Acute otitis media in kids

Advise saving antibiotics for infants under 6 months, kids under 2 with BOTH ears infected or any child with ear drainage or severe symptoms...
Abdelwahab Ward, BS Pharm, PharmD

Winter will lead to an uptick of acute otitis media in kids. Help promote appropriate antibiotic use to limit resistance... Reinforce "watchful waiting" for many kids. Point out that antibiotics rarely help, since most ear infections are viral. Antibiotics resolve ear pain at 2 to 3 days in about 1 in 20 kids, but 1 in 14 will have side effects (diarrhea, rash, etc).

     Clarify that acetaminophen (Cetal) 15 mg/kg every 8 hours or ibuprofen (Brufen) 5 mg/kg every 8 hours is often enough for pain. Don't recommend other OTCs, such as antihistamines, decongestants, or nasal steroids, these don't seem to help. Explain that "natural" ear drops, such as olive oil or Earocure drops don't have proven benefit. And discourage "ear candling" due to possible burns and eardrum damage. Advise saving antibiotics for infants under 6 months, kids under 2 with BOTH ears infected or any child with ear drainage or severe symptoms (fever of 39°C or higher, ear pain for 48 hours or more, or moderate to severe pain). Generally recommend amoxicillin (Amoxil) 80 to 90 mg/kg/day divided BID. But go to amoxicillin/clavulanate (Augmentin, Hibiotic) if amoxicillin was used in the past 30 days. For kids with a NONsevere penicillin allergy, such as a non-itchy rash, suggest a cephalosporin such as cefprozil (Cefzil) and cefuroxime (Zinnat, Zinacef).

Reserve azithromycin (Zithromax), clarithromycin (Klacid, Clarithro), or clindamycin (Dalacin C) for kids with a SEVERE penicillin allergy (angioedema, etc). Keep in mind, these generally aren't as effective as beta-lactam antibiotics against S. pneumoniae and H. influenzae. Advise treating kids under age 2 for 10 days and older kids for 5 to 7 days. Don't suggest antibiotic prophylaxis, it only reduces infections by about 1/year and likely increases resistance. Be aware that ear tubes are often a better option for frequent ear infections. Get our note, "Antibiotics prescribing acute otitis media (AOM)", for details on antibiotic dosing.

Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have Failed Initial Antibiotic Treatment
Initial Immediate or Delayed Antibiotic Treatment Antibiotic Treatment After 48–72 h of Failure of Initial Antibiotic Treatment
Recommended First-line Treatment Alternative Treatment (if Penicillin Allergy) Recommended First-line Treatment Alternative Treatment
Amoxicillin (80–90 mg/ kg per day in 2 divided doses) Cefdinir (14 mg/kg per day in 1 or 2 doses) Amoxicillin-clavulanate (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses) Ceftriaxone, 3 d Clindamycin (30–40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin
or Cefuroxime (30 mg/kg per day in 2 divided doses) or Failure of second antibiotic
Amoxicillin-clavulanate (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate [amoxicillin to clavulanate ratio, 14:1] in 2 divided doses) Cefpodoxime (10 mg/kg per day in 2 divided doses) Ceftriaxone (50 mg IM or IV for 3 d) Clindamycin (30–40 mg/kg per day in 3 divided doses) plus third-generation cephalosporin
Tympanocentesis
Ceftriaxone (50 mg IM or IV per day for 1 or 3 d) Consult specialist

REFERENCES

Abdelwahab Ward, BS Pharm, PharmD