Treatment Guideline Chart
Otitis media is a general term used to describe inflammation of the middle ear which may be caused by an acute infection.
The symptoms are usually nonspecific and include otalgia (pulling of ear in an infant), irritability, otorrhea with or without fever.
Symptoms of upper respiratory tract infection may also be present

Otitis%20media%20-%20acute%20(pediatric) Treatment

Principles of Therapy

  • Depending on the diagnostic certainty, patient’s age, illness severity and assurance of follow-up, selected patients may be treated with observation without antibiotic therapy
    • Placebo-controlled trials have shown that most patients improve without adverse consequences without antimicrobial therapy
  • An antibiotic prescription may be given to the guardian if patient’s symptoms worsen within 2-3 days or anytime during the observation period
Patients Who Should be Treated Initially with Antibiotics
  • <6 months old, with acute otitis media, regardless if with mild, moderate or severe symptoms
  • ≥6 months old, with either unilateral or bilateral acute otitis media (AOM), presenting with severe illness
    • Severe illness is considered if otalgia is moderate to severe for >48 hours or if fever ≥39°C (102.2°F)
  • ≥6 months old, with AOM, with otorrhea
  • 6-23 months old, with bilateral AOM, presenting with mild otalgia for <48 hours and fever <39°C, no otorrhea
  • 6-23 months old, with unilateral AOM, and presenting with non-severe illness (mild otalgia for <48 hours and fever <39°C), no otorrhea
  • >2 years old with severe bilateral AOM
  • ≥2 years old, with unilateral or bilateral AOM, with non-severe illness (mild otalgia for <48 hours and fever <39°C)
  • Recurrent otitis media
Patient Who May be Observed Initially (Ensure Follow-up)
  • ≥2 years old, with unilateral or bilateral uncomplicated AOM, with confirmed diagnosis, and presenting with non-severe illness (no otorrhea)
  • Back-up antibiotics may be considered for those with worsening symptoms or if no improvement is seen within 3 days
Patients Who have been Previously Treated with Antibiotics
  • Children previously treated with Amoxicillin within the last 30 days OR diagnosed with concurrent purulent conjunctivitis or with a history of recurrent AOM unresponsive to Amoxicillin, should be given antibiotics with beta-lactamase coverage
  • Shift to other antibiotics if child’s symptoms worsen or disease is unresponsive within 48-72 hours of treatment


Symptomatic Therapy


  • Eg Paracetamol (Acetaminophen), Ibuprofen
  • Considered the mainstay of pain relief for acute otitis media (AOM)
  • Effective analgesia for mild-moderate pain

Topical Agents

  • Eg Benzocaine, Lidocaine, Procaine
  • May provide temporary relief in patients >5 years old
Antibiotic Therapy
  • May help reduce the risk of hearing loss and eardrum perforation
Amoxicillin/High-dose Amoxicillin
  • Amoxicillin at sufficient doses is still considered the 1st-line agent for AOM
  • Recommended for pediatric patients without history of antibiotic intake within the last 30 days prior to administration of Amoxicillin
    • Child should be concurrent purulent conjunctivitis-free and without history of allergy to Penicillin
  • It is effective against most of the bacteria which cause AOM including susceptible and intermediate-resistant pneumococci
  • In areas where Penicillin-resistant pneumococci are common, high-dose Amoxicillin should be given
Amoxicillin/clavulanic acid (High Dose)
  • High doses of Amoxicillin combined with Clavulanic acid are recommended for patients who fail standard Amoxicillin therapy or in those who present with severe or recurrent illness
  • This combination will provide coverage for beta-lactamase producing organisms (eg H influenzae and M catarrhalis) along with Penicillin-resistant/nonsusceptible S pneumoniae
  • Effective against beta-lactamase producing bacterial strains (eg S pneumoniae, H influenzae and M catarrhalis)
  • Indicated for treatment of infections resistant to single therapy with beta-lactam or cephalosporins
Ceftriaxone (Intravenous [IV]/Intramuscular [IM])
  • May be considered in patients unable to take oral medications or if with treatment failure after 1st-line therapy
  • Treatment x 3 days is also recommended in patients who have failed Amoxicillin/clavulanic acid therapy and those with type I allergy to Penicillin
  • Has superior efficacy to S pneumoniae compared with alternative oral antibiotics
Cephalosporins (2nd and 3rd Generation)
  • Cefdinir, Cefixime, Cefpodoxime, Cefprozil and Cefuroxime are the preferred agents because of their effectiveness against drug-resistant S pneumoniae, H influenzae and M catarrhalis
  • Cefdinir, Cefpodoxime and Cefuroxime are highly unlikely to develop cross-reactivity to Penicillin
  • These agents may be considered in patients with non-type 1 hypersensitivity reaction to Penicillin
  • May be given to patients with type I allergy to Penicillin and those refractory to advanced antibiotic therapy
  • May be considered in a patient who has persistent AOM after previous complete antibiotic therapy and in whom tympanocentesis is not possible for Gram stain and culture
  • Clindamycin may be effective against Penicillin-resistant pneumococcal infection not responding to other treatment
  • Clindamycin is not active against H influenzae or M catarrhalis and should not be used if these organisms are suspected
Co-trimoxazole (Trimethoprim/Sulfamethoxazole)
  • Co-trimoxazole may be considered in patients with type 1 allergy to Penicillin
  • Used less frequently due to local S pneumoniae resistance patterns
  • Eg Azithromycin, Clarithromycin, Erythromycin
  • May be given to patients with type 1 allergy to Penicillin and those refractory to advanced antibiotic therapy
  • Less efficacy against S pneumoniae and H influenzae compared to Penicillin
    • Drug resistance to pneumococcus should be checked
  • Depending on local resistance patterns, may be preferred over Co-trimoxazole
Duration of Antibiotic Therapy
  • Optimal duration of antimicrobial therapy in AOM patients is uncertain; should depend on patient's age and disease severity
Patient <2 years old, severe illness or complicated presentation
  • Continue antibiotics x 10 days
Patient 2-5 years old, mild-moderate illness and uncomplicated presentation
  • Continue antibiotics x 7 days
Patient ≥6 years old, mild-moderate illness and uncomplicated presentation
  • Continue antibiotics x 5-7 days

Non-Pharmacological Therapy

Pain Management
  • Application of warm or cold compress on the affected ear may help alleviate pain
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