Systemic antibiotics used for the initial treatment of acute otitis media in children

Antibiotic	Route	Dose	Maximum daily dose
First-line agents
Communities with increased prevalence of penicillin-nonsusceptible Streptococcus pneumoniae
Amoxicillin	Oral	90 mg/kg per day in 2 doses	3 g/day
Amoxicillin-clavulanate*^¶	Oral	Amoxicillin 90 mg/kg per day, clavulanate 6.4 mg/kg per day in 2 doses	3 g/day (amoxicillin component)
Extended release amoxicillin-clavulanate (for those age ≥16 years*^¶)	Oral	Amoxicillin 1 g, clavulanate 62.5 mg every 12 hours, or Amoxicillin 2 g, clavulanate 125 mg every 12 hours	4 g/day (amoxicillin component)
Communities with low prevalence of penicillin-nonsusceptible S. pneumoniae
Amoxicillin	Oral	40 mg/kg per day in 2 or 3 doses	3 g/day
Amoxicillin-clavulanate*^¶	Oral	Amoxicillin 40 mg/kg per day, clavulanate 5.7 mg/kg per day in 2 doses^Δ	3 g/day (amoxicillin component)
Alternatives for children with mild non-IgE-mediated reactions to penicillins (ie, without anaphylaxis, bronchospasm, or angioedema)
Cefdinir	Oral	14 mg/kg per day in 1 or 2 doses	600 mg/day
Cefpodoxime	Oral	10 mg/kg per day in 2 doses	400 mg/day
Cefuroxime suspension (no longer available in the United States)^¶	Oral	30 mg/kg per day in 2 doses	1 g/day
Cefuroxime tablets (for children who weigh >17 kg and can swallow the tablet whole)	Oral	250 mg twice daily
Ceftriaxone^¶	Intramuscular or intravenous	50 mg/kg per day	1 g/day
Alternatives for children with IgE-mediated or serious delayed reaction^◊ to beta-lactams including cephalosporins
Azithromycin	Oral	10 mg/kg once on day 1, then 5 mg/kg once per day on days 2 through 5	500 mg/day on day 1; 250 mg/day on days 2 through 5
Clarithromycin^§	Oral	15 mg/kg per day in 2 doses	1 g/day
Clindamycin	Oral	30 mg/kg per day in 3 doses	1.8 g/day

This table is meant to be used in conjunction with the UpToDate topics related to acute otitis media in children. Refer to UpToDate content for additional information regarding choice of therapy. The duration of treatment varies with age, associated clinical features, and antimicrobial agent:

For amoxicillin, amoxicillin-clavulanate, oral cephalosporins, clarithromycin, and clindamycin:
- Children <2 years and children (any age) with tympanic membrane perforation or history of recurrent AOM: 10 days
- Children ≥2 years with intact tympanic membrane and no history of recurrent AOM: 5 to 7 days
For ceftriaxone: 1 to 3 doses, depending on persistence of symptoms
For azithromycin: 5 days

AOM: acute otitis media; IgE: immunoglobulin E.

* For children at increased risk for beta-lactamase-producing nontypeable Haemophilus influenzae: those who have received a beta-lactam antibiotic (eg, penicillins, cephalosporins) in the previous 30 days, have concomitant purulent conjunctivitis, have a history of recurrent otitis media unresponsive to amoxicillin, or live in a community with high uptake of pneumococcal conjugate vaccine in children.

¶ Frequently used if amoxicillin fails.

Δ The availability of this ratio of amoxicillin to clavulanate (7:1) varies geographically.

◊ IgE-mediated reactions classically begin within 1 hour of the initial or last-administered dose; common features include anaphylaxis, angioedema, wheezing, laryngeal edema, hypotension, and hives/urticaria. Delayed reactions appear after multiple. Examples of serious delayed reactions include Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug-induced cytopenias.

§ Infrequently used because of drug interactions.

Graphic 76491 Version 15.0

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Systemic antibiotics used for the initial treatment of acute otitis media in children