Otitis Media, Acute Clinical Pathway — Emergency, Inpatient, Outpatient Specialty Care, Primary Care

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Initial Management of Acute Otitis Media (AOM)

Diagnostic Considerations
Pain Management
Allergy Considerations
Follow-up
ENT Referral
Prevention

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
First line for majority	Amoxicillin	80-90 mg/kg/day in 2 doses MAX 2000 mg/dose, 4000 mg/day
First line if: Patient received amoxicillin preceding 30 days or Concurrent conjunctivitis (suggests β-lactamase +)	Amoxicillin-clavulanate	90 mg/kg/day of Amoxicillin in 2 doses Use ES formulation
Amoxicillin Failure	Amoxicillin-clavulanate	90 mg/kg/day of Amoxicillin in 2 doses
Amoxicillin-clavulanate or oral Cephalosporin failure	Ceftriaxone	50 mg/kg IM or IV x 3 days
Ceftriaxone failure	Clindamycin + 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
Perforation	Oral antibiotic and Floxin-ocuflox Drops (Ofloxacin)	5 drops affected ear BID 10 days

Posted: November 2008
Revised: April 2011, December 2013, January 2016, December 2017, January 2020
Author: M. Joffe, MD

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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