Acute Otitis Media

in Children
Translated from the original French version published October 2009
This clinical guide is provided for information purposes and is not a substitute for the practitioners judgment.

GENERAL
Bacterial pathogens most frequently found in acute otitis media (AOM):
Streptococcus pneumoniae

Nontypeable Haemophilus influenzae

Moraxella catarrhalis
Streptococcus pyogenes

Important considerations for Streptococcus pneumoniae :

Children < 1 year: 60% of AOMs.
Pneumococcal resistance is stable in Qubec and may easily be countered by increasing the dose of amoxicillin.
Most of AOM complications (mastoiditis, etc.) occur in a pneumococcal otitis context and in children < 2 years.
Conjugate vaccines have little effect on the occurrence of otitis.
Risk factors for pneumococcal resistance to penicillin and other antibiotics include:
- Daycare attendance
- Child < 2 years
- Recent antibiotic treatment (< 30 days)

DIAGNOSIS
Clinical diagnosis depends on history and the methodical assessment of the position, color, transparency and mobility of the
tympanic membrane.
Diagnosis of AOM is marked by:
Recent, usually abrupt, onset of signs and symptoms.
Presence of middle-ear effusion indicated by at least one of the following:
- Bulging of the tympanic membrane OR
- Air-fluid level behind the tympanic membrane OR
- Tympanic membrane color (whitish, yellowish) and opaque OR
- Otorrhea OR
- Mobility of the tympanic membrane absent or limited
And middle-ear inflammation as indicated by at least one of the following:
- Marked or diffuse erythema of the tympanic membrane OR
- Otalgia (discomfort clearly referable to the ear interfering with or precluding normal activity or sleep)
It is necessary to differentiate acute otitis media from an effusion without inflammation (serous or mucoid otitis media) which
does not require antibiotics.
REFERENCES

American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media
with Effusion. Otitis Media with effusion. Pediatrics. 2004;113:1412-29.
American Academy of Pediatrics and American Academy of Family Physicians. Clinical practice Guideline, Subcommittee on Management of Acute Otitis Media. Diagnosis
and Management of Acute Otitis Media. Pediatrics. 2004;113:1451-65.
Comit des maladies infectieuses et dimmunisation, Socit canadienne de Pdiatrie. Lantibiothrapie de lotite moyenne aigu, 2009, sous presse.
Vanderkooi OG, Low DE, Green K, et al. Predicting antimicrobial resistance in invasive pneumococcal infections. Clin Infect Dis. 2005 May 1;40(9):1288-97.
Please note that other references have been consulted.

www.cdm.gouv.qc.ca

TREATMENT GUIDELINES
Prevention:
- Smoke-free home
- Adequate nasal hygiene according to childs age

Most cases of otitis recover without antibacterial therapy.

Assessment and management of pain: analgesics/antipyretics

Criteria for initial treatment or observation of children with AOM

Age

Clear diagnosis

Unclear diagnosis

<6 months

Antibiotic treatment

Antibiotic treatment

6 months to 2 years

Antibiotic treatment

Antibiotic treatment if severe symptoms*

Observation option if mild symptoms

>2 years

Antibiotic treatment if severe symptoms*

Observation option if mild symptoms

Observation option if mild symptoms

* Severe symptoms: moderate to severe otalgia or fever 39C.

Observation option: defer antibiotic treatment for 48-72 hours appropriate only when there is assurance of a medical follow-up and when antibiotic treatment is initiated if illness persists or worsens.
This option requires an explanatory discussion with parents.
Mild symptoms: mild otalgia and fever <39C in previous 24 hours.

High-dose amoxicillin (90 mg/kg/day):

Adequate concentrations in middle ear for treating pneumococci intermediately

resistant to penicillin and most of pneumococci highly resistant to penicillin

First-line antibacterial treatment of AOM

Better activity against penicillin-sensitive pneumococci
than all cephalosporins and macrolides
High doses usually well-tolerated by children

Antibiotic treatment of AOM

Antibiotic*

First-line treatment

Amoxicillin

Second-line treatment
Antibiotic if failure to respond to
treatment after 48-72 hours
Antibiotic in
case of allergy
to penicillin

Daily oral dosage

Maximum oral
dosage

Duration of therapy
according to age
Under 2 years

2 years and over

90 mg/kg/day BID

1 500 mg BID

10 days

5-7 days

Amoxicillin-clavulanate
potassium (Clavulin)

90 mg/kg/day BID

1 000 mg BID

10 days

10 days

CeftriaxoneII

50 mg/kg/day IV or IM

2 000 mg/dose

3 days

3 days

If non-type I
allergy
to penicillin

Cefprozil (Cefzil)

30 mg/kg/day BID

500 mg BID

10 days

5-7 days

Cefuroxime axetil (Ceftin)

30 mg/kg/day BID

500 mg BID

10 days

5-7 days

If type I allergy
to penicillin

Clarithromycin (Biaxin)

15 mg/kg/day BID

500 mg BID

10 days

5-7 days

AzithromycinIII
(Zithromax)

10 mg/kg DIE on 1st day then

5 mg/kg/day DIE x 4 days

500 mg DIE day 1 then

250 mg DIE x 4 days

5 days

5 days

Clindamycin (Dalacin C)

20-30 mg/kg/day TID

450 mg TID

10 days

10 days

* The antibiotics are usually listed in alphabetical order of their generic name. Only one brand name product is listed although several manufacturers may market other brand names.
Daily dosage must be divided as recommended.
Amoxicillin (50 mg/kg/day) may be used in children without risk factors for antibiotic resistance.
The 7:1 (BID) formulation of amoxicillin-clavulanate potassium (Clavulin) is preferred because of its better GI tolerance. For certain clinicians, adverse GI effects are lessened with a combination
of amoxicillin (45 mg/kg/day) and amoxicillin-clavulanate potassium (45 mg/kg/day).
II After failure with high-dose amoxicillin, then failure with high-dose amoxicillin-clavulanate potassium (Clavulin), ceftriaxone may be given at a dose of 50 mg/kg/day IV or IM
(maximum of 2g/dose) and consultation in ORL. According to the history, the treatment is DIE for 3 days or consider myringotomy and tube (general anesthesia). This is rarely necessary
if high-doses of amoxicillin or amoxicillin-clavulanate potassium had been used in a previous treatment.
III A Canadian prospective cohort study (Vanderkooi et al, 2005) has shown a significantly lower risk of emergence of macrolide resistance with the use of clarithromycin
(Biaxin, Biaxin Bid, Biaxin XL) as compared to azithromycin (Zithromax).

Acute Otitis Media in Children

This guide was developed with the collaboration of the professional corporations (CMQ, OPQ), the federations (FMOQ, FMSQ) and Qubec associations of pharmacists and physicians.