Acute otitis media (AOM) is a common infection involving inflammation of the middle ear, the space located behind the eardrum. AOM typically presents with a rapid onset of symptoms like ear pain and sometimes fever. Although antibiotics are frequently prescribed, they are not required for every case. The decision to use an antibiotic depends on clinical factors that determine the underlying cause and severity of the infection.
Determining When Antibiotics Are Necessary
Not all ear infections are caused by bacteria; many are viral, and antibiotics are ineffective against viruses. Unnecessary antibiotic use exposes the patient to side effects and contributes to antibiotic resistance. For children aged two years and older with mild symptoms, or children 6 to 23 months with mild, unilateral AOM, a strategy called “watchful waiting” may be used.
Watchful Waiting
Watchful waiting involves observing the patient for 48 to 72 hours without starting antibiotics, as many infections resolve spontaneously. If symptoms worsen or do not improve within this period, an antibiotic prescription is then filled. Antibiotics are generally prescribed immediately for infants under six months of age, or for any patient with severe symptoms, such as a high fever (102.2°F or greater) or moderate to severe ear pain.
Standard First-Line Treatments
When a bacterial cause is suspected or the infection is severe, the first-line treatment is typically high-dose amoxicillin. This drug is favored because it is highly effective against Streptococcus pneumoniae, a common bacterial cause of AOM. Amoxicillin is well-tolerated, has a favorable safety profile, and achieves high concentrations in the middle ear fluid. The dosage is typically 80 to 90 milligrams per kilogram per day to overcome potential intermediate resistance.
Amoxicillin-Clavulanate
If a patient was recently treated with amoxicillin (within the past 30 days) or has concurrent purulent conjunctivitis, amoxicillin-clavulanate is often selected. The clavulanate component protects the amoxicillin from being broken down by beta-lactamase enzymes produced by pathogens like Haemophilus influenzae and Moraxella catarrhalis. Treatment duration varies by age and severity. A 10-day course is recommended for children under two years old or those with severe symptoms, while children aged two and older with non-severe infections may receive a shorter course of 5 to 7 days.
Alternative Options and Treatment Completion
Patients with a documented penicillin allergy require alternative antibiotic options based on the severity of the reaction. For those with a non-severe allergy, cephalosporins such as cefdinir or cefuroxime are often considered. These drugs are structurally different from penicillin, meaning the risk of cross-reactivity is low. If the patient has a severe, immediate-type penicillin allergy, macrolides such as azithromycin may be prescribed instead.
Treatment Failure and Completion
If the first-line antibiotic treatment does not lead to improvement within 48 to 72 hours, the patient must be re-evaluated. Treatment failure may indicate the bacteria were resistant to the chosen drug or that the infection is caused by an organism not covered by the initial choice. In such cases, the provider may switch to a broader-spectrum agent, such as high-dose amoxicillin-clavulanate, or a different class of antibiotic. It is important to complete the entire course of the prescribed antibiotic, even if symptoms disappear quickly. Stopping treatment early can lead to recurrence and promotes the survival of resistant bacteria, making future infections harder to treat.