Lesson 6 of8
In Progress

Pharmacologic Management

Jimmy October 26, 2021

OM is considered to be a self-limited disease and recommendations follow observation as an initial treatment option, then use of antibiotics if the patient’s condition did not improve within 72 hours.

As OM may cause substantial pain, Acetaminophen and Ibuprofen are safe, over-the-counter, first-line analgesics to relieve pain and discomfort. Often, a few drops of analgesic ear drops placed in the ear canal until it is filled seem to relieve pain. If symptoms persist or progressively worsen in the next 48 to 72 hours, begin treatment with antibiotics.

If observation option is used, strictly ensure follow-up to check for the condition of the child. If the child worsens or fails to improve within 48 – 72 hours of onset of symptoms, proceed with antibiotic therapy.


Antibiotic therapy can greatly reduce risk of suppurative complications such as mastoiditis.

Immediate antibiotic use is indicated for infants < 6 months old and children with severe illness due to OM or any underlying condition that might affect the usual clinical course, including:

  • Craniofacial malformation (such as cleft palate) or genetic condition associated with craniofacial abnormalities (such as Down syndrome)
  • Immunodeficiency
  • Tympanostomy tubes
  • Cochlear implants


  • Dose: Intraoral, 80-90 mg/kg/day in 2 divided doses
  • Duration: recommended 5-7 days
  • Adverse effects: abdominal pain, stomach pain, black stool, blistering or loosening of the skin, bloating, blood in urine, bloody nose, chest pain
  • Pearls: first-line antibiotic, recommended if child has not received amoxicillin in past 30 days, does not have concurrent purulent conjunctivitis, and is not allergic to penicillin. Otherwise, recommend treatment via Antibiotic with additional beta-lactamase coverage; associated with increased risk of recurrent pediatric OM


  • Dose: Intraoral, Amoxicillin at 90 mg/kg/day plus Clavulanate at 6.4 mg/kg/day in 2 divided doses
  • Duration: recommended 10 day course
  • Adverse effects: diarrhea, eczema, nausea, vomiting, headache, stomach pain, white patches in mouth and throat
  • Pearls: first-line antibiotic after 48 – 72 hour failure of initial antibiotic treatment, recommended if additional beta-lactamase coverage is indicated where child has received amoxicillin in the past 30 days, has concurrent purulent conjunctivitis, or has history or recurrent OM unresponsive to OM

Alternative Cephalosporin antibiotics used if patient is allergic to penicillin:


  • Dose: Intraoral, 14 mg/kg/day once daily or in 2 divided doses
  • Duration: recommended 10 day course
  • Adverse effects: vomiting, nausea, stomach pain, diarrhea, headache, vaginal itching, reddish colored stools
  • Pearls: alternative treatment to penicillin-allergic patients


  • Dose: Intraoral, 30 mg/kg/day once in 2 divided doses
  • Duration: recommended 10 day course
  • Adverse effects: diaper rash in young children, nausea, vomiting, diarrhea, strange taste in the mouth, stomach pain
  • Pearls: alternative treatment to penicillin-allergic patients


  • Dose: Intraoral, 10 mg/kg/day in 2 divided doses
  • Duration: recommended 10 day course
  • Adverse effects: abdominal pain, anxiety, back pain, bloating, body aches, chest tightness, chills, confusion, weakness
  • Pearls: alternative treatment to penicillin-allergic patients


  • Dose: Intramuscular, 50 mg IM or IV/day 
  • Duration: 1 or 3 days
  • Adverse effects: rash, diarrhea, nausea, vomiting, upset stomach, blood clots, dizziness, headache
  • Pearls: alternative treatment to penicillin-allergic patients; considered as first-line antibiotics for patients initially treated with amoxicillin-clavulanate or substitute first-line of choice after failure of treatment with amoxicillin 

Alternative Macrolide antibiotics:


  • Dose: Intraoral, choose between:
    • 30 mg/kg single dose
    • 10 mg/kg once daily for 3 days
    • 10 mg/kg single dose on day 1, followed by 5 mg/kg orally once daily on days 2 through 5
  • Duration: 1-5 days
  • Adverse effects: diarrhea or loose stools, nausea, abdominal pain, stomach upset, vomiting, constipation, dizziness, tiredness
  • Pearls: associated with increased treatment failure compared to amoxicillin (with or without clavulanate)


  • Dose: Intraoral, 15 mg/kg/day divided every 12 hours
  • Duration: 10 days
  • Adverse effects: nausea, vomiting, loss of appetite, bloating and indigestion, headaches, insomnia
  • Pearls: 

Alternative Lincosamide antibiotics:


  • Dose: Intraoral, 30-40 mg/kg/day in 3 divided doses
  • Duration: 2-5 days
  • Adverse effects: nausea, vomiting, unpleasant or metallic taste in mouth, joint pain, pain when swallowing, heartburn, white patches in mouth
  • Pearls: Clindamycin with or without Cephalosporin is an alternative to first-line antibiotic treatment failure; Clindamycin plus third-generation Cephalosporin is considered after failure of initial and second antibiotics