AOM, Rhinosinusitis, and Pharyngitis Pharmacotherapy

Acute otitis media (AOM), acute bacterial rhinosinusitis (ABRS), and streptococcal pharyngitis are common outpatient infections in which appropriate pharmacotherapy depends as much on recognizing when antibiotics are unnecessary as on selecting the correct antimicrobial when bacterial disease is established. Most upper respiratory tract infections are viral and resolve spontaneously. Chapter 75 therefore emphasizes accurate diagnosis, symptom management, judicious antibiotic use, and reassessment when the expected clinical response does not occur (Girand, 2026).

Acute Otitis Media

AOM is an inflammatory and infectious process of the middle ear, usually developing after a viral upper respiratory infection disrupts eustachian-tube function and mucociliary clearance. This creates conditions that allow bacterial proliferation within the middle ear. Children are particularly susceptible because their eustachian tubes are shorter, more horizontal, and less effective at drainage than those of adults (Girand, 2026).

AOM should be distinguished from otitis media with effusion (OME). OME involves middle-ear fluid without an acute infectious illness and does not automatically require antimicrobial treatment.

Diagnosing AOM

Accurate diagnosis is important because a mildly erythematous tympanic membrane alone does not establish AOM. Chapter 75 supports the diagnosis when there is moderate-to-severe bulging of the tympanic membrane; mild bulging accompanied by recent otalgia or intense erythema; or new-onset otorrhea that is not caused by acute otitis externa. Impaired tympanic-membrane mobility and middle-ear effusion further support the diagnosis (Girand, 2026).

Severe AOM is defined by moderate-to-severe otalgia, otalgia lasting at least 48 hours, or a temperature of at least 39°C (102.2°F). Most uncomplicated cases improve spontaneously, and untreated AOM improves in more than 80% of children between days 2 and 3 without an increase in complications (Girand, 2026).

Observation Versus Immediate Antibiotics

Observation or a delayed antibiotic prescription can be appropriate for otherwise healthy children with less severe uncomplicated AOM when the clinician and caregiver make the decision jointly and reliable follow-up is available. A delayed prescription is filled only if symptoms persist or worsen within approximately 48–72 hours (Girand, 2026).

Age, laterality, otorrhea, and severity should guide this decision. The assigned chapter reports greater antibiotic benefit in children younger than 2 years with bilateral AOM and in children with AOM accompanied by otorrhea. Children 6–23 months also have poorer outcomes without initial antibiotics than older children, and severe disease has lower spontaneous recovery rates, particularly in children younger than 2 years. Observation is therefore best reserved for carefully selected patients with less severe disease and dependable follow-up rather than applied uniformly to all children (Girand, 2026).

Pain Management in AOM

Pain treatment should not depend on whether an antibiotic is prescribed. Acetaminophen and ibuprofen are common options for mild-to-moderate otalgia. Ibuprofen should be avoided in infants younger than 6 months. Alternating acetaminophen and ibuprofen is not recommended in the assigned text because of dosing-error risk and insufficient safety and efficacy data. Aspirin should be avoided in children because of the risk of Reye syndrome (Girand, 2026).

Decongestants, antihistamines, and corticosteroids do not have a therapeutic role in uncomplicated AOM and may prolong middle-ear effusion. Evidence is also insufficient to support routine topical anesthetic drops for AOM (Girand, 2026).

Amoxicillin for AOM

When antibiotic therapy is indicated, amoxicillin is the preferred agent for most uncomplicated AOM because of its effectiveness, high middle-ear concentrations, safety, relatively narrow spectrum, low cost, and palatable pediatric formulation. For children, Chapter 75 recommends high-dose amoxicillin, 80–90 mg/kg/day divided twice daily, to improve activity against penicillin-resistant Streptococcus pneumoniae (Girand, 2026).

The adult doses listed in the assigned text are 875 mg twice daily or 500 mg three times daily (Girand, 2026).

When Amoxicillin-Clavulanate Is Preferred

High-dose amoxicillin-clavulanate is preferred in children when additional beta-lactamase coverage is needed. Chapter 75 specifically identifies amoxicillin exposure within the previous 30 days, concurrent purulent conjunctivitis, recurrent AOM previously unresponsive to amoxicillin, and a clinical need for coverage of beta-lactamase-producing organisms. The pediatric dose is based on 90 mg/kg/day of the amoxicillin component, divided twice daily (Girand, 2026).

