Clinical Pathway for Evaluation/Treatment of
Acute Otitis Media in Children 2 Months to 12 Years Old*
Acute Otitis Media (AOM)
Diagnostic Criteria for AOM (all 3 required)
OnsetAcute onset of signs and symptoms
Bulging MembraneBest predictor of bacterial infection
Middle Ear EffusionReduced TM mobility with pneumatic otoscopy

AOM should be diagnosed in children with new onset otorrhea without otitis externa

OME diagnosis is based on a middle ear effusion w/o middle ear inflammation

Mild Bulging
Moderate Bulging
Severe Bulging

May observe 48-72 hours, only if follow-up is ensured, provide analgesia

Antibiotic prescription can be provided at discharge with instructions to start if symptoms worsen/persist over the next 48-72 hours

Severe DiseaseModerate to severe otalgia or fever ≥ 39°C
Initial Acute Otitis Media (AOM)
 < 6 months 6-24 months > 2 years
ObservationNot indicatedUnilateral and illness is not severe

Illness not severe

Strongly consider treatment for bilateral AOM

Severe Disease10 days10 days7 days
Antibiotic Failure No clinical improvement in 48-72 hours
Antibiotic Therapy for Acute Otitis Media
IndicationsAntibiotic Dose
First line for majorityAmoxicillin80-90 mg/kg/day in 2 doses
First line if:
Patient received amoxicillin preceding 30 days or
Concurrent conjunctivitis
(suggests β-lactamase +)

90 mg/kg/day of Amoxicillin in 2 doses

Use ES formulation

Amoxicillin FailureAmoxicillin-clavulinate90 mg/kg/day of Amoxicillin in 2 doses
Amoxicillin-clavulinate or
oral Cephalosporin failure
Ceftriaxone50 mg/kg IM or IV x 3 days
Ceftriaxone failureClindamycin + Cefdinir or cefpodoxime 
Penicillin Allergy
  • Cefdinir
  • Cefuroxime
  • Cefpodoxime
  • Ceftriaxone
  • Cross-reactivity among penicillin and cephalosporin allergy is very low, especially when using specific cephalosporin above
  • 14 mg/kg/day in 1 or 2 doses
  • 30 mg/kg/day in 2 doses
  • 10 mg/kg/day in 2 doses
  • 50 mg/kg/dose IM or IV x3 days
PerforationFloxin-ocuflox Drops (Ofloxacin)5 drops affected ear BID 10 days
Posted: November 2008
Revised: April 2011, December 2013, January 2016
Author: M. Joffe, MD
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