Treatment
To determine the most appropriate treatment for AOM, several factors must be taken into consideration, including the patient's characteristics such as age and allergies, whether the infection is unilateral or bilateral, and severity of signs and symptoms. Antibiotics should be prescribed in children aged 6 months and older who are experiencing severe signs and symptoms with either unilateral or bilateral AOM. Antibiotics are also indicated in patients aged <24 months who are experiencing nonsevere bilateral AOM. However, in children aged 6 to 24 months with nonsevere unilateral AOM and in patients aged > 24 months with either unilateral or bilateral nonsevere AOM, an observation and a follow-up within 48 to 72 hours prior to initiating antibiotics may be offered to assess patient improvement. If no improvement is noticed or symptoms have worsened, antibiotic therapy is then warranted for these patients.
Table 1 summarizes antibiotic regimens commonly used in the treatment of pediatric AOM, and Table 2 details their side-effect profiles. The recommended antibiotic for the treatment of AOM in patients who have not received amoxicillin within the last 30 days and have no concurrent purulent conjunctivitis or allergy to penicillin is a high-dose amoxicillin. Amoxicillin is recommended due to its effectiveness against the common bacterial pathogens associated with AOM as well as its favorable side-effect profile, low cost, tolerable taste, and relatively narrow spectrum of activity. For patients who have used amoxicillin within the last 30 days, have purulent conjunctivitis, or experience recurrent AOM unresponsive to amoxicillin, antibiotic therapy with additional beta-lactamase coverage, such as high-dose amoxicillin-clavulanate, is preferred. A cephalosporin is recommended in patients who have a mild penicillin allergy, and clindamycin is recommended in patients with severe penicillin allergy. Macrolides and sulfonamides are not routinely recommended because of their limited effectiveness against the common pathogens associated with AOM.
All patients who have been prescribed antibiotics should be monitored for signs and symptoms of improvement including a decrease in inflammation and/or pain and return to afebrile status. If the patient has not improved in 48 to 72 hours or if the patient has persistent severe symptoms after initial treatment, it is recommended that the current antibiotic be changed. If the patient was initially on amoxicillin, he or she should be switched to amoxicillin-clavulanate or a 3-day regimen of ceftriaxone.
In the first 24 hours, the sole use of antibiotics is unlikely to provide adequate pain relief in patients with AOM. Whether or not antibiotics are prescribed, oral analgesics are recommended in the absence of any contraindications. The recommended treatment options for mild-to-moderate pain associated with AOM are acetaminophen and ibuprofen, which are considered equally efficacious. In patients experiencing moderate-to-severe pain, opioid analgesics can be prescribed for symptom control. Aspirin should be avoided in children with viral illnesses because of an increased risk of Reye syndrome. In addition, topical agents such as benzocaine, lidocaine, and procaine should be avoided in the presence of perforated tympanic membrane.