Acute Otitis Media Clinical Pathway — All Settings

Antibiotic Therapy for Acute Otitis Media

General Principles

  • The following table guides empiric antibiotic choices based on clinical evaluation. Please refer to durations table for duration recommendations according to age.
  • Children with acute otitis media with perforation should be prescribed antibiotics per table below; additional topical antibiotics or steroids not needed.
  • Consider ENT consult for children with amoxicillin-clavulanate or oral cephalosporin failure or recurrent acute otitis media.
  • Ceftriaxone is not recommended as first-line therapy due to broad spectrum of activity. However, a single dose of ceftriaxone is effective for uncomplicated otitis media. Three doses of ceftriaxone are recommended for treatment failure.
  • Definitions:
    • Antibiotic treatment failure: no clinical improvement in 48-72 hours. A determination of lack of clinical improvement should be based on clinical signs and symptoms (e.g., fever, ear pain) rather than physical exam findings, such as erythematous tympanic membrane, which can lag behind clinical improvement.

Common Pathogens

  • S. pneumoniae (pneumococcus)
  • Nontypeable Haemophilus influenzae
  • Moraxella catarrhalis
Azithromycin has poor activity against Streptococcus pneumoniae and Haemophilus influenzae and is not recommended for otitis media
Oral cephalosporins (including cefdinir) are inferior to high-dose amoxicillin for S.pneumoniae, the most common bacterial cause of acute otitis media that requires antibiotic treatment. Oral cephalosporins can be used for true amoxicillin allergy but are unlikely to provide additional benefit in the case of amoxicillin or amoxicillin-clavulanate treatment failure.

Antibiotic Therapy for Acute Otitis Media

Indications First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative
Initial Therapy if No Amoxicillin in Preceding 30 Days
  • Amoxicillin, PO
    • ≤ 3 months:
      30 mg/kg/day in 2 divided doses
    • > 3 months:
      90 mg/kg/day in 2 divided doses
      Max: 2,000 mg/dose
    • Cefdinir, PO
      • ≥ 6 months:
        7 mg/kg/dose twice daily for 5-10 day durations
        or
        14 mg/kg/dose daily for 10 day durations
        Max: 600 mg/day
    • Cefpodoxime, PO
      • ≥ 2 months:
        10 mg/kg/day in 2 divided doses
        Max: 200 mg/dose
    • Ceftriaxone, IV or IM
      • 50 mg/kg in a single dose
        Max: 1000 mg/dose
  • Cephalosporin allergy:
    • Clindamycin, PO
      Infants PMA > 44 weeks, children and adolescents:
      14 mg/kg/dose 3 times a day
      Max: 600 mg/dose
Initial Therapy if Patient Received Amoxicillin in the Preceding 30 Days or Has Concurrent Conjunctivitis
(Suggests β-lactamase +)
  • Amoxicillin-Clavulanate, PO
    • < 3 months:
      30 mg/kg/day of amoxicillin component in 2 divided doses
    • ≥ 3 months:
      90 mg/kg/day of amoxicillin component in 2 divided doses
      Max: 2,000 mg/dose
    • For oral suspension, use ES formulation and for tablet, use ER formulation
Amoxicillin Failure
  • Amoxicillin-Clavulanate, PO
    • < 3 months:
      30 mg/kg/day of amoxicillin component in 2 divided doses
    • ≥ 3 months:
      90 mg/kg/day of amoxicillin component in 2 divided doses Max: 2,000 mg/dose
    • For oral suspension, use ES formulation and for tablet, use ER formulation
 Not applicable
Amoxicillin-Clavulanate or Oral Cephalosporin Failure
  • Ceftriaxone, IV or IM:
    • 50 mg/kg daily for 3 days
      Max: 1,000 mg/dose
  • Levofloxacin, PO:
    • ≥ 6 months and < 5 years:
      10 mg/kg/dose twice daily
      Max: 375 mg/dose
    • ≥ 5 years:
      10 mg/kg/dose daily
      Max: 750 mg/dose

CHOP Formulary for complete drug information.