The purulent-conjunctivitis association is particularly useful clinically because it increases concern for beta-lactamase-producing Haemophilus influenzae and can shift initial therapy from amoxicillin to amoxicillin-clavulanate. The course materials identify this linked presentation as conjunctivitis-otitis syndrome, an important example of how a finding outside the ear changes empiric antibiotic selection (F.A. Davis Company, 2021; Girand, 2026).

Penicillin Allergy and AOM

A reported penicillin allergy should be characterized rather than automatically treated as a reason to avoid all beta-lactams. Chapter 75 supports use of selected cephalosporins such as cefdinir, cefpodoxime, cefuroxime, or ceftriaxone in appropriate patients. Macrolides and trimethoprim-sulfamethoxazole provide less reliable activity against S. pneumoniae and H. influenzae and are therefore less appropriate for many patients labeled penicillin allergic (Girand, 2026).

Ceftriaxone is an option when oral therapy cannot be tolerated. The assigned text notes that a 3-day regimen may be preferable in selected resistant pneumococcal infections because failures have occurred with single-dose treatment (Girand, 2026).

AOM Treatment Duration

  • 10 days for severe AOM.
  • 10 days for children younger than 2 years.
  • Approximately 7 days for mild-to-moderate disease in children ages 2–5 years.
  • Approximately 5–7 days for mild-to-moderate disease in children age 6 years and older.

Shorter regimens have higher failure rates in some younger children and in children with tympanic-membrane perforation (Girand, 2026).

Monitoring, Recurrent AOM, and Referral

Pain, fever, and tympanic-membrane inflammation should begin improving within approximately 72 hours of appropriate therapy. Lack of improvement or clinical worsening during the first 48–72 hours should prompt reassessment of both the diagnosis and antimicrobial selection (Girand, 2026).

Middle-ear effusion can remain after the acute infection resolves and does not, by itself, indicate treatment failure. Persistent effusion lasting approximately 3 months in an otherwise healthy child should prompt hearing evaluation, with earlier assessment when speech, language, or developmental impairment is a concern (Girand, 2026).

Recurrent AOM is commonly defined as at least three episodes within 6 months or four episodes within 12 months with one episode in the preceding 6 months. Recurrent AOM or chronic OME with hearing or speech impairment can warrant otolaryngology referral for consideration of tympanostomy tubes or other surgical management (Girand, 2026).

Acute Rhinosinusitis

Rhinosinusitis involves inflammation of the nasal and paranasal sinus mucosa. Most acute cases are caused by respiratory viruses rather than bacteria. Secondary bacterial infection occurs in only a small proportion of viral illnesses, yet rhinosinusitis remains a common reason for antibiotic prescribing. The major pharmacotherapy challenge is therefore distinguishing acute bacterial rhinosinusitis (ABRS) from an uncomplicated viral URI (Girand, 2026).

When ABRS Is More Likely

  • Persistent illness: symptoms continue for at least 10 days without evidence of improvement.
  • Worsening illness: symptoms worsen within 10 days after initially improving.
  • Pediatric severe-onset pattern: fever of at least 39°C (102.2°F) with purulent nasal discharge during the first 3–4 days of illness.

For adults, the 2025 AAO-HNS guideline uses two principal diagnostic patterns: symptoms of acute rhinosinusitis that persist without improvement for at least 10 days, or symptoms that worsen within 10 days after an initial improvement. The severe-onset fever/purulence pattern remains useful in pediatric guidance and in the assigned chapter, but it should not be presented as a stand-alone adult diagnostic criterion (American Academy of Otolaryngology–Head and Neck Surgery Foundation [AAO-HNSF], 2025; Girand, 2026).

These patterns are more useful than the color of nasal discharge alone. Purulent or colored secretions can occur during viral infection because neutrophils change the appearance of mucus. Green or yellow nasal drainage alone therefore does not establish bacterial sinusitis (Girand, 2026).

