Pediatric Acute Otitis Media Empiric Therapy 

Updated: Jan 24, 2019
  • 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 who have been treated with amoxicillin in the past 30 days, have conjunctivitis, or need beta-lactamase coverage (eg, suspected Haemophilus influenzae resistance):

  • Children 3 months or older -  Amoxicillin/clavulanate 90 mg/kg/day PO divided BID; dose based on amoxicillin component; not to exceed 4 g amoxicillin/day
  • Neonates and infants younger than 3 months - Amoxicillin/clavulanate 30 mg/kg/day PO divided BID; dose based on amoxicillin component; use 125 mg/5 mL oral suspension in this age group

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