Initial management of acute otitis media in children

AOM: acute otitis media; IgE: immunoglobulin E; IM: intramuscular.

* We use acetaminophen, ibuprofen, or a combination of the 2 (ie, alternating medications and giving 1 every 4 hours).

¶ We recommend that the decision be made collaboratively with caregivers. While antibiotics may hasten pain resolution, observation allows for the avoidance of side effects and limits the emergence of antibiotic resistance. This is consistent with the American Academy of Pediatrics 2024-2027 Red Book recommendations.

Δ IgE-mediated reactions typically begin within 1 hour of the initial or last-administered dose; common features include anaphylaxis, angioedema, wheezing, laryngeal edema, hypotension, and hives/urticaria. Delayed reactions appear after multiple doses of antibiotic. Examples include Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug-induced cytopenias. For additional details, refer to UpToDate content on penicillin allergy.

◊ If appropriate, follow local protocol to remove (delabel) allergy to penicillin.

§ Examples include azithromycin and clarithromycin.

¥ Examples include cefpodoxime, cefuroxime, and cefdinir. Oral cephalosporins should be reserved for children who are unable to take penicillin-containing antibiotics and should not be routinely used as first-line therapy for AOM.

‡ If symptoms persist for >72 hours or worsen, refer to otolaryngologist for tympanocentesis.

† Levofloxacin should be reserved for children with contraindications to ceftriaxone or AOM that is refractory to other antibiotics.