Pediatric Guidelines: Respiratory Infections - Acute Otitis Media

Condition Major Pathogens First Choice Therapy Alternative Therapy Comments
Acute otitis media

Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

Consider 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 infection
  • >=2 years old: no otorrhea, non-severe infection

Amoxicillin 45mg/kg/dose PO BID (max 1000mg/dose)*

If patient 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) 45mg/kg/dose amoxicillin PO BID (max 1000mg amoxicillin/dose)*

Duration for beta lactam therapy (not Azithromycin):

< 2 years old or severe infection: 10 days

2-5 years old: 7 days

> 5 years old: 5 days

Pain control recommended for all patients

*Click here for guidance on Amoxicillin and Amoxicillin-Clavulanate maximum dosing and formulations


Non-severe penicillin allergy:

Cefdinir 7mg/kg/dose PO BID (max 600mg/day)

Severe beta lactam allergy:

Azithromycin 10mg/kg/dose PO x 1 on day 1 (max 500mg/dose) then 5mg/kg/dose PO daily on days 2-5 (max 250mg/dose)

Failed oral therapy:

Ceftriaxone 50mg/kg IM/IV q24h (max 1g/dose) 

Single dose may be sufficient if there is clinical improvement within 48h, but up to 3 doses may be necessary

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

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. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP).