Sandbox aom

# Overview
Acute otitis media (AOM) usually follows a viral upper respiratory tract infection leading to Eustachian tube dysfunction with impaired clearance and pressure regulation of the middle ear.  Current guidelines recommend observation for children age 6 to 24 months with unilateral AOM without otorrhea or children older than 2 years with unilateral or bilateral AOM without otorrhea.  Antibiotics covering common bacterial pathogens (e.g., Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae) have been used with success in selected patients to accelerate the recovery and lower the risk of tympanic membrane perforations and contralateral AOM episodes.  High-dose amoxicillin (90 mg/kg/day) is the drug of choice for initial antibiotic therapy; high-dose amoxicillin-clavulanate or intramuscular ceftriaxone should be reserved for patients who fail to respond to first-line treatment within 48 to 72 hours.  The optimal duration of antibiotics remains uncertain: a 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms. In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively.  Otalgia is generally managed with acetaminophen, ibuprofen, or narcotic analgesics with codeine.

# Initial Management of Uncomplicated AOM with High Certainty of Diagnosis
 A toxic-appearing child, persistent otalgia more than 48 h, temperature 39C (102.2F) in the past 48 h, or if there is uncertain access to follow-up after the visit.

# Observation
Due to the self-limited nature of most episodes of AOM (particularly in children 2 years and older), initial observation is advisable for selected patients if close follow-up can be ensured and rescue antibiotics administered for persistent or worsening symptoms in 48 to 72 hours.

# Antibiotic Therapy

## Rationale for Antibiotic Choice
The rationale for antibiotic therapy in children with AOM is based on a high prevalence of bacteria from tympanocentesis cultures.  A significant benefit of immediate antibiotic therapy is most evident in bilateral AOM, AOM with severe symptotms, AOM with otorrhea, or Streptococcus pneumoniae infection.  Antibiotic therapy is recommended in the following settings:
- AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours, or temperature 39C  or higher)
- Bilateral AOM in children younger than 24 months without severe signs or symptoms
When a decision to treat with antibiotics has been made, high-dose amoxicillin is recommended if all of the following criteria are fulfilled:
- The patient has not received amoxicillin in the past 30 days.
- The patient does not have concurrent purulent conjunctivitis.
- The patient is not allergic to penicillin.
Additional -lactamase coverage should be considered if any of the following criteria is fulfilled:
- The patient has received amoxicillin in the past 30 days.
- The patient has concurrent purulent conjunctivitis.
- The patient has a history of recurrent AOM unresponsive to amoxicillin.

## Duration of Therapy
The optimal duration of antibiotics remains unsettled.  Standard 10-day course of antibiotic therapy is recommended for children younger than 2 years and children with severe symptoms.  In the absence of severe symptoms, a 7- or 5-day course is advisable for children 2 to 5 years of age or children 6 years and older, respectively.

## Antibiotic Regimens

### Initial (Immediate or Delayed) Antibiotic Treatment
Amoxicillin (8090 mg/kg/d bid) OR Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d)
Cefdinir (14 mg/kg/d qd or bid) OR Cefuroxime (30 mg/kg/d bid) OR Cefpodoxime (10 mg/kg/d bid) OR Ceftriaxone (50 mg IM/IV qd)

### After Failure of Initial Antibiotic Treatment
Amoxicillin (90 mg/kg/d) with Clavulanate (6.4 mg/kg/d) OR Ceftriaxone (50 mg IM/IV qd)
Clindamycin (3040 mg/kg/d tid)  3 Cephalosporin  Tympanocentesis

# Pain Management
Episodes of AOM are commonly associated with otalgia.  Acetaminophen and ibuprofen are the mainstay of management for mild to moderate ear pain.  Narcotic analgesia with codeine should be used with caution in the treatment of severe otalgia due to the risk of respiratory depression, altered mental status, gastrointestinal upset, and constipation.