Otitis media is one of the most common diagnoses made by pediatricians. However, a great deal of variability remains in diagnostic criteria, approaches to therapy, and follow-up. This self-study activity provides practical guidance to clinicians about diagnosing and treating otitis media based on available empirical evidence.

Key and newer aspects of care that are elaborated in the guideline include:

• Deferring antibiotic therapy should be considered for children age 2 and older with acute otitis media (AOM) and mild to moderate symptoms.
• Analgesic therapy should be recommended for all children with AOM
• When antibiotic therapy is deferred, facilitate patient access to antibiotics if symptoms worsen (e.g., a "back-up" prescription given at visit or a convenient system for subsequent call-in).
• For children with AOM unresponsive to amoxicillin, either amoxicillin/clavalanate or high dose azithromycin are appropriate second line therapies.
• Oral cephalosporins should not be used to treat AOM
• Referral to otolaryngology should be made based on the symptoms of OME or concern for anatomic damage to middle ear structures, rather the simple duration of the effusion

When medical antibiotic treatment is indicated:

• High dose amoxicillin is the first choice of antibiotic therapy for all cases of AOM. 
  • For children under 4 years of age, 80 mg/kg/day divided BID for 5- 10 days.
  • For children 4 years of age or older, 40- 60 mg/kg/day is probably adequate.
  • For adults, either 875 mg BID x 10 days or 500 mg 2 tabs BID x 10 days.
• Treat AOM that is clinically unresponsive to amoxicillin after 72 hours of therapy with either:
  • amoxicillin/clavulanate – pediatric 80 mg/kg divided BID x 10 days; adult 875/125 mg BID x 10 day
  • azithromycin – pediatric 20 mg/kg daily for 3 days; adult 1 g daily for 3 days
• Patients with persistent symptoms on these agent should receive: ceftriaxone – pediatric 50-75 mg/kg/day IM x 1-3 days; adult 1-2g IM/IV daily x 1-3 days.  The decision to use ceftriaxone should take into account the possible impact of this antibiotic on patterns of antibiotic resistance. 

This self-study activity is appropriate for primary care clinicians and other health care providers who diagnosis and treat otitis media in children and adults.

Team Leader	Richard Linsk, MD      General Pediatrics
Team Members	Alexander Blackwood, MD      Pediatric Infectious Disease James Cooke, MD      Family Medicine Van Harrison, PhD      Medical Education Peter P. Passamani, MD      Pediatric Otolaryngology
Author Disclosures	Team Member Company Relationship Alexander Blackwood, MD, PhD (None) James Cooke, MD (None) Van Harrison, PhD (None) Richard Linsk, MD (None)   Peter P. Passamani, MD (None)

UMHS Guidelines Oversight Team:	William E. Chavey, MD R. Van Harrison, PhD
Literature search services:	Taubman Medical Library
Production of Internet format and web site maintenance:	Ellen Patrick-Dunlavey