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Acute Otitis Media (AOM)

URI / Outpatient

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1. Clinical Syndrome

Middle-ear infection — bulging tympanic membrane with effusion + erythema + ear pain (or otorrhea from perforation), typically following or coincident with a viral URI. AAP 2013 diagnostic criteria for children require bulging TM or new otorrhea (mere erythema or effusion ≠ AOM).

Excludes: otitis media with effusion (OME — middle-ear fluid without acute infection, no antibiotics, watchful waiting), otitis externa ("swimmer's ear" — external canal, topical fluoroquinolone), mastoiditis (post-auricular swelling, escalation), bullous myringitis (often Mycoplasma — same drug + amox doesn't cover, consider macrolide). Adult AOM is uncommon; if recurrent / severe, evaluate for nasopharyngeal mass or eustachian dysfunction.

2. Pathogens

Consider the patient: Children 6 mo–6 y (peak incidence), recent URI, daycare attendance, parental smoking, supine bottle-feeding, cleft palate, Down syndrome.

Consider the case: Most AOM is viral (40–70%) and self-limited. Observation with delayed antibiotic is acceptable in 6 mo–2 y unilateral non-severe OR ≥2 y non-severe (AAP 2013) — give if no improvement in 48–72 h. Treat antibiotics upfront if: <6 mo, severe (T ≥39, severe pain, ≥48 h), bilateral in <2 y, otorrhea, immunocompromised, cleft palate, recurrent.

Common

Less common

3. Empiric Therapy

TierFirst choiceAlternativesDurationComments
Outpatient
  • 80–90 mg/kg/day · PO divided BID (max 1 g BID adult) · PO · 10 d (<2 y or severe / perforated), 7 d (2–5 y), 5–7 d (≥6 y)

    **High-dose** for pneumococcus PNSSP coverage. First-line if no β-lactamase risk.

  • 90 mg/kg/day amox component · PO divided BID · PO · 10 d (<2 y) or 7 d (older)

    **Preferred when β-lactamase suspected**: prior amox in 30 d, conjunctivitis-otitis syndrome (H. flu), recurrent AOM, severe. **Now first-line in many practices** given M. catarrhalis prevalence.

  • 10 mg/kg/day · PO divided BID · PO · 5–10 d depending on age

    Mild non-anaphylactic PCN allergy. Adult dose 200 mg BID.

  • 50 mg/kg/dose (max 1 g) IM · daily × 1–3 days · IM

    Treatment-failure or unable to tolerate PO. 1 dose for treatment-naive failure; 3 doses for treated AOM failure.

  • 10 mg/kg day 1, 5 mg/kg days 2–5 · PO daily · PO · 5 days

    True PCN anaphylaxis only — high macrolide resistance in pneumococcus (~30–40% in US); inferior. Doxycycline ≥8 y or clindamycin alternative; otherwise refer.

5–10 days (age-dependent)**Observation 48–72 h** (no antibiotics) acceptable for 6 mo–2 y unilateral non-severe AOM and ≥2 y non-severe AOM with reliable follow-up + analgesia. **Antibiotic upfront** if: <6 mo any AOM, severe (T ≥39, severe pain ≥48 h), bilateral <2 y, otorrhea, immunocompromised, cleft palate, recurrent. **Treat pain** in all (acetaminophen, ibuprofen, topical lidocaine drops if TM intact).

4. Directed Therapy

Treatment failure (no improvement at 48–72 h):

  • If on amoxicillin → switch to amox-clav (β-lactamase H. flu / Moraxella likely).
  • If on amox-clav → ceftriaxone 50 mg/kg IM × 3 d.
  • If on ceftriaxone → tympanocentesis with culture (ENT referral) — uncommon pathogen.

Mastoiditis (post-auricular swelling, fluctuance, displaced ear) → admit, IV ceftriaxone + vancomycin (MRSA), CT temporal bone, ENT consult — drainage if abscess.

TM perforation with otorrhea: treat as AOM (oral antibiotics) PLUS topical fluoroquinolone (ofloxacin or ciprodex drops) for 7 days.

5. Monitoring

Reassess at 48–72 h — improvement (less pain, less fever) expected; if not → switch antibiotics.

TM mobility / effusion can persist 4–12 weeks post-AOM — this is NOT treatment failure (it's the normal resolution course). Audiology at 3 months if effusion persists, especially bilateral, to monitor for hearing/speech impact.

Toxicity: amox-clav diarrhea (give with food, consider probiotic), C. diff risk (rare in peds), rash (often non-allergic viral exanthem in URI co-infection).

Pearls

Bulging TM is the key sign — erythema alone ≠ AOM, effusion alone ≠ AOM. Observation is appropriate for non-severe AOM in 6 mo–2 y unilateral and ≥2 y. High-dose amoxicillin (80–90 mg/kg/d) covers PNSSP. Amox-clav when β-lactamase risk (prior amox, conjunctivitis-otitis, severe, recurrent). Pain control is the most important intervention regardless of antibiotic choice. Macrolides are inferior in US due to pneumococcal resistance. Refer recurrent AOM to ENT for tubes.

References