UMEM Educational Pearls

Category: Pediatrics

Title: Acute Otitis Media

Posted: 11/29/2019 by Rose Chasm, MD (Updated: 2/19/2020)
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Antibiotic stewardship has led various organizations such as the AAP, AAFP, and IDSA to introduce two different approaches to the treatment of acute otitis media (AOM):

  • Immediate treatment with antibiotics versus
  • initial observation for 48-72 hours without antibiotics.

Immediate treatment with antibiotics should always include the following patients:

  • Children <6 months old
  • Toxic appearing
  • Severe signs/symptoms: otorhea, persistent pain, fever>39C, bilateral ear disease

The observation approach can be considered in the following very slect patient group:

  • Otherwise healthy children >2 years of age
  • Non-severe illness
  • Unilateral ear disease
  • Access to follow up within 48-72 hours
  • Parental comfort / Shared decision making

Often the issue with pediatric AOM isn't necessarily the overprescribing of antibiotics, but the inaccurate/inappropriate over diagnosis of acute otitis media.  An erythematous tympanic membrane does not equal AOM.  Crying and fever can result in a red TM. Fluid seen behind the TM, is often just serous otitis media, which isn't AOM. 

When antibiotics are warranted, first-line treatment is with high dose amoxicillin, 90 mg/kg per day divided into two doses; unless the child has received beta-lactam antibiotics in the previous 90 days and/or also has puruent conjunctivitis mandating amoxicillin-clavulanate instead.  In the later case, prescribing the Augment ES, 600 mg/5mL formlation with a lower clavulanic concentration lessening GI upset and diarrhea is prefered.

 

 

References

Liebeerthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics 2013; 131.

Shaikh N, et al. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr 2012;12:214.