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


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 +)

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