Symptomatic Therapy for Rhinosinusitis

Symptom management can include analgesics and antipyretics for headache, facial pain, and fever. Saline sprays, drops, humidification, and nasal irrigation may improve comfort and mucociliary clearance. Irrigation solutions should be prepared with sterile or distilled water rather than untreated tap water because of the risk of infectious contamination (Girand, 2026).

Adjunctive symptom treatment should be selective. Pseudoephedrine may reduce congestion but requires attention to age and sympathomimetic risk; oral phenylephrine lacks demonstrated meaningful efficacy at recommended OTC doses, and FDA has proposed removing it from the OTC nasal-decongestant monograph. Topical decongestants should be brief because of rebound congestion, and antihistamines are generally reserved for a coexisting allergic indication. Detailed pharmacology and safety considerations for these agents are covered on the Allergic Rhinitis and Upper Respiratory Symptom Medications page (FDA, n.d.; Girand, 2026).

Observation and Antibiotic Stewardship in ABRS

Even clinically diagnosed ABRS has a substantial spontaneous resolution rate. The 2025 AAO-HNS guideline recommends offering watchful waiting to adults with uncomplicated ABRS when reliable follow-up is assured. The follow-up plan should specify when to start antibiotics or return for reassessment if symptoms fail to improve or worsen. This approach preserves antibiotic benefit for patients who need it while reducing unnecessary exposure in a condition that frequently improves without antimicrobial treatment (AAO-HNSF, 2025).

In children with persistent illness for at least 10 days without improvement, approximately 3 days of observation with close follow-up is an alternative to immediate antibiotics in appropriately selected cases. Severe or complicated infection should not be managed through prolonged observation and may require specialty involvement (Girand, 2026).

Antibiotic Selection for ABRS

When antibiotics are selected, empiric therapy should primarily cover S. pneumoniae and H. influenzae. For most adults, the 2025 AAO-HNS guideline recommends amoxicillin with or without clavulanate as first-line therapy. Pediatric selection remains more dependent on age, severity, recent antibiotic exposure, resistance risk, and local guidance (AAO-HNSF, 2025; Girand, 2026).

Amoxicillin-clavulanate becomes more attractive when beta-lactamase-producing organisms or amoxicillin resistance are concerns. Recent antibiotic exposure is one such risk factor. High-dose amoxicillin or amoxicillin-clavulanate is recommended when resistance risk is increased, including moderate-to-severe illness, daycare exposure, or high community prevalence of resistant pneumococci (Girand, 2026).

Penicillin Allergy and ABRS

An appropriate cephalosporin or doxycycline may be considered depending on the severity of the reported beta-lactam allergy and local susceptibility patterns. In selected circumstances, combination therapy with clindamycin may be used when additional resistant pneumococcal coverage is needed, but this increases adverse-effect risk, including Clostridioides difficile infection (Girand, 2026).

Respiratory fluoroquinolones such as levofloxacin or moxifloxacin have activity against relevant pathogens, but their serious adverse-effect profile limits routine use. Macrolides and trimethoprim-sulfamethoxazole are not recommended for routine ABRS therapy because resistance among S. pneumoniae and H. influenzae is too high (Girand, 2026).

ABRS Treatment Duration and Monitoring

For most adults treated with antibiotics, the 2025 AAO-HNS guideline recommends amoxicillin with or without clavulanate for 5–7 days. If an adult fails to improve or worsens despite an appropriate antibiotic after 3–5 days, the diagnosis should be reassessed, alternative causes and complications should be considered, and the antibiotic should be changed if ABRS is confirmed. The assigned pediatric chapter describes longer courses, commonly 10–14 days, reflecting the different evidence base and pediatric guidance (AAO-HNSF, 2025; Girand, 2026).

Streptococcal Pharyngitis

Most acute pharyngitis is viral and self-limited. Streptococcus pyogenes, or group A Streptococcus (GAS), is the most important bacterial cause because appropriate treatment can reduce transmission and prevent acute rheumatic fever. GAS causes a greater proportion of pharyngitis in children than adults, accounting for approximately 20%–30% of pediatric cases and 5%–15% of adult cases in the assigned text (Girand, 2026).

Clinical Features Suggesting GAS

  • Abrupt sore throat and pain with swallowing.
  • Fever.
  • Tonsillopharyngeal erythema with or without exudate.
  • Tender anterior cervical lymphadenopathy.
  • Soft-palate petechiae.
  • Absence of cough.

