The recommendations are not intended for treating children <6 months of age or for those with craniofacial abnormalities, immunocompromising conditions, tympanostomy tubes or recurrent acute otitis media (AOM).
Most likely pathogens
Children greater than 2 years of age if no known complications: 5 days
Children less than 2 years of age, frequent, recurrent AOM, perforation or failed initially: 10 days
AOM presents with recent (one to several days) onset of symptoms. Often, especially in pre-verbal children, these
symptoms are non-specific (such as fever, crying or irritability) and can be similar to other viral or bacterial infections.
Therefore, diagnosis rests on a detailed examination of the middle ear to identify whether or not there is probable bacterial
infection in the middle ear, irrespective of the presence of fever at time of presentation.
» The two required criteria for AOM are:
1) Presence of a middle ear effusion as evidenced by:
» a full or bulging tympanic membrane (TM) -OR-
» loss of bony landmarks or presence of an air-fluid level on the TM -OR-
» absent or significant decreased motility of the TM with a pneumatic otoscope
2) Signs of inflammation in the middle ear:
» distinct intense erythema or hemorrhagic patches over a bulging TM -OR-
» yellow TM
» An acutely ruptured TM in the setting of acute otitis media should always be presumed to be caused by a bacteria
(usually Group A streptococcus) and treated with antimicrobials. A bacterial culture should be done if pus is present in
the ear canal.
» AOM should be distinguished from chronic suppurative otitis media (>3 weeks of painless otorrhea without acute
symptoms) through a previously ruptured TM or a myringotomy tube. In these cases, cultures of the fluid should be
obtained to direct therapy. Topical therapy or systemic therapy can be prescribed empirically depending on the clinical
severity of illness pending culture results. If symptoms persist despite treatment, children should be referred to
otolaryngology as there is a risk of chronic mastoiditis.
DECIDING WHO REQUIRES IMMEDIATE TREATMENT WITH ANTIBIOTICS:
» AOM associated with mild symptoms will often resolve spontaneously and should not be unnecessarily treated with
antibiotics. Overuse of antibiotics for this condition could lead to an increase in bacterial resistance and may subject the
child to unnecessary side effects from antibiotics.
» Children > 6 months who are mildly ill (e.g. alert, responsive, responding well to analgesia) with illness that is of short
duration (<48 hours), with a temperature <39◦ C, can be observed for 24 - 48 hrs to see if symptoms resolve on their
own. Ensure dialogue with caregivers to discuss monitoring and ongoing care or follow-up with a healthcare provider.
MODERATE OR SEVERE SYMPTOMS
The following are not likely to respond to conservative measure and should be treated with antibiotics to relieve symptoms
and prevent complications:
» Children who are moderately or severely ill (e.g. difficulty sleeping, severe pain, temperature ≥39◦ C, poor feeding
and/or irritable) or who have already been ill for >48 hours.
» Children who have an acutely perforated TM (pus noted in the ear canal or perforation seen on examination) should
be treated with antibiotics. Most of these cases will be caused by S. pyogenes (Group A streptococci) but a culture of
the fluid from the ear is useful to direct therapy, especially if they have received prior antibiotics and infection is
TREATMENT OF INITIAL, UNCOMPLICATED AOM
» There is NO evidence to support the use of topical antibiotics for treatment of acute AOM as they do not provide an
added benefit even in the setting of an acute perforation. If there is chronic drainage, the diagnosis of chronic
suppurative otitis media must be considered.
» It is important to manage the child’s pain while treatment is underway: ibuprofen is preferred (10 mg/kg/dose every
6 hours; max 4 doses per day). Second line treatment of oral acetaminophen (15 mg/kg/dose every 4 hours; max 4
doses per day). With effective treatment of AOM, most children will not need pain medication beyond 24-36 hours.
» Since most cases of AOM are due to S. pneumoniae and Group A streptococci, amoxicillin is the drug of choice as
initial treatment. Amoxicillin achieves good concentrations in the middle ear when given at recommended doses.
Amoxicillin 75-90 mg/kg/24h PO divided q12h
Maximum: 3 grams/24h
Amoxicillin 45-60 mg/kg/24h PO divided q8h
Maximum: 3 grams/24h
For patients who fail to respond to therapy with Amoxicillin:(ie no significant improvement after 2-3 days) or present with otitis-conjunctivitis syndrome
Children who have bacterial AOM should be at least somewhat better within 24 hours
Verify diagnosis and ensure that no complications have developed. Discontinue amoxicillin and start amoxicillin/clavulanate (7:1 formulation)
Amoxicillin-Clavulanate 45-60 mg/kg/24h PO divided q8h (dosing based on amoxicillin component) [using the 80 mg/mL (7:1) formulation only]
If the patient has NOT had a previous IgE mediated reaction to amoxicillin:
Cefprozil 30 mg/kg/24h PO divided q12h
Maximum: 1 gram/24h
If IgE-mediated amoxicillin allergy (anaphylaxis, hypotension, urticarial and/or angioedema)
Cefuroxime axetil 30 mg/kg/24h PO divided q8h-q12h (Streptococcus Pneumoniae is increasingly becoming resistant to macrolides)
Maximum: 1 gram/24h