2013 AAP Clinical Practice Guideline:
Diagnosis & Management of Acute Otitis Media
Below is a summarization of the 2013 AOM guideline. Please review the complete
guideline for details & explainations.
Guideline for 6 months – 12 years for uncomplicated AOM
Key Action Statements:
Diagnosis:
1A: Clinicians should diagnose AOM in children who present with moderate
to severe bulging of the tympanic membrane or new onset of otorrhea not
due to acute otitis externa (GRADE B RECOMMENDATION)
1B: Clinicians may diagnose AOM in children who present with mild bulging
of the tympanic membrane and recent (<48hrs) onset of ear pain (holding,
tugging, rubbing of ear in non-verbal children) or intense erythema of TM
(GRADE C RECOMMENDATION)
1C: Clinicians should not diagnose AOM in children who do not have middle
ear effusion (MEE) based on pneumatic otoscopy and/or tympanometry
(GRADE B RECOMMENDATION)
2: The management of AOM should include an assessment of pain. If pain is
present, the clinician should recommend treatment to reduce pain (GRADE B
STRONG RECOMMENDATION)
 Pain in non-verbal children: tugging, rubbing, holding ear. Excessive
crying, changes in sleep patterns, change in behavior pattern
 Antibiotic therapy of AOM does not provide symptomatic relief in the
first 24 hours & even after 3-7 days there may be persistent pain,
fever, or both in 30% of children <2 yrs
 Management of pain, especially during first 24 hours of an episode of
AOM should be addressed regardless of the use of antibiotics. No
specific treatments have been well studied, so should be selected
based on risks/benefits
o Acetaminophen, ibuprofen- effective for mild to moderate pain
o Home remedies (distraction, oil drips, external heat/cold)- no
controlled studies
o Topical agents (Benzocaine, procaine, lidocaine)- additional
but brief benefit over acetaminophen in patients >5 yrs old
o Narcotic analgesia with codeine or analogs- effective for
moderate to severe pain but not without risks
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Management:
3A: Severe AOM: The clinician should prescribe antibiotic therapy for AOM
(bilateral or unilateral) in children 6 months or older with severe signs or
symptoms (GRADE B STRONG RECOMMENDATION)
 Moderate or severe otalgia ≥ 48hrs
 Temperature 39 C (102.2 F) or higher
3B: Non-severe Bilateral AOM in 6m-23 months: The clinician should
prescribe antibiotic therapy for bilateral AOM without severe signs or
symptoms (GRADE B RECOMMENDATION)
 Mild otalgia for <48 hrs
 Temperature <39 C
3C: Non-severe Unilateral AOM in 6m-23months: The clinician should either
prescribe antibiotic therapy or offer observation with close follow-up based
on joint decision with parent(s)/caregiver for unilateral AOM without severe
symptoms or signs. When observation is used, a mechanism must be in place
to ensure follow-up and begin antibiotics if the child worsens or fails to
improve within 48-72 hours of onset of symptoms (GRADE B
RECOMMENDATION)
 Mild otalgia for <48 hrs
 Temperature <39 C
3D: Non-severe AOM in 24 m-12 years: The clinician should prescribe
antibiotic therapy or offer observation with close follow-up based on joint
decision with parent(s)/caregiver for AOM (bilateral or unilateral) without
severe signs or symptoms. When observation is used, a mechanism must be
in place to ensure follow-up and begin antibiotics if the child worsens or fails
to improve within 48-72 hours of onset of symptoms (GRADE B
RECOMMENDATION)
TABLE 4: Recommendations for Initial Management for Uncomplicated AOMa
Age
Otorrhea With
AOMa
Unilateral or
Bilateral AOMa
With Severe
Symptomsb
Bilateral AOMa
Without
Otorrhea
Unilateral AOMa
Without
Otorrhea
6 mo to
2y
Antibiotic
therapy
Antibiotic
therapy
Antibiotic
therapy
≥2 y
Antibiotic
therapy
Antibiotic
therapy
Antibiotic
therapy or
additional
observation
Antibiotic
therapy or
additional
observation
Antibiotic
therapy or
additional
observationc
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Treatment:
4A: Clinicians should prescribe amoxicillin for AOM when a decision to treat
with antibiotics has been made & the child has not received amoxicillin in the
last 30 days or the child does not have concurrent purulent conjunctivitis or
the child is not allergic to PCN (GRADE B RECOMMENDATION)
 96% of AOM have microbiologic pathogen: 66% bacteria & virus, 27%
bacteria alone, 4% virus alone
 3 most common pathogens: S pneumonaie, nontypeable Haemophilius
influenza, and Moraxella catarrhalis. Group A step occurs <5%
 Published evidence has suggested that AOM associated with
conjunctivitis (purulent) is more likely cause by non-typeable H.
