Treatment algorithm
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
Guide de pratique clinique sur la prise en charge de l’otite moyenne aiguëPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Richtlijnen voor de aanpak van acute otitis media in de eerste lijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
oral or rectal analgesia
Pain control is central to managing the condition.
Rectal preparations can be used as needed until the symptoms have resolved.[49]
Oral paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) demonstrated better short-term ear pain relief than placebo in children with AOM.[28] There was insufficient evidence of a difference between ibuprofen and paracetamol. Whether the combination of ibuprofen and paracetamol is more effective than either agent alone remains uncertain.[28]
Evidence to support the use of antihistamine or decongestant treatment for AOM is lacking.[29]
Analgesic otic drops (e.g., antipyrine/benzocaine) are sometimes recommended; however, they may not be available in some countries.[50]
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Primary options
paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day
and/or
ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day
oral or rectal analgesia
Pain control is central to managing the condition.
Rectal preparations can be used as needed until the symptoms have resolved.[49]
Oral paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) demonstrated better short-term ear pain relief than placebo in children with AOM.[28] There was insufficient evidence of a difference between ibuprofen and paracetamol. Whether the combination of ibuprofen and paracetamol is more effective than either agent alone remains uncertain.[28]
Evidence to support antihistamines or decongestants in the treatment of AOM is lacking.[29]
Analgesic otic drops (e.g., antipyrine/benzocaine) are sometimes recommended; however, they may not be available in some countries.[50]
[ ]
Primary options
paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day
and/or
ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day
antibiotic therapy
Additional treatment recommended for SOME patients in selected patient group
Delayed therapy is an option in healthy patients 6 months or older with reliable follow-up, particularly patients who do not meet the diagnostic criteria or have a less certain diagnosis.
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A recommended approach is to provide analgesia and observe for 2 to 3 days. If the patient remains symptomatic after the observation period ends, the antibiotic is started.[41][42][43] Delayed antibiotic therapy may reduce the number of unnecessary antibiotic courses, decrease the occurrence of adverse antibiotic reactions, improve the benefit provided by antibiotics, and reduce healthcare expenditures.[46] Children under 2 years of age and with bilateral disease or who have severe tympanic membrane bulging may respond less well with this approach.[44][45]
In high-income countries, antibiotics may be most beneficial in children under 2 years of age with bilateral AOM (NNT = 4) or in children with both AOM and otorrhoea suggestive of tympanic membrane perforation (NNT = 3).[35]
Antibiotics are prescribed in a stepwise fashion beginning with a first-line antibiotic.[19] Although the optimal antibiotic regimen is not entirely clear, there is some evidence to suggest that amoxicillin or amoxicillin/clavulanate may be preferable to a range of other antibiotics.[36][37][38]
Duration of therapy in children 6 to 23 months of age should be 10 days.[40] The American Academy of Paediatrics advises that a 7-day course of oral antibiotic appears to be effective in children 2 to 5 years of age with mild or moderate AOM.[19] For children 6 years and older with mild to moderate symptoms, a 5- to 7-day course is adequate.[19]
A lack of improvement in the patient's condition may require a change to a second- or third-line agent.[19]
Azithromycin is a suitable option in patients allergic to beta-lactam antibiotics. One study reports that a single dose of extended-release azithromycin is as effective as a 10-day regimen of amoxicillin/clavulanate in the treatment of children with AOM.[27] Various azithromycin regimens may be used.
Primary options
amoxicillin: children: 80-90 mg/kg/day orally given in divided doses every 12 hours for 10 days
OR
amoxicillin/clavulanate: children >3 months of age: 80-90 mg/kg/day orally given in divided doses every 12 hours for 10 days
MoreSecondary options
cefdinir: children >6 months of age: 14 mg/kg/day for 10 days
OR
cefuroxime: children: 30 mg/kg/day orally given in divided doses every 12 hours for 10 days
Tertiary options
azithromycin: children ≥6 months of age: 10 mg/kg/day orally (immediate-release) on the first day, followed by 5 mg/kg/day for 4 days; or 10 mg/kg/day orally (immediate-release) for 3 days; or 30 mg/kg/day orally (immediate-release) as a single dose; or 60 mg/kg/day orally (extended-release) as a single dose
OR
ceftriaxone: children: 50 mg/kg/day intramuscularly/intravenously for 3 days
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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