Our approach to antibiotic therapy for acute otitis media in children

AOM: acute otitis media; IgE: immunoglobulin E; SJS: Stevens-Johnson syndrome; TEN: toxic epidermal necrolysis; ID: infectious diseases; TM: tympanic membrane; NTHi: nontypeable Haemophilus influenzae.

* We provide initial antibiotic treatment for AOM in infants <6 months, children 6 months to 2 years with unilateral or bilateral AOM of any severity, and children ≥2 years who appear toxic, have persistent ear pain for >48 hours, had temperature ≥102.2°F (39°C) in the past 48 hours, have bilateral AOM or otorrhea, or have uncertain access to follow-up. Other experts support initial observation for children 6 months to 2 years with unilateral AOM and mild symptoms (ie, mild ear pain for <48 hours and temperature <102.2°F [39°C]).

¶ Refer to UpToDate content on penicillin allergy for details.

Δ Beta-lactam antibiotics include penicillins, cephalosporins, cephamycins (cefoxitin, cefotetan), carbapenems, aztreonam, and beta-lactamase inhibitors (clavulanate, sulbactam, tazobactam).

◊ Refer to UpToDate content on treatment of AOM in children for doses.

§ These agents have less activity against penicillin-resistant S. pneumoniae than amoxicillin or amoxicillin-clavulanate.

¥ Cefuroxime has less activity against beta-lactamase-producing NTHi than amoxicillin-clavulanate.

‡ Tympanocentesis, if available, will provide pain relief and permit culture and susceptibility testing to guide antimicrobial selection. If tympanocentesis is not available, we suggest oral levofloxacin (if not used previously).

• For amoxicillin, amoxicillin-clavulanate, clarithromycin, oral cephalosporins, clindamycin, and levofloxacin:
  • 10 days for children <2 years, TM perforation, or recurrent AOM
  • 5 to 7 days for children ≥2 years, no TM perforation, and no history of recurrent AOM
• For ceftriaxone: 1 to 3 doses, depending upon persistence of symptoms

** Levofloxacin should be reserved for children with AOM refractory to other drugs, ideally only for children who have levofloxacin-susceptible S. pneumoniae type 19A isolated from the middle ear.