Inflammatory Diseases of the Middle Ear Guidelines

Updated: Jul 07, 2022
  • Author: Diego A Preciado, MD, PhD, FAAP; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Guidelines Summary

Italian Society of Pediatrics

In 2019, the Italian Society of Pediatrics published updated recommendations regarding the management of acute otitis media (AOM) in children. They include the following. [6]

The assessment and treatment of otalgia should be prioritized in AOM management.

The administration of adequate doses of ibuprofen or paracetamol should be the mainstay of otalgia therapy.

All children with otorrhea, intracranial complications and/or a history of recurrence, as well as AOM patients under age 6 months, should receive prompt antibiotic treatment. Children aged 6 months to 2 years should undergo prompt antibiotic treatment for all forms of unilateral and bilateral AOM, whether mild or severe. Children over age 2 years with severe bilateral AOM should also receive prompt antibiotic therapy.

Children over age 2 years with mild or severe unilateral AOM or mild bilateral AOM can be managed with watchful waiting.

It is necessary to assess watchful waiting on a case-by-case basis and discuss it with the patient’s parents; the watchful waiting approach is appropriate only when follow-up is possible within 48-72 hours.

In children with no risk factors for bacterial resistance and no history of recurrence, uncomplicated AOM with mild signs and symptoms should be treated with amoxicillin at a dose of 80-90 mg/kg/day.

Treatment of AOM with amoxicillin-clavulanic acid 80-90 mg/kg/day (dose of amoxicillin) is recommended for children who have taken antibiotics in the last 30 days, have severe symptoms and/or purulent conjunctivitis, have a history of recurrent AOM that is unresponsive to amoxicillin, have otorrhea from a spontaneous perforation, or are at high risk of bacterial resistance (ie, those attending day care, who are not vaccinated against pneumococcus, or who reside in area with a high prevalence of resistant isolates).

Only children with a documented history of recent and/or severe allergy to penicillin should receive macrolides (clarithromycin 15 mg/kg/day). In children who are not severely allergic to penicillin, class II or III cephalosporins are recommended, since molecular cross-reaction is rare.

Treatment with amoxicillin or amoxicillin-clavulanic acid should last 10 days in children at greater risk for unfavorable evolution (ie, those under age 2 years and/or with spontaneous otorrhea).

Quinolone use should be avoided subsequent to AOM treatment failure.

Aside from pain relief therapy, it is not recommended that treatments be combined with antibiotic therapy.

Avoid systemic and topical decongestant and steroid use.

Ototopical antibiotic treatment, whether or not associated with steroid therapy, is recommended only for patients with tympanostomy tubes.