Otitis Media - Acute Management

Consider expert referral if any of the following occurs: No response to second-line agents (tympanocentesis with Gram stain and culture is recommended); otitis media with effusion for ≥3 months with bilateral hearing loss ≥20 dB; two or more episodes in 6 months, and ≥4 episodes in 12 months; retracted tympanic membrane; subjective hearing loss persisting ≥1-2 weeks after resolution of infection and effusion; and tympanic membrane perforation ≥6 weeks.

Symptomatic Therapy

Analgesics

Example drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg Ibuprofen), Paracetamol

Analgesics are considered the mainstay of pain relief for acute otitis media and are effective for mild to moderate pain. Opioids may occasionally be indicated.

Antibiotic Therapy

There is no data regarding initially withholding antimicrobial therapy in adult patients with acute otitis media. This prevents the development of complications.

Amoxicillin/clavulanic acid

Amoxicillin/clavulanic acid is considered the first-line therapy for acute otitis media and may also be used in patients who fail standard Amoxicillin therapy. In patients with more severe infections, at high risk for severe infections with resistant S pneumoniae, >65 years old, immunocompromised, or who have used antibiotics in the past month, a higher dose of the Amoxicillin component should be used. This combination provides coverage for beta-lactamase-producing organisms (eg H influenzae and M catarrhalis along with Penicillin-resistant S pneumoniae).

Amoxicillin

If Amoxicillin/clavulanic acid or cephalosporins are not available or cost-prohibitive, Amoxicillin may be given as a first-line agent for acute otitis media. In patients with more severe infections, at high risk for severe infections with resistant S pneumoniae, >65 years old, immunocompromised, or have used antibiotics in the past month, high-dose Amoxicillin should be used. This is effective against most of the bacteria that cause acute otitis media, including susceptible and intermediate-resistant pneumococci.

Cephalosporins (Second and Third Generation)

Cefdinir, Cefpodoxime, Cefprozil and Cefuroxime are the preferred agents because of their effectiveness against drug-resistant S pneumoniae, H influenzae and M catarrhalis. These agents may be considered alternative first-line therapy in patients with non-type 1 hypersensitivity reactions to Penicillin.

Ceftriaxone (intravenous [IV] or intramuscular [IM]) may be considered in patients unable to take oral medications (eg vomiting). This is also recommended for 3 days in patients who fail Amoxicillin/clavulanic acid. This has superior efficacy against S pneumoniae compared with alternative oral antibiotics.

Clindamycin







Clindamycin may be considered in a patient who has persistent acute otitis media after previous completion of antibiotic therapy and in whom tympanocentesis is not possible for Gram stain and culture. This may be effective against Penicillin-resistant pneumococcal infection not responding to other treatment. This is not active against H influenzae or M catarrhalis and should not be used if these are suspected.

Co-trimoxazole

Co-trimoxazole may be considered in patients with type 1 allergy to Penicillin but use may be limited by local resistance patterns. This may be added to the regimen if methicillin-resistant S aureus is suspected.

Doxycycline

Doxycycline is an alternative for patients with a known severe allergy to beta-lactams or cephalosporins. This may be added to the regimen if methicillin-resistant S aureus is suspected.

Fluoroquinolones

Example drugs: Levofloxacin, Moxifloxacin

Fluoroquinolones may be considered as an alternative treatment for patients who failed initial treatment with Amoxicillin/clavulanic acid or for those with a known severe allergy to beta-lactams or cephalosporins.

Macrolides







Example drugs: Azithromycin, Clarithromycin, Erythromycin

Macrolides are a treatment option for patients who have contraindications to Doxycycline or fluoroquinolones. These are active against the major pathogens that cause acute otitis media but have decreased activity against drug-resistant S pneumoniae.

Duration of Antibiotic Therapy

The optimal duration of antimicrobial therapy in acute otitis media patients is uncertain. Antibiotics may be given for 5-7 days in mild to moderate illness and up to 10 days if severe.

Topical Therapy

There is currently no data to support the benefit of adding topical antibiotic therapy over oral antibiotics alone in treating acute otitis media. If topical antibiotics are considered, agents with known ototoxicity (eg aminoglycoside) should be avoided. 

Patient Education

Reassure the patient regarding the good long-term prognosis of acute otitis media. Advise smoking cessation. Advise patients with tympanic membrane perforation to observe water precautions such as avoidance of swimming or diving and prevention of getting water in the affected ear when bathing or showering until there is documented healing of the perforation.

Use of Analgesics

Discuss the regular use of analgesics until pain decreases. Pain must be addressed regardless of the need for antibacterial agents, especially in the first 24 hours of illness.

Use of Antibiotics

The patient should be made aware that in most cases, antibiotics do not improve prognosis. Review the risks such as side effects, or antibiotic resistance in the community. Educate the patient that antibiotics are recommended only in severe cases, in young patients, or if there is no improvement or worsening after 2-3 days of analgesics.