RISK FACTORS: Bottle feeds while supine, Day care, Formula feeding, Smoking inhousehold
, Male gender, Family history of middle ear disease, AOM in 1st year of life is a risk factor for recurrent AOM, Sibling history of otitis media
GENERAL MEASURES
β’ AOM: outpatient except for febrile infants < 2 months
β’ May use watchful waiting approach, treating symptoms without antibiotics for fi rst 2-3 days. If symptoms
persist, then amoxicillin is fi rst line treatment.
β’ OME: presence of effusion without signs or symptoms of acute infection does not require antibiotics for initial
treatment
β’ Antihistamine-decongestant preparations offer no added benefit to resolution of symptoms
SURGICAL MEASURES
β’ OME: Referral for surgery if: > 4-6 months bilateral OME, and/or > 6 months unilateral OME, and/or hearing
loss > 25 decibels
β’ Recurrent AOM: Referral for surgery if > 2 or 3 AOM while on chemoprophylaxis. Tympanostomy tubes and
adenoidectomy/adenotonsillectomy effective surgical procedures for OME and recurrent AOM, but not in all
cases.
DRUG(S) OF CHOICE
β’ AOM: Amoxicillin 40-45 mg/kg bid >age 2 years, 5-7 day course with no complications; probably the most
effective of penicillins/cephalosporins against relatively resistant (but not highly resistant) pneumococci.
β’ Recurrent AOM: Only consider antibiotic prophylaxis for recurrent AOM (> 3 distinct, well documented episodes in 6 months). Amoxicillin 20 mg/kg daily for 3-6 months or until summer.
β’ OME: Antihistamines and decongestants ineffective, indications for steroids not defined, amoxicillin promotes
resolution in 10-15% but effect is usually transitory - not recommended, no long term benefit.
β’ Note: if patient not toxic appearing, may choose to treat with antipyrine-benzocaine (Auralgan) drops and
acetaminophen (Tylenol) as long as close follow up available. 81% of patients not treated with medication
resolve.
ALTERNATIVE DRUGS
. Alternative drugs are indicated for the following AOM patients:
. Patients with penicillin allergy
. Persistent symptoms after 48-72 hrs of amoxicillin
. AOM within 1 month of amoxicillin therapy
. AOM with severe earache
. Infants less than 6 months with high fever
. Immunocompromised hosts
. AOM due to Chlamydia trachomatis will respond to macrolides and sulfonamides
. AOM due to Mycoplasma pneumoniae will respond to macrolides
. AOM: Alternative drugs (treat for 10 days):
. Amoxicillin-clavulanate (Augmentin) 40 mg/kg/day of amoxicillin component tid - effective against resistant
H. influenzae and M. catarrhalis , amoxicillin component effective against relatively resistant pneumococci
. Cefaclor (Ceclor) 40 mg/kg/day bid or tid is less effective than other alternatives
. Cefixime (Suprax) 8 mg/kg/day bid or single daily dose - effective against resistant H. influenzae and M. catarrhalis less effective than amoxicillin for pneumococci
. Cefpodoxime (Vantin) 10 mg/kg/day bid - less effective in vivo against H. influenzae than other drugs
. Ceftriaxone (Rocephin) 50 mg/kg IM single dose - effective against major pathogens, but expensive and
painful so reserved for sick infants
. Clarithromycin (Biaxin) 15 mg/kg/day divided bid - not effective in vivo against H. influenzae
. Trimethoprim-sulfamethoxazole (Septra, Bactrim) 8 mg TMP/kg/day divided bid: up to 30% of pneumococci
are resistant
. Erythromycin-sulfisoxazole (Pediazole) 40 mg erythromycin component/kg/day divided qid - some strains of pneumococci are resistant
. Recurrent AOM:
. Sulfisoxazole 75 mg/kg single daily dose for penicillin allergic patients
. Analgesics and antipyretics as needed
PATIENT MONITORING
β’ AOM: Otoscopic examination 4 weeks after diagnosis
β’ OME: Monthly otoscopic or tympanometric exams as long as OME persists
PREVENTION/AVOIDANCE
β’ Breast-feeding decreases incidence of AOM
β’ Eliminate cigarette smoking in the household
β’ The heptavalent pneumococcal conjugate vaccine (PCV-78) [with nontoxic diphtheria-toxin analogue carrier protein, CRM197] is safe and efficacious in the prevention of acute otitis media caused by the serotypes included in the vaccine.
POSSIBLE COMPLICATIONS
β’ AOM: Perforation/otorrhea, acute mastoiditis, facial nerve paralysis, otitic hydrocephalus, meningitis, hearing
impairment
β’ OME: Hearing loss, speech and language disabilities may occur with hearing impairment
β’ Recurrent AOM and OME: Atrophy and scarring of eardrum, chronic perforation and otorrhea,cholesteatoma,
permanent hearing loss, chronic mastoiditis, brain abscess and other intracranial suppurative complications
EXPECTED COURSE/PROGNOSIS
β’ Children treated immediately with antibiotics had one less day of symptoms
β’ Symptoms of AOM (mostly otalgia) spontaneously resolve in 2/3 of children by 24 hours and in 80% at 2-7
days (NNT=17)
β’ AOM: Symptoms usually improve in 48-72 hrs; OME following AOM resolved in 90% by 3 months
β’ OME: Approximately 50% resolve after 8 weeks of observation
β’ Recurrent AOM and OME: Usually subsides in school age children; only a small percentage have complications