From the Guidelines
For acute otitis media (AOM) that fails to respond to initial amoxicillin treatment, the next step is typically switching to amoxicillin-clavulanate (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses) or ceftriaxone (50 mg IM or IV for 3 d).
Key Considerations
- The choice of second-line treatment depends on factors such as the patient's history of antibiotic use, presence of conjunctivitis, and potential allergies to penicillin [ 1 ].
- Amoxicillin-clavulanate is a suitable option for patients who have received amoxicillin in the previous 30 days or have the otitis-conjunctivitis syndrome [ 1 ].
- Ceftriaxone is an alternative option for patients who fail to respond to initial antibiotic treatment, and it can be administered intramuscularly or intravenously for 3 days [ 1 ].
Treatment Options
- Amoxicillin-clavulanate (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses)
- Ceftriaxone (50 mg IM or IV for 3 d)
- Clindamycin (30–40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin (in cases of penicillin allergy)
Important Notes
- Treatment failure may be due to beta-lactamase-producing organisms like Haemophilus influenzae or Moraxella catarrhalis, or resistant Streptococcus pneumoniae [ 1 ].
- If symptoms persist despite second-line therapy, tympanocentesis for culture and sensitivity testing may be necessary to guide targeted antibiotic selection, and consultation with an otolaryngologist should be considered to evaluate for complications or alternative diagnoses [ 1 ].
From the Research
Definition of Treatment Failure
Treatment failure in acute otitis media (AOM) is a critical point that may require a change in antibiotic treatment or even surgical intervention 2. However, there is no consensus on the definition of treatment failure, leading to confusion in clinical decision-making.
Causes of Treatment Failure
The most common pathogens responsible for AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3, 4. The increasing isolation of beta-lactamase-producing organisms and penicillin-resistant S pneumoniae has led to an increase in amoxicillin treatment failures 3.
Next Steps in Treatment
When AOM fails to respond to initial antibiotic treatment with amoxicillin, several factors should be considered when selecting alternative antibiotics, including:
- The most likely pathogens and their susceptibility patterns
- Antibiotic issues such as clinical efficacy, adverse reactions, palatability, dosing schedules, and cost 3
- Enhanced beta-lactamase stability and activity against penicillin-resistant S pneumoniae 3
Alternative Antibiotics
Studies have compared the efficacy of amoxicillin-clavulanate and azithromycin in treating AOM:
- Amoxicillin-clavulanate has been shown to have superior bacteriologic and clinical efficacy compared to azithromycin in children with AOM 5
- Amoxicillin-clavulanate was more likely to eradicate all bacterial pathogens, including Haemophilus influenzae, from middle ear fluid than azithromycin 5
- However, another study found that the clinical efficiency of amoxicillin-clavulanate was equal to azithromycin in children with AOM 4
Key Considerations
When treating AOM, it is essential to consider the following:
- The severity of the infection, including the presence of severe bulging of the tympanic membrane 6
- The age of the patient, with older children (24-35 months) being less likely to experience treatment failure 6
- The use of a peaked tympanogram, which may indicate a lower risk of treatment failure and suitability for initial observation 6