Acute Otitis Media Clinical Pathway — All Settings | Children's Hospital of Philadelphia

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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: May 2021
Author: M. Joffe, MD, B. Ku, MD, J. Gerber, MD, T. Metjian, PharmD, K. Chiotos, MD

Evidence

The Diagnosis and Management of Acute Otitis Media

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

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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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