Acute otitis media


  • Peak incidence: 6-18 months of age
  • 2nd most common cause of ED visits after URI


  • Viral (70% of cases)
  • Bacterial
    • S. pneumo (50%)
    • Nontypable H. flu (30%)
    • Moraxella (30%)

Clinical Features

  • Symptoms typically include ear pain, fever
  • Acute onset (<48hr) AND
  • Middle ear effusion AND
  • Signs of middle ear inflammation
    • Middle Ear Effusion: bulging TM, impaired TM movement, otorrhea, or air/fluid level
    • Middle Ear inflammation: erythema of TM or otalgia

Differential Diagnosis

Ear Diagnoses




Less common

Pediatric fever


  • Typically clinical
  • Erythema alone not enough to diagnose
  • Other clinical features: acute onset pain, bulging TM, opacified TM/loss of landmarks, otorrhea



2013 AAP Decision to Treat Guidelines[1]

Age Otorrhea Severe Symptoms^ Bilateral without Otorrhea Unilateral without Otorrhea
6mo-2yAntibioticsAntibioticsAntibioticsAntibiotics or observation period (wait and see)
≥2yAntibioticsAntibioticsAntibiotics or observation period (wait and see)Antibiotics or observation period (wait and see)

^Fever > 39C or severe otalgia <48 hrs

Also Consider In:

  • Age <6mo
  • Ill-appearing
  • Recurrent acute otitis media (within 2-4wk)
  • Concurrent antibiotic treatment
  • Other bacterial infections
  • Immunocompromised
  • Craniofacial abnormalities

Wait-and-see antibiotic prescription (WASP)

  • Rather that routine prescription is an option to avoid over use if the patient does not meet any of the prescription criteria[2]
  • If symptoms worsen or persist for 48-72 then caretaker fill the prescription
  • Fever (relative risk [RR], 2.95; 95% confidence interval [CI], 1.75 - 4.99; P<.001) and otalgia (RR, 1.62; 95% CI, 1.26 - 2.03; P<.001) were associated with filling the prescription in the WASP group

Antibiotics Options

  • Consider treating for a standard of 10 days as opposed to a shorter duration of 5 days to reduce treatment failure in young children[3]
    • Treatment failure for 10 day at 16% and for 5 day at 34% for amoxicillin-clavulanate
    • RTC of 520 children aged 6-23 months

Initial Treatment

  1. Amoxicillin 80-90mg/kg/day divided into 2 daily doses 7-10 days

Treatment during prior Month

  1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea
  2. Cefdinir 14mg/kg/day BID x7-10 days
  3. Cefpodoxime 10mg/kg PO daily x7-10 days
  4. Cefuroxime 15mg/kg PO BID x7-10 days
  5. Cefprozil 15mg/kg PO BID x7-10 days


  • Suggestive of non-typeable H.flu
  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
  2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
    • Use if cannot tolerate PO

Penicillin Allergy

  1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
  2. Clarithromycin 7.5mg/kg PO BID x 10 days
  3. Clindamycin 10mg/kg PO three times daily
    • Clindamycin does not cover H. influenza and M. catarrhalis and treatment should favor Azithromycin use


  • Outpatient management


See Also


  1. AAP Clinical Practice Guideline The Diagnosis and Management of Acute Otitis Media
  2. Spiro DM. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA. 2006 Sep 13;296(10):1235-41.
  3. Hoberman A et al. Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children. N Engl J Med 2016; 375:2446-2456.
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