Clinical Pathway for Evaluation/Treatment of
Acute Otitis Media in Children 2 Months to 12 Years Old
Initial Management of Acute Otitis Media (AOM)
Diagnostic Criteria for AOM (all 3 required)
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
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)
  < 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
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

  • Clindamycin:
    • Infants PMA > 44 weeks, Children and Adolescents: 14 mg/kg/dose PO TID; maximum: 600 mg/dose
  • Cefdinir:
    • Infants ≥ 6 months and Children ≤ 12 years: 14 mg/kg/day PO in divided doses every 12 to 24 hours; maximum: 600 mg/day
  • Cefpodoxime:
    • Infants and Children 2 months to 12 years: 10 mg/kg/day PO in 2 divided doses; maximum dose: 200 mg/dose
Non-severe penicillin allergy initial therapy
  • Cefdinir
  • Cefpodoxime
  • Ceftriaxone
  • Cross-reactivity among penicillin and cephalosporin allergy is very low (0.1%), especially when using specific cephalosporin above
  • Cefdinir:
    • Infants ≥ 6 months and Children ≤ 12 years: 14 mg/kg/day PO in divided doses every 12 to 24 hours; maximum: 600 mg/day
  • Cefpodoxime:
    • Infants ≥ 6 months and Children ≤ 12 years: 14 mg/kg/day PO in divided doses every 12 to 24 hours; maximum: 600 mg/day
  • Ceftriaxone:
    • Infants, Children and Adolescents: 50 mg/kg/dose IM or IV for 1-3 days; maximum dose: 1000 mg/dose
Severe1 penicillin or cephalosporin allergy Clindamycin
    • Infants PMA > 44 weeks, Children and Adolescents: 14 mg/kg/dose PO TID; maximum: 600 mg/dose
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).

  • Notes:
  • Although not recommended as first line therapy given unnecessarily broad spectrum of activity, ceftriaxone for 1-3 days is effective for the majority of uncomplicated otitis media.
  • Azithromycin has poor activity against Streptococcus pneumoniae and Haemophilus influenzae and is not recommended for otitis media.
Posted: November 2008
Revised: April 2011, December 2013, January 2016, December 2017, January 2020, May 2021
Author: M. Joffe, MD, B. Ku, MD, J. Gerber, MD, T. Metjian, PharmD, K. Chiotos, MD