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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.