Headache, abdominal pain, nausea, or vomiting may be particularly prominent in children. Cough, rhinorrhea, hoarseness, conjunctivitis, discrete oral ulcerations, and diarrhea instead support a viral etiology (Girand, 2026).

When clear viral features are present, GAS testing is generally unnecessary. Testing is most useful when the clinical presentation remains compatible with GAS and microbiologic confirmation would change management (Centers for Disease Control and Prevention [CDC], 2025).

Centor Criteria and Testing

Clinical scoring systems such as Centor or McIsaac can help determine who is likely to benefit from GAS testing. The 2025 IDSA update recommends using a clinical scoring system in both children and adults with sore throat, primarily to identify patients at sufficiently low probability that further testing is unlikely to help. Scores do not establish the diagnosis and should not replace microbiologic confirmation when GAS remains plausible. The recommendation does not apply to children younger than 3 years, and high-risk patients may warrant testing even with a low score (Infectious Diseases Society of America [IDSA], 2025).

RADT, Culture, and PCR

A rapid antigen detection test (RADT) provides results within minutes and has high specificity but variable sensitivity compared with throat culture. CDC recommends a backup throat culture after a negative RADT in symptomatic children age 3 years or older; routine backup culture is not recommended for other age groups because acute rheumatic fever is rare. Throat culture remains the diagnostic gold standard. Nucleic-acid amplification tests can provide highly sensitive rapid testing when locally available, but their interpretation should follow the performance characteristics of the specific assay and local protocol (CDC, 2025; Girand, 2026).

Antibiotics Require Confirmation

Antibiotics should be prescribed for laboratory-confirmed streptococcal pharyngitis accompanied by compatible clinical symptoms rather than for sore throat or exudates alone. This prevents unnecessary treatment of viral disease and avoids treating asymptomatic streptococcal carriage as though it were an acute infection (Girand, 2026).

Penicillin and Amoxicillin

Penicillin remains the drug of choice for GAS pharyngitis because of its narrow spectrum, safety, low cost, reliable eradication of GAS, and established evidence for prevention of acute rheumatic fever. Penicillin V is generally administered for 10 days. Benzathine penicillin G can be given as a single intramuscular dose when adherence to a 10-day oral regimen is doubtful (Girand, 2026).

Amoxicillin is an effective alternative, particularly in children because of better palatability and once-daily dosing. The assigned table lists 50 mg/kg once daily, to a maximum of 1 g, for 10 days in children (Girand, 2026).

Penicillin Allergy in Streptococcal Pharyngitis

A first-generation cephalosporin such as cephalexin can be used in many patients with a non-severe or non-type I penicillin allergy. Chapter 75 identifies azithromycin or clindamycin as alternatives for patients with severe reactions such as anaphylaxis, angioedema, or serious delayed hypersensitivity reactions (Girand, 2026).

GAS remains predictably susceptible to beta-lactam therapy: CDC reports no clinical isolate of GAS resistant to penicillin or cephalosporins. In contrast, resistance to azithromycin, clarithromycin, and clindamycin is well recognized and varies geographically and over time. This difference supports preserving penicillin or amoxicillin as preferred therapy when they can be used safely (CDC, 2025; Girand, 2026).

Symptomatic Pharyngitis Treatment

Treatment should also address pain and hydration. Warm liquids, cold foods or ice, honey or hard candy when age appropriate, saline gargles, humidification, and avoidance of smoke exposure can reduce throat irritation. Oral analgesics can improve pain sufficiently to allow normal eating and drinking (Girand, 2026).

Medicated lozenges and throat sprays may provide short-term relief, but Chapter 75 does not identify one product type as clearly superior. Benzocaine sprays should be avoided because of the rare but serious risk of methemoglobinemia (Girand, 2026).

Monitoring Streptococcal Pharyngitis

With effective antibiotic treatment, symptoms should begin improving within approximately 1–2 days and generally resolve within several days. Current CDC guidance advises remaining home from work, school, or daycare until the patient is afebrile and at least 12–24 hours have passed after starting appropriate antibiotic therapy. Persistent or worsening symptoms after approximately 72 hours require reevaluation. Routine test-of-cure throat cultures are not recommended when symptoms resolve (CDC, 2025; Girand, 2026).

