Acute Otitis Media (AOM) is the most common infection for which antibacterial agents are prescribed for children in the United States. The diagnosis of AOM requires 1) acute onset, 2) middle ear inflammation, and 3) presence of Middle Ear Effusion (MEE). Tympanograms are useful to confirm the presence of MEE.

To address the rising rates of antibacterial resistance and the growing costs of antibacterial prescriptions, Mercy Clinics, Inc. endorses the following recommendations regarding the management of uncomplicated AOM in otherwise healthy children from 2 months through 12 years of age (excluded are children with a recurrence of AOM within 30 days):

1. The management of AOM should include a pain assessment regardless of the use of antibacterial agents.  Acetaminophen or ibuprofen is considered the mainstay of pain management for AOM.
2. Observation without the use of antibacterial agents in a child age greater than 6 months with uncomplicated AOM is an option for selected children based upon diagnostic certainty, illness severity and the assurance of follow-up systems.
3. When the decision is made to treat with an antibiotics, the recommended agents are:
   

   Temp > 102 and/or Severe Otalgia	Initial Antibiotic Choice		ATB Choice After Failure at 48-72 Hours of Initial ATB
   	Recommended	Penicillin Allergy	Recommended	Penicillin Allergy
   No	Amoxicillin, 80-90 mg/kg per day	Non-type I: Cefdnir, cefuroxime, cefpodoxime; Type I: Azithromycin, Clarithromycin	Amox-Clavulanate, 90 mg/kg per day of Amoxicillin, with 6.4 mg/kg per day of Clavulante	Non-type I: Ceftriaxone, 3 days; Type I: Clindamycin
   Yes	Amox-Clavulanate, 90 mg/kg per day of Amoxicillin, with 6.4 mg/kg per day of Clavulanate	Type I reaction is anaphylaxis or urticaria Ceftriaxone, 1 or 3 days	Ceftriaxone, 3 days	Refer to ENT, Clindamycin

4. If the patient fails to respond to initial management within 48-72 hours, the clinician must reassess the patient to confirm AOM.  If the patient was initially managed with observation, the clinician should begin ATB therapy.  If the patient was initially managed with ATB, the clinician should change the ATB. 
5. The above guidelines are suggested for acute non-recurrent otitis media.  The treatment of chronic otitis media with effusion would require individual clinician decision.

Reference: 

 Diagnosis and Mangement of Acute Otitis Media-AAP and AAFP Clinical Practice Guideline. Pediatrics, 113 (5).  May 2004: 1451-1465.

Variation from this guideline is always acceptable if in the opinion of the attending physician individual circumstances require it