Pediatric Acute Otitis Media Empiric Therapy 

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Empiric therapeutic regimens for acute otitis media in children are outlined below, including general recommendations, first- and second-line treatments, treatment for penicillin-allergic patients, and treatments for patients with recurrent illness or treatment failures. ^{[1, 2, 3, 4, 5, 6, 7, 8]}

Adequate pain and fever control with either oral acetaminophen or ibuprofen or topical pain control with topical benzocaine preparations is imperative whether antibiotics are given or not.

Age < 6mo:

Should receive antibiotics whether the diagnosis of acute otitis media is certain or not

Age 6mo to 2y:

Should receive antibiotics if the diagnosis is certain

If the diagnosis is uncertain, an observation period can be considered if the illness is nonsevere

Age > 2y:

Should receive antibiotics if the diagnosis is certain and if the illness is severe

An observation period is advised if the diagnosis is uncertain or if it is certain and nonsevere

See the list below:

Amoxicillin 80-90 mg/kg/day PO (maximum 3 g/24h) divided BID for 5-7d; 10d may be required if illness is severe or

Ceftriaxone 50 mg/kg IM × 1 dose (maximum 1 g); recommended for children unable to take antibiotics PO and for patients with compliance issues

Children who have been treated with amoxicillin in the past 30 days, have conjunctivitis, or need beta-lactamase coverage (eg, suspected Haemophilus influenzae resistance):

Children with acute otitis media with tympanostomy tubes:

Ciprofloxacin 0.3%/dexamethasone 0.1% otic solution 4 drops BID × 7d or

Ofloxacin otic solution 5 drops BID × 10d

Penicillin allergic:

Non – type-1 hypersensitivity:

Cefdinir 14 mg/kg/day (maximum 600 mg/24h) PO qd or divided BID for 5-10d or

Cefpodoxime 10 mg/kg/day (maximum 400 mg/24h) PO qd or divided BID for 5-10d or

Cefuroxime 30 mg/kg/day PO (maximum 1 g/24h) divided BID for 5-10d

Type-1 hypersensitivity:

Azithromycin 10 mg/kg/day (maximum 500 mg) PO × 1 dose, then 5 mg/kg/day (maximum 250 mg/24h) PO qd × 4d or

Azithromycin 10 mg/kg/day (maximum 500 mg/24h) PO qd × 3d or

Clarithromycin 15 mg/kg/day (maximum 1 g/24h) PO divided BID for 5-10d

See the list below:

Amoxicillin/clavulanate 90 mg/kg/day (based on amoxicillin component using XR formulation; maximum 4 g/24h) PO divided BID for 5-7d or

Cefdinir 7 mg/kg q12h or 14 mg/kg q24h for 5-7d or

Cefpodoxime 10 mg/kg/day as a single dose or

Cefprozil 15 mg/kg q12h for 5-7d or

Cefuroxime 30 mg/kg/day divided q12h for 5-7d or

Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d

See the list below:

Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d or

Clindamycin 20-30 mg/kg/day divided QID for 5-7d

Brook I, Gober AE. Microscopic characteristics of persistent otitis media. Arch Otolaryngol Head Neck Surg. 1998. 124:1350-2.

Coker TR, Chan LS, Newberry SJ, Limbos MA, Suttorp MJ, Shekelle PG, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: a systematic review. JAMA. 2010 Nov 17. 304(19):2161-9. [Medline].

Dohar J, Giles W, Roland P, Bikhazi N, Carroll S, Moe R, et al. Topical ciprofloxacin/dexamethasone superior to oral amoxicillin/clavulanic acid in acute otitis media with otorrhea through tympanostomy tubes. Pediatrics. 2006 Sep. 118(3):e561-9. [Medline]. [Full Text].

Steele RW, Blumer JL, Kalish GH. Patient, physician, and nurse satisfaction with antibiotics. Clin Pediatr (Phila). 2002 Jun. 41(5):285-99. [Medline].

Donaldson JD. Acute Otitis Media. Medscape Drugs & Diseases. Updated 2018 Apr 13. [Full Text].

[Guideline] American Academy of Pediatrics. The diagnosis and management of acute otitis media. Pediatr. Mar 1 2013. 131(3):e964-99. [Full Text].

Wald ER, DeMuri GP. Antibiotic Recommendations for Acute Otitis Media and Acute Bacterial Sinusitis: Conundrum No More. Pediatr Infect Dis J. 2018 Dec. 37 (12):1255-1257. [Medline].

Harmes KM, Blackwood RA, Burrows HL, Cooke JM, Harrison RV, Passamani PP. Otitis media: diagnosis and treatment. Am Fam Physician. 2013 Oct 1. 88 (7):435-40. [Medline]. [Full Text].

Brenda L Natal, MD, MPH Assistant Professor of Emergency Medicine, Simulation Director, Rutgers New Jersey Medical School; Attending Physician, Department of Emergency Medicine, University Hospital of Newark

Brenda L Natal, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Pediatric Acute Otitis Media Empiric Therapy 

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