Acute Otitis Media in children - empiric therapy

Empiric Therapy Regimens

Empiric therapeutic regimens for acute otitis media in children are outlined below, including general recommendations, first- and second-line treatments, treatment for penicillin-allergic patients, and treatments for patients with recurrent illness or treatment failures.^{[1, 2, 3, 4, 5, 6, 7]}

General recommendations

Adequate pain and fever control with either oral acetaminophen or ibuprofen or topical pain control with topicalbenzocaine preparations is imperative whether antibiotics are given or not.

Age < 6mo:

• Should receive antibiotics whether the diagnosis of acute otitis media is certain or not

Age 6mo to 2y:

• Should receive antibiotics if the diagnosis is certain
• If the diagnosis is uncertain, an observation period can be considered if the illness is nonsevere

Age > 2y:

• Should receive antibiotics if the diagnosis is certain and if the illness is severe
• An observation period is advised if the diagnosis is uncertain or if it is certain and nonsevere

First-line treatment

• Amoxicillin 80-90 mg/kg/day PO (maximum 3 g/24h) divided BID for 5-7d; 10d may be required if illness is severe or
• Ceftriaxone 50 mg/kg IM × 1 dose (maximum 1 g); recommended for children unable to take antibiotics PO and for patients with compliance issues

Children with acute otitis media with tympanostomy tubes:

• Ciprofloxacin 0.3%/dexamethasone 0.1% otic solution 4 drops BID × 7d or
• Ofloxacin otic solution 5 drops BID × 10d

Second-line treatment

Penicillin allergic:

Non – type-1 hypersensitivity:

• Cefdinir 14 mg/kg/day (maximum 600 mg/24h) PO qd or divided BID for 5-10d or
• Cefpodoxime 10 mg/kg/day (maximum 400 mg/24h) PO qd or divided BID for 5-10d or
• Cefuroxime 30 mg/kg/day PO (maximum 1 g/24h) divided BID for 5-10d

Type-1 hypersensitivity:

• Azithromycin 10 mg/kg/day (maximum 500 mg) PO × 1 dose, then 5 mg/kg/day (maximum 250 mg/24h) PO qd × 4d or
• Azithromycin 10 mg/kg/day (maximum 500 mg/24h) PO qd × 3d or
• Clarithromycin 15 mg/kg/day (maximum 1 g/24h) PO divided BID for 5-10d

Recurrent acute otitis media/treatment failure

• Amoxicillin-clavulanate 90 mg/kg/day (based on amoxicillin component using ES formulation; maximum 4 g/24h) PO divided BID for 5-7d or
• Cefdinir 7 mg/kg q12h or 14 mg/kg q24h for 5-7d or
• Cefpodoxime 10 mg/kg/day as a single dose or
• Cefprozil 15 mg/kg q12h for 5-7d or
• Cefuroxime 30 mg/kg/day divided q12h for 5-7d or
• Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d

Persistent treatment failure

• Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d or
• Clindamycin 20-30 mg/kg/day divided QID for 5-7d