Definition of Acute OM
A diagnosis of AOM requires:
Recent, usually abrupt, onset of signs and symptoms of middle-ear
The presence of MEE that is indicated by any of the following:
Bulging of the tympanic
Limited or absent mobility
of the tympanic membrane
Air-fluid level behind
the tympanic membrane
Signs or symptoms of middle-ear inflammation as indicated by either
Distinct erythema of
the tympanic membrane or
(discomfort clearly referable to the ear[s] that results in interference
with or precludes normal activity or sleep)
- Clinical history alone is poorly predictive of the presence of
AOM, especially in younger children
- Acoustic reflectometry can be helpful, because it requires no
seal of the canal and can determine the presence of middle-ear
fluid through only a small opening in the cerumen
- The management of AOM should include an assessment of pain. If
pain is present, the clinician should recommend treatment to reduce
pain. Treatments for otalgia.
About 80% of otherwise healthy kids with acute otitis media get better
without antibiotics. The American Academy of Pediatrics and American Academy of Family
Physicians now recommend "watchful waiting" for some kids.
- They say to hold off antibiotics for 2 to 3 days to
see if they're really necessary.
- Watchful waiting is generally appropriate for
children 2 years and older with mild symptoms.
- It's NOT appropriate for babies
under 6 months...or ANY
child with moderate to severe pain or fever over 102˚F.
These kids usually need antibiotics.
- Have parents give acetaminophen or ibuprofen if needed for pain...whether
or not the child is getting an antibiotic.
- Criteria for Initial Antibacterial-Agent
Treatment or Observation in Children With AOM
Placebo-controlled trials of AOM over the past 30 years have shown
consistently that most children do well, without adverse sequelae,
even without antibacterial therapy. By
24 hours, 61% of children
have decreased symptoms
whether they receive placebo or antibacterial agents.
By 7 days, approximately 75% of children
have resolution of symptoms. Watchful waiting and mastoiditis;
current evidence does not suggest a clinically important increased
risk of mastoiditis in children
when AOM is managed only with initial symptomatic treatment without
antibacterial agents. Clinicians should remain aware that
antibacterial-agent treatment might mask mastoiditis signs and
symptoms, producing a subtle presentation that can delay diagnosis.
The potential of antibacterial therapy
at the initial visit
to shorten symptoms by 1 day in 5%
to 14% of children can be compared with the avoidance of
common antibacterial side effects
in 5% to 10% of children,
infrequent serious side effects, and
the adverse effects of
antibacterial resistance. If there is worsening of illness or
if there is no improvement in 48 to 72 hours while a child is under
observation, institution of antibacterial therapy should be
(From PEDIATRICS Vol. 113 No. 5 May 2004, pp.
- Strep pneumoniae: 25-50% (decreasing) (resistance: altered PBP)
- H. flu (nontypable): 15-30% (increasing) (resistance: B-lactamase) **update: now H. flu is the most common**
- in a nine-year, prospective study conducted by Pichichero, Janet Casey, MD, and colleagues, researchers followed 551 children with acute otitis media to examine whether the causative pathogens in persistent AOM had changed in frequency or distribution following the introduction of high-dose amoxicillin therapy and pneumococcal conjugate vaccination.
Results indicated that “H. influenzae has become the predominant pathogen of persistent AOM and AOM treatment failure since universal immunization with the pneumococcal conjugate vaccine [PCV7, Prevnar, Wyeth].” The researchers added that more Streptococcus pneumoniae AOM isolates are becoming penicillin resistant again and more H. influenzae are beta-lactamase–producing.
In another 2007 study conducted by Casey et al, data suggested an emergence in non-PCV7 serotypes since 2003; 80% were penicillin-resistant.
“Although the current AAP/AAFP guidelines endorse amoxicillin high dose (90 mg/kg/day), the better antibiotic selection would be amoxicillin/clavulanate high dose, or if tolerability is an issue, then one of the AAP/AAFP–recommended cephalosporins,” Pichichero said.
- Published in Infectious Diseases in Children February 2009
- moraxella catarrhalis 3-20% (resistance: B-lactamase)
- Viruses have been found in resp secr and/or MEE in 40-75% of AOM (RSV,
rhino-, corona-, parainfluenza, adeno, enterovirus) - may be responsible for
many cases of abx failure
The results favoring standard 10-day therapy have been most
significant in children younger than 2 years and suggestive of
increased efficacy in those 2 to 5 years of age. Thus, for younger
children and for children with severe disease, a standard
course is recommended. For children
6 years of
and older with mild to moderate disease, a 5- to 7-day
is appropriate. Stepwise pattern (if one fails, try the next):
- watchful waiting
- amoxicillin 80-90 mg/kg/da
- amox-clavulanate: 90
mg/kg/d amox (start here for temp >39 or severe otalgia)b (consider
- A patient who fails amoxicillin-potassium clavulanate should be
treated with a 3-day course of
of its superior efficacy against S pneumoniae, compared with
alternative oral antibacterials
- If AOM persists, tympanocentesis
should be recommended to make a bacteriologic diagnosis.
is not available, a course of
clindamycin may be considered for the rare case of
penicillin-resistant pneumococcal infection not responding to the
previous regimens. If the patient still does not improve,
tympanocentesis with Gram-stain, culture, and antibacterial-agent
sensitivity studies of the fluid is essential to guide additional
- Special cases
- non-type I allergic
reaction to penicillins: cefdinir, cefpodoxime, cefuroxime
- type I reactions: azithromycinc, clarithromycin, erythromycin-sulfisoxazole*,
sulfamethoxazole-trimethoprim* (*resistance is substantial, not recommended
for failure w/ amox)
- vomiting, unable to PO:
ceftriaxone 50mg/kg IV/IM qdx3 (1 or 3 day regimen)
a.The justification to use amoxicillin as first-line
therapy in most patients with AOM relates to its general effectiveness
when used in sufficient doses
against susceptible and intermediate
as well as its safety, low cost, acceptable taste, and narrow
microbiologic spectrum. Only S pneumoniae that are highly
resistant to penicillin will not respond to conventional doses of
amoxicillin. Accordingly, approximately 80% of children with AOM will
respond to treatment with high-dose amoxicillin, including many
caused by resistant pneumococci.
