg/kg qd (up to 2 g) PO in divided doses (bid), plus clavulanate, 6.4 mg/kg qd PO in divided doses (bid); or

Ceftriaxone, 50 mg/kg IV/IM qd for 3 d; or

Clindamycin, 30-40 mg/kg qd PO in divided doses (tid)

Severe

As above, with temperature ≥39.0°C (102°F); or Moderate to severe otalgia

Initial therapy^a

Amoxicillin, 90 mg/kg qd (up to 2 g) PO in divided doses (bid), plus clavulanate, 6.4 mg/kg qd PO in divided doses (bid); or

Ceftriaxone, 50 mg/kg IV/IM qd for 3 d

Exposure to antibiotics within 30 d or recent treatment failure^a,b

Ceftriaxone, 50 mg/kg IV/IM qd for 3 d; or

Clindamycin, 30-40 mg/kg qd PO in divided doses (tid);

Consider tympanocentesis with culture

^aDuration (unless otherwise specified): 10 days for pts <6 years old and pts with severe disease; 5-7 days (with consideration of observation only in previously healthy individuals with mild disease) for pts ≥6 years old.

^bFailure to improve and/or clinical worsening after 48-72 h of observation or treatment.

Abbreviation: TM, tympanic membrane.

Source: American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media, 2004.

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Table 58-2