Acute Otitis Media in Children 2 Months to 12 Years Old
Diagnostic Criteria for AOM (all 3 required) | |
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Onset | Acute onset of signs and symptoms |
Bulging Membrane | Best predictor of bacterial infection |
Middle Ear Effusion | Reduced 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
Definitions | |
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Observation |
May observe 48-72 hours if > 6 months and not severe. Ensure follow-up and provide analgesia Antibiotic prescription provided at discharge with instructions to start if symptoms worsen/persist over the next 48-72 hours |
Severe Disease | Moderate to severe otalgia or fever ≥ 39°C |
Initial Acute Otitis Media (AOM) | |||
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< 6 months | 6-24 months | > 2 years | |
Observation | Not indicated | Unilateral and illness is not severe |
Illness not severe Strongly consider treatment for bilateral AOM |
Severe Disease | 10 days | 10 days | 7 days |
Antibiotic Failure | No clinical improvement in 48-72 hours |
Antibiotic Therapy for Acute Otitis Media | ||
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Indications | Antibiotic | Dose |
Initial therapy if no exposure to amoxicillin in the preceding 30 days | Amoxicillin | Infants ≤ 3 months: 30 mg/kg/day PO in 2 divided doses Infants > 3 months, Children, and Adolescents: 80-90 mg/kg/day PO in 2 divided doses; maximum dose: 2000 mg/dose; 4000 mg/day |
Initial therapy if patient received amoxicillin in the preceding 30 days or has concurrent conjunctivitis (suggests β-lactamase +) | Amoxicillin-clavulanate |
Infants < 3 months: 30 mg/kg/day of amoxicillin component PO in 2 divided doses Infants ≥ 3 months, Children, and Adolescents: 90 mg/kg/day of amoxicillin component PO in 2 divided doses; maximum dose: 2000 mg/dose; 4000 mg/day For oral suspension, use ES formulation and for tablet use ER formulation |
Amoxicillin failure | Amoxicillin-clavulanate | |
Amoxicillin-clavulanate or oral cephalosporin failure |
Ceftriaxone | Infants, Children and Adolescents: 50 mg/kg/dose IM or IV for 3 days; maximum dose: 1000 mg/dose |
Ceftriaxone failure | Clindamycin + Cefdinir or Cefpodoxime Consider tympanocentesis |
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Non-severe penicillin allergy initial therapy |
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Severe1 penicillin or cephalosporin allergy | Clindamycin |
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Acute otitis media with perforation | Enteral antibiotic as above, additional topical antibiotics or steroids not needed |   |
Please see the CHOP Formulary monograph for complete information. 1Severe penicillin allergy: Severe penicillin allergy includes any of the following: anaphylaxis, angioedema, cardiac arrest, respiratory distress, severe cutaneous reaction (for example, Stevens-Johnson syndrome, erythema multiforme, DRESS and TEN).
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Revised: May 2021
Author: M. Joffe, MD, B. Ku, MD, J. Gerber, MD, T. Metjian, PharmD, K. Chiotos, MD