The higher dose will yield
middle-ear fluid levels
that exceed the minimum inhibitory
concentration of all S
in resistance to penicillin and many,
but not all, highly
resistant S pneumoniae.
Risk factors for the presence of bacterial species
likely to be resistant to amoxicillin include attendance at
child care, recent receipt
(less than 30 days)
of antibacterial treatment, and age
than 2 years.
b. This dose has sufficient potassium clavulanate to
inhibit all ▀-lactamase-producing
H influenzae and M catarrhalis. Note: per
Sept 2004 Pediatric news, 3rd gen cephalosporins cefdinir (better
tasting, once/day) and cefpodoxime (bad tasting) are highly effective against H.
flu and other B-lactamase producing organisms, and have less gastrointestinal
c. Sept 2004 Pediatric news: because of PCV7
vaccination, there is an upward trend of H. flu infection in response to the
decrease in strep. Standard doses of azithro has marginal B-lactamase coverage,
but recent data suggest that a double dose of azithromycin 20/kg/d x 3d, is as
effective as augmentin in kids < 2yo and under w/ persistent or recurrent AOM.
(Antimicrob. Agents Chemother. 47:3179-86, 2003).
Persistent Middle Ear Effusion
Persistent MEE after resolution of acute symptoms is common and
should not be viewed as a need for active therapy. OME must
be differentiated clinically from AOM and requires additional
monitoring but not antibacterial therapy. Assurance that OME resolves
is particularly important for children with cognitive or
developmental delays that may be impacted adversely by
hearing loss associated with
- Two weeks after an episode of AOM, 60% to 70% of children have
- 1 month after: 40%
- 3 months: 10% to 25% after 3 months.
- breastfeeding for at least the first 6 months also seems to be
helpful against the development of early episodes of AOM
- Avoiding supine bottle feeding ("bottle propping")
- reducing or eliminating pacifier use in the second 6 months of
- eliminating exposure to passive tobacco smoke
- Pneumococcal conjugate vaccines have proven effective in
preventing vaccine-serotype pneumococcal
but their overall benefit is small, with only a 6% reduction in the
incidence of AOM
CLINICAL PRACTICE GUIDELINE
Diagnosis and Management of Acute
Media Subcommittee on
Management of Acute Otitis
PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1451-1465
- There are two major forms of antibiotic resistance currently.
- The primary mode of resistance for
is alteration in the
penicillin-binding protein site. This may be overcome by use of
- Bacterial resistance can also occur to beta-lactam antibiotics such as
penicillin, amoxicillin, and ampicillin by
production of beta-lactamases,
enzymes that inactivate the antibiotic by disrupting the beta-lactam ring.
Moraxella catarrhalis, and
Staphylococcus aureus are the
three most common beta-lactamase-producing pathogens affecting children.
- Because Streptococcus
causes a higher proportion of cases of acute
media than beta-lactamase-
producing bacteria, it makes sense to use
high-dose amoxicillin as first-line
- If the acute otitis media does not resolve with high-dose amoxicillin, as
described for the child in the vignette, the infection may be due to a
organism, which requires the use of a beta-lactamase-resistant
antibiotic, such as amoxicillin-
clavulanate (or cefdinir (omnicef))
- Clindamycin, a lincosamide, and cephalexin, a first-generation
cephalosporin, do not have activity against either H influenzae or M
- Because the patient in the vignette is still symptomatic after 3 days of
therapy, he has experienced treatment failure. Thus, continued high-dose
amoxicillin is not indicated.
- Although azithromycin may be effective against H influenzae,
remains the drug of choice for those who have clinically failed treatment with
high-dose amoxicillin. Recent pneumococcal surveillance studies
indicate resistance to erythromycin at approximately 10%. Substantial
cross-resistance between erythromycin and beta-lactam agents exists.
Therefore, patients who have already
failed amoxicillin treatment are more likely to have
infections as well.
Baquero F, Loza E. Antibiotic resistance of microorganisms involved in
ear, nose and throat infections. Pediatr Infect Dis J. 1994;13(suppl
Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media:
management and surveillance in an era of pneumococcal
resistanceŚreport from the Drug-resistant Streptococcus pneumoniae
Therapeutic Working Group. Pediatr Infect Dis J. 1999;18:1-9
Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis
mediaŚprinciples of judicious use of antimicrobial agents. Pediatrics.
Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of
antimicrobial drugs for acute otitis media: metaanalysis of 5400
children from thirty-three randomized trials. J Pediatr.
- Pichichero ME. New research in otitis media and sinusitis 2008. Presented at: 21st Annual IDC NY Symposium; Nov. 22-23, 2008; New York.
- Pediatr Infect Dis J. 2004;23:824-828.
- JAMA. 2007;298:1772-1778.