Acute Otitis Media

Patient Population: Pediatric
Condition Major Pathogens  First-choice Therapy Alternative Therapy Comments
Acute otitis media 

Streptococcus pneumoniae 

Haemophilus influenzae 

Moraxella catarrhalis 


Severe symptoms: moderate or severe otalgia or otalgia > 48 hours, or temperature 39C or higher 

Non-severe symptoms: mild otalgia < 48 hours, temperature <39C 

Recommend initial observation without antibiotic therapy for 48-72 hours in immunocompetent patients with the following criteria: 

6 months-2 years old: unilateral, no otorrhea, non-severe symptoms (see second column) 


>=2 years old: no otorrhea, non-severe symptoms (see second column) 

Ensure that reassessment and initiation of antibiotic will be feasible if symptoms do not improve during observation 


For patients not meeting above criteria

45 mg/kg/dose (max 1000 mg/dose)* enterally bid  


If patient meets criteria for treatment (same as 3rd column), and has received Amoxicillin within preceding 30 days, has purulent conjunctivitis, history of recurrent AOM not responsive to Amoxicillin, or does not respond to initial therapy with Amoxicillin x 48-72 hours

Amoxicillin-clavulanate (Augmentin)
45 mg amoxicillin/kg/dose (max 1000 mg amoxicillin/dose)* enterally bid   

Penicillin allergy with lower risk for allergic reaction

Oral cephalosporin (follow link for options) 

Penicillin allergy with higher risk for allergic reaction:  

Consult AAP/AAFP guidelines (linked below) or ASP. Azithromycin is not recommended for this indication. 


Failed oral therapy:  

Consult AAP/AAFP guidelines (linked below) 

Duration for beta lactam therapy

< 2 years old or any age with severe symptoms: 10 days 

2-5 years old: 7 days 

> 5 years old: 5 days 

Pain control recommended for all patients 

*See guidance on Amoxicillin and Amoxicillin-clavulanate maximum dosing and formulation


Lieberthal, AS, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-e999. 

American Academy of Family Physicians Choosing Wisely Recommendation (updated 2018).

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.  

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.