What is the appropriate antibiotic (abx) for a 4-year-old patient with recurrent acute otitis media (AOM), with the last episode occurring 10 days prior, and no allergy to penicillin (PCN)?

From the Guidelines

For a 4-year-old child with recurrent acute otitis media (AOM) who had their last episode 10 days ago and is not allergic to penicillin, the appropriate antibiotic treatment would be high-dose amoxicillin at 80 to 90 mg per kg per day, as recommended by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) 1. The choice of amoxicillin is based on its effectiveness against susceptible and intermediate resistant pneumococci, as well as its safety, affordability, and acceptable taste.

• The dosage of 80 to 90 mg per kg per day is supported by microbiologic studies and expert opinion, with the preponderance of benefit over risk 1.
• Amoxicillin is recommended as first-line therapy for AOM due to its narrow microbiologic spectrum and effectiveness against common pathogens.
• The optimal duration of therapy for patients with AOM is uncertain, but the recommended dosage should be used to guide treatment decisions. Key considerations in the management of recurrent AOM include:
• The child's history of previous episodes and treatment outcomes
• The presence of risk factors such as daycare attendance, secondhand smoke exposure, or anatomical factors that might contribute to recurrent infections
• The potential need for alternative treatments, such as cefdinir, cefpodoxime, or cefuroxime, if the child is allergic to amoxicillin or has experienced treatment failure 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

For a 4-year-old patient with recurrent acute otitis media (AOM) and the last AOM 10 days prior, the appropriate antibiotic treatment with azithromycin would be:

• 30 mg/kg as a single dose, or
• 10 mg/kg once daily for 3 days, or
• 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5. Given the patient is not allergic to penicillin, other antibiotics like amoxicillin may also be considered. However, based on the provided information, azithromycin is a viable option. 2

From the Research

Appropriate Antibiotics for Recurrent AOM

• For a 4-year-old child with recurrent AOM, not allergic to penicillin, the appropriate antibiotic can be determined based on the latest clinical recommendations and studies 3, 4, 5, 6.
• Amoxicillin at conventional or high doses (80-90 mg/kg/day) remains an appropriate choice for first-line therapy for AOM 3, 6.
• If the child has failed previous treatment with amoxicillin, second-line therapy options include high-dose amoxicillin/clavulanate (90 mg/kg/day based on the amoxicillin component) and ceftriaxone 3.
• The choice of antibiotic should consider the possibility of beta-lactamase-producing pathogens, such as Haemophilus influenzae and Moraxella catarrhalis, which may be resistant to amoxicillin 4, 6.

Considerations for Recurrent AOM

• Recurrent AOM is defined as at least 3 or more separate episodes of acute otitis media within 6 months or four or more episodes over a 12-month period 7.
• The treatment of recurrent otitis media is complicated by the increasing acquired resistance of bacteria to antimicrobial drugs 7, 5.
• Systemic antibiotics are still needed as treatment against episodes of AOM in children with recurrent AOM, but must be used with caution due to emerging antibiotic resistance 5.