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Otitis Media Acute Treatment

See Also
1. Otitis Media Prophylaxis
Pitfalls
1. Antihistamines and Decongestants are not useful
2. Antibiotic dosages are often too low
Risk factors: Treatment Failure
1. Otitis Media within the last month
2. Antibiotic within the last month
3. Day Care attendance
4. Bilateral Otitis Media
5. Age less than 2 years old
6. Age at first Otitis Media less than 6 months old
7. Over 3 episodes Acute Otitis Media in last 6 months
Management: Observation protocol
1. Background
  1. Most Otitis Media cases resolve without antibiotics
  2. Consider symptomatic treatment
2. Indications for observation protocol
  1. No fever
  2. No Vomiting
  3. Parents willing to trial symptomatic therapy
3. Relative contraindications to observation protocol
  1. Three or more antibiotic courses in the current year
  2. Antibiotic course within the last 2 weeks
  3. Ear discharge
  4. Chronic Suppurative Otitis Media
4. Protocol
  1. Treat symptomatically for 3 days (see Otalgia for pain management)
  2. By day 3, outcomes same with or without antibiotics
    1. Distress: 19% (15% with antibiotics)
    2. Sleep disturbed 27% (20% with antibiotics)
  3. If still symptomatic at day 3 may start antibiotics
5. Efficacy
  1. Placebo: 81% of infections resolve within 1 week
  2. Antibiotics: 94% of infections resolve within 1 week
  3. Outcomes
    1. Middle ear fluid same at 3 months
    2. Mastoiditis
      1. Without antibiotics: 4 per 100,000 children/year
      2. With antibiotics: 2 per 100,000 children per year
6. References
  1. Hendley (2002) N Engl J Med 345:1169
  2. Little (2002) BMJ 325:22
Protocol: No Penicillin or Cephalosporin allergy
1. Antibiotic duration
  1. Age under 6 years
2. First Line
  1. Amoxicillin 80-90 mg/kg/day PO divided twice daily for 10 days (7 days if age>6)
  2. If Penicillin Allergy, use Macrolide (e.g. Azithromycin) as shown below
3. Second Line (10 day course)
  1. Amoxicillin with clavulanate (Augmentin) 90 mg/kg/day divided twice daily for 10 days
  2. Cefuroxime (Zinacef, Ceftin) 30 mg/kg/day divided twice daily for 10 days
  3. Cefprozil (Cefzil) 30 mg/kg/day divided twice daily for 10 days
  4. Cefdinir (Omnicef) 14 mg/kg/day divided one to two times daily fo 10 days
  5. Cefpodoxime (Vantin) 30 mg/kg once daily for 10 days
4. Third Line
  1. Strongly consider Tympanocentesis for bacterial culture
  2. Ceftriaxone (Rocephin) 50 mg/kg IM daily for 3 days
  3. Clindamycin 30-40 mg/kg/day divided four times daily for 10 days
Protocol: Agents if Penicillin and/or Cephalosporin Allergy
1. Consider Tympanocentesis
2. Clindamycin (Cleocin) 30-40 mg/kg/day (max 1800 mg) divided four times daily for 10 days
3. Macrolide antibiotics (High bacterial resistance rate)
  1. Erythromycin
  2. Clarithromycin (Biaxin) 15 mg/kg/day divided twice daily for 10 days
  3. Azithromycin (Zithromax)
    1. One dose of Azithromycin XR (Zmax) at 30 mg/kg (up to 1500 mg) or
    2. Three days of Azithromycin at 20 mg/kg/day once daily (up to 500 mg/day) or
      1. This high dose approached Augmentin efficacy in one study
      2. Arrieta (2003) Antimicrob Agents Chemother 47:3179
    3. Azithromycin 10 mg/kg (max: 500 mg) day 1, then 5 mg/kg/day (max 250 mg) for 5 days
4. Fluoroquinolones (avoid under age 16 years)
  1. Gatifloxacin (Tequin)
  2. Levofloxacin (Levaquin)
  3. Moxifloxacin (Avelox)
Protocol: Topical agents if patent Tympanostomy Tubes
1. Ciprofloxacin with Hydrocortisone (Cipro HC Otic) 3 drops twice daily for 7-10 days
2. Ofloxacin (Floxin Otic) 5 drops (10 drops if over age 12) twice daily for 7-10 days
Follow-up: Persistence of Middle Ear Effusion
1. At 2 weeks: 70% have persistent effusion
2. At 4 weeks: 40%
3. At 2 months: 20%
4. At 3 months: 10%
References

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 8/14/2009. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.