Cephalosporins are not as effective as high-dose amoxicillin against S pneumonia and should not be chosen as first-line therapy in patients who can take amoxicillin Azithromycin and other macrolides have limited efficacy against S pneumoniae and H influenza and should not be used for the treatment of AOM A 10-day course of antibiotics is recommended for children less than 24 months of age with AOM In patients with mild or moderate AOM who are over 24 months of age, a 7-day course of antibiotics is adequate Evidence does not support routine 10- to 14-day follow-up for patients after treatment of AOM A majority of children will have persistent middle ear fluid weeks after the start of treatment, and almost half will still have fluid at month Children with persistent symptoms after treatment for AOM should follow up with their primary care provider Oral decongestants, intranasal decongestants, oral antihistamines, and steroid preparations are ineffective in the treatment of AOM and OME and should not be prescribed Persistent middle ear fluid without acute symptoms (OME) may be associated with a conductive hearing loss Though the evidence for a long-term impact of mild and transient conductive hearing loss on otherwise normal children is weak, those in whom there is concern for developmental or cognitive delays should be followed more closely Children with persistent middle ear effusion should not generally receive antibiotic prophylaxis There is a modest, short-term benefit of antibiotic prophylaxis in reducing episodes of recurrent AOM Antibiotic prophylaxis is not recommended for most children with recurrent AOM Tympanostomy tube placement is a decision that is best made by primary care providers in consultation with otolaryngologists, and should be considered if a child has had three documented episodes of AOM within months or four episodes within the preceding year OTORRHEA Children with AOM and perforation improve more quickly when treated with oral antibiotic therapy rather than topical therapy Many experts also recommend antibiotic ear drops in this setting, though there is little evidence for this dual therapy Fluoroquinolone otic drops are safe in patients with perforated TMs If the otorrhea is chronic, there is benefit from otic drops with a combination of fluoroquinolone and steroid Patients with tympanostomy tubes who present with otorrhea without acute symptoms should be treated with ototopical antibiotic– steroid combination drops for to days, which is superior to oral antibiotics in resolving the otorrhea COMPLICATIONS OF ACUTE OTITIS MEDIA