Infuenza than by any other bacteria
 High dose amoxicillin is recommended as first line treatment in
most patients
4B: Clinicians should prescribe an antibiotic with additional β-lactamase
coverage from AOM when a decision to treat has been made and the child has
received amoxicillin in the last 30 days, or has concurrent purulent
conjunctivitis, or has a history of recurrent AOM unresponsive to amoxicillin
(GRADE C RECOMMENDATION)
 High dose amoxicillin-clavulanate is recommended as the treatment
of choice in non-PCN allergic
o Clinical Pearl: Never write for the amoxicillin-clavulanate
200mg/62.5mg (clavulanic)/5ml suspension as this has the
highest amount of clavulanic acid of any of the suspensions
resulting in overdose (max is 10mg/kg, recommended
6.4mg/kg) & GI side effects.
 Suspensions available: amoxicillin/clavulanate/ml
1. 125mg/31.25/5ml- I do not recommend
2. 200mg/28.5mg/5ml
3. 250mg/62.5mg/5ml- I do not recommend
4. 400mg/57mg/5ml
5. 600mg/42.9mg/5ml- I typically use
 Tablets available:
1. 200mg/28.5mg (chewable)
2. 250mg/125mg- I do not recommend
3. 400mg/57mg (chewable)
4. 500mg/125mg
5. 875mg/125mg
6. 1000mg/62.5mg (XR)
 Alternative antibiotics (see table 5 below)
o Recent data shows susceptibility of S. Pneumoniae to cefdinir &
cefuroxime are 70-80%, compared to 84-92% for amoxicillin
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o Recent data shows susceptibility of H. Influenza to cefdinir is
98%, compared to 58% for amoxicillin and 100% for
amoxicillin-clavulanate
o PCN Allergy: recent data suggest that cross reactivity among
pencillins and cephalosporins is lower than historically
reported (10%)
 Degree of cross reactivity is higher between PCN &
first generation cephalosporins but is negligible with
second & third generation cephalosporins
 Joint task force on practice parameters; American
Academy of Allergy, Asthma & Immunology; Joint
council of allergy, asthma, and Immunology state that
“cephalosporin treatment in patients with history of
penicillin allergy, selecting out those with severe
reaction histories, show reaction rate of 0.1%”
 Recommend a cephalosporin in cases without severe
and/or recent pencillin allergy reaction history when
skin test is not available
o Macrolides have limited efficacy against both H. Influenza & S.
Pneumo
o Bactrim has substantial resistance for S. Pneumo, so is
therefore not recommended
o Clinamycin lacks efficacy against H. Influenza, but may be used
for suspected PCN resistant S. Pneumo
4C: Clinicians should reassess the patient if the caregiver reports that the
child’s symptoms have worsened or failed to respond to treatment within 4872 hours & determine whether a change in therapy is needed (GRADE B
RECOMMENDATION)
 Can be either RTC in 2-3 days or rescue antibiotics ("safety net” or
“wait & see antibiotics”) to start in 2-3 days if child fails to improve or
symptoms worsen
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TABLE 5: Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients
Who Have Failed Initial Antibiotic Treatment
Initial Immediate or Delayed Antibiotic
Treatment
Recommended Firstline Treatment
Alternative
Treatment (if
Penicillin Allergy)
Antibiotic Treatment After 48–72 h of
Failure of Initial Antibiotic Treatment
Recommended
First-line
Treatment
Alternative
Treatment
Amoxicillin (80–90 mg/
kg per day in 2 divided
doses)
Cefdinir (14 mg/kg
per day in 1 or 2
doses)
Amoxicillinclavulanatea (90
mg/kg per day of
amoxicillin, with
6.4 mg/kg per day
of clavulanate in 2
divided doses)
Ceftriaxone, 3 d
Clindamycin (30–40
mg/kg per day in 3
divided doses), with
or without thirdgeneration
cephalosporin
or
Cefuroxime (30
mg/kg per day in 2
divided doses)
or
Failure of second
antibiotic
Amoxicillin-clavulanatea
(90 mg/kg per day of
amoxicillin, with 6.4
mg/kg per day of
clavulanate [amoxicillin
to clavulanate ratio,
14:1] in 2 divided
doses)
Cefpodoxime (10
mg/kg per day in 2
divided doses)
Ceftriaxone (50
mg IM or IV for 3
d)
Clindamycin (30–40
mg/kg per day in 3
divided doses) plus
third-generation
cephalosporin
Tympanocentesisb
Ceftriaxone (50 mg
IM or IV per day for
1 or 3 d)
Consult specialistb
Recurrent AOM:
5A: Clinicians should not prescribe prophylactic antibiotics to reduce the
frequency of episodes of AOM in children with recurrent AOM (GRADE B
RECOMMENDATION)
5B: Clinicians may offer tympanostomy tubes for recurrent AOM (GRADE B
OPINION)
 3 episodes in 6 months
 4 episodes in 1 year with 1 episode in the preceding 6 months
Prevention:
6A: Clinicians should recommend pneumococcal conjugate vaccine to all
children according to the schedule of the ACIP, AAP (GRADE B STRONG
RECOMMENDATION)
6B: Clinicians should recommend annual influenza vaccine to all children
according to the schedule (GRADE B RECOMMENDATION)
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6C: Clinicians should encourage exclusive breast-feeding for at least 6
months (GRADE B RECOMMENDATION)
6D: Clinicians should encourage avoidance of tobacco smoke exposure
(GRADE C RECOMMENDATION)
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