Pediatric Acute Otitis Media Empiric Therapy 

Updated: Dec 11, 2014
  • Author: Brenda L Natal, MD, MPH; Chief Editor: Thomas E Herchline, MD  more...
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Empiric Therapy Regimens

Empiric therapeutic regimens for acute otitis media in children are outlined below, including general recommendations, first- and second-line treatments, treatment for penicillin-allergic patients, and treatments for patients with recurrent illness or treatment failures. [1, 2, 3, 4, 5, 6, 7, 8]

General recommendations

Adequate pain and fever control with either oral acetaminophen or ibuprofen or topical pain control with topical benzocaine preparations is imperative whether antibiotics are given or not.

Age < 6mo:

  • Should receive antibiotics whether the diagnosis of acute otitis media is certain or not

Age 6mo to 2y:

  • Should receive antibiotics if the diagnosis is certain
  • If the diagnosis is uncertain, an observation period can be considered if the illness is nonsevere

Age > 2y:

  • Should receive antibiotics if the diagnosis is certain and if the illness is severe
  • An observation period is advised if the diagnosis is uncertain or if it is certain and nonsevere

First-line treatment

See the list below:

  • Amoxicillin 80-90 mg/kg/day PO (maximum 3 g/24h) divided BID for 5-7d; 10d may be required if illness is severe or
  • Ceftriaxone 50 mg/kg IM × 1 dose (maximum 1 g); recommended for children unable to take antibiotics PO and for patients with compliance issues

Children with acute otitis media with tympanostomy tubes:

Second-line treatment

Penicillin allergic:

Non – type-1 hypersensitivity:

  • Cefdinir 14 mg/kg/day (maximum 600 mg/24h) PO qd or divided BID for 5-10d or
  • Cefpodoxime 10 mg/kg/day (maximum 400 mg/24h) PO qd or divided BID for 5-10d or
  • Cefuroxime 30 mg/kg/day PO (maximum 1 g/24h) divided BID for 5-10d

Type-1 hypersensitivity:

  • Azithromycin 10 mg/kg/day (maximum 500 mg) PO × 1 dose, then 5 mg/kg/day (maximum 250 mg/24h) PO qd × 4d or
  • Azithromycin 10 mg/kg/day (maximum 500 mg/24h) PO qd × 3d or
  • Clarithromycin 15 mg/kg/day (maximum 1 g/24h) PO divided BID for 5-10d

Recurrent acute otitis media/treatment failure

See the list below:

  • Amoxicillin-clavulanate 90 mg/kg/day (based on amoxicillin component using XR formulation; maximum 4 g/24h) PO divided BID for 5-7d or
  • Cefdinir 7 mg/kg q12h or 14 mg/kg q24h for 5-7d or
  • Cefpodoxime 10 mg/kg/day as a single dose or
  • Cefprozil 15 mg/kg q12h for 5-7d or
  • Cefuroxime 30 mg/kg/day divided q12h for 5-7d or
  • Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d

Persistent treatment failure

See the list below:

  • Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d or
  • Clindamycin 20-30 mg/kg/day divided QID for 5-7d