Antibiotic Stewardship Across All Three Conditions

AOM, ABRS, and pharyngitis illustrate three different reasons to avoid automatic antibiotic prescribing. With AOM, some accurately diagnosed cases still improve without antibiotics, making observation appropriate for selected children. With rhinosinusitis, the major challenge is determining whether bacterial infection is present at all; duration and pattern of illness are more informative than mucus color. With pharyngitis, compatible symptoms identify who should be tested, but antibiotic therapy should generally wait for microbiologic confirmation of GAS.

Across all three conditions, treatment failure should trigger reassessment of the diagnosis, adherence, antimicrobial selection, and possible complication rather than automatic progression to a broader-spectrum antibiotic.

High-Yield Distinctions

  • AOM diagnosis: tympanic-membrane bulging or qualifying new otorrhea is more meaningful than erythema alone.
  • AOM analgesia: treat pain regardless of whether antibiotics are prescribed.
  • AOM first-line antibiotic: high-dose amoxicillin for most children who require antimicrobial treatment.
  • AOM plus purulent conjunctivitis or recent amoxicillin: favor amoxicillin-clavulanate.
  • Conjunctivitis-otitis syndrome: concurrent purulent conjunctivitis and AOM increases concern for beta-lactamase-producing H. influenzae and changes empiric therapy.
  • AOM observation: most appropriate in carefully selected, less severe cases with dependable follow-up; younger children with bilateral disease, otorrhea, or severe illness are more likely to benefit from immediate antibiotics.
  • Recurrent AOM: at least three episodes in 6 months or four in 12 months with one in the preceding 6 months can warrant ENT evaluation.
  • ABRS persistent pattern: at least 10 days without improvement.
  • ABRS worsening pattern: deterioration after initial improvement.
  • Pediatric ABRS severe-onset pattern: fever ≥39°C with purulent discharge early in the illness; adult 2025 AAO-HNS criteria emphasize persistence ≥10 days or double worsening.
  • Colored nasal drainage alone does not diagnose bacterial sinusitis.
  • Adult ABRS first-line therapy: amoxicillin with or without clavulanate for 5–7 days for most adults when antibiotics are chosen; pediatric regimens differ by age and clinical context.
  • ABRS macrolides/TMP-SMX: not preferred because of resistance.
  • Clear viral pharyngitis features: GAS testing is generally unnecessary.
  • GAS pharyngitis: confirm with appropriate testing before prescribing antibiotics.
  • Negative RADT: obtain a backup throat culture in symptomatic children age 3 years or older; routine backup culture is not indicated for other age groups.
  • Penicillin: preferred therapy for confirmed GAS because of narrow spectrum and evidence for rheumatic-fever prevention.
  • GAS return to school/work: patient should be afebrile and at least 12–24 hours into appropriate antibiotic therapy.
  • Routine test of cure: unnecessary after successfully treated GAS pharyngitis.

Content last reviewed:

References

American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2025). Clinical practice guideline: Adult sinusitis update. https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/cpg-adult-sinusitis/

Centers for Disease Control and Prevention. (2025, November 18). Clinical guidance for group A streptococcal pharyngitis. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html

F.A. Davis Company. (2021). Drugs used to treat eye and ear disorders [PowerPoint slides].

Girand, H. L. (2026). Upper respiratory tract infections. In M. A. Chisholm-Burns, P. M. Malone, J. M. Kolesar, K. C. Lee, P. B. Bookstaver, & K. R. Matthias (Eds.), Pharmacotherapy principles & practice (7th ed.). McGraw Hill.

Infectious Diseases Society of America. (2025). Clinical practice guideline update on group A streptococcal pharyngitis: Risk assessment using clinical scoring systems in children and adults. https://www.idsociety.org/practice-guideline/streptococcal-pharyngitis2/

U.S. Food and Drug Administration. (n.d.). Key information about nonprescription, over-the-counter (OTC), oral phenylephrine. https://www.fda.gov/drugs/understanding-over-counter-medicines/key-information-about-nonprescription-over-counter-otc-oral-phenylephrine