From the Guidelines
The nurse practitioner should prescribe amoxicillin-clavulanate (Augmentin) as the first-line treatment for the 3-year-old child with recurrent acute otitis media. The recommended dosage is high-dose amoxicillin-clavulanate at 90 mg/kg/day of the amoxicillin component, divided into two doses daily for 10 days 1. This choice is appropriate because the child's presentation with fever, bulging tympanic membrane, and type B tympanogram indicates a new infection occurring shortly after previous treatment with amoxicillin. The addition of clavulanate addresses potential beta-lactamase producing organisms that may have developed resistance to the previous amoxicillin treatment.
Key considerations for this decision include:
- The child had a recent episode of AOM 3 weeks prior, which increases the likelihood of resistant organisms 1
- The child's symptoms, including fever and bulging tympanic membrane, indicate a need for effective antibiotic treatment 1
- Amoxicillin-clavulanate is effective against common AOM bacterial pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
- The use of high-dose amoxicillin-clavulanate is recommended for children who have received amoxicillin in the previous 30 days, as in this case 1
If the child has a penicillin allergy, alternatives include cefdinir, cefuroxime, or ceftriaxone 1. It's essential to complete the full course of antibiotics even if symptoms improve within a few days. Parents should be advised to administer the medication with food to minimize gastrointestinal side effects, and to follow up if the child's symptoms don't improve within 48-72 hours or worsen at any point. This approach targets the most likely pathogens in recurrent AOM, including resistant Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
From the FDA Drug Label
14.2 Acute Bacterial Otitis Media and Diarrhea in Pediatric Patients One U.S./Canadian clinical trial was conducted which compared 45/6. 4 mg/kg/day (divided every 12 hours) of amoxicillin and clavulanate potassium for 10 days versus 40/10 mg/kg/day (divided every 8 hours) of amoxicillin and clavulanate potassium for 10 days in the treatment of acute otitis media.
The nurse practitioner will likely order amoxicillin-clavulanate for the 3-year-old child with acute otitis media, given the recent episode of AOM 3 weeks prior treated with amoxicillin, and now presenting with fever, bulging tympanic membrane, and a type B tympanogram.
- The child's symptoms suggest a new infection or treatment failure, which may require a different or broader-spectrum antibiotic.
- Amoxicillin-clavulanate is a suitable option for the treatment of acute otitis media, especially in cases where there is a high suspicion of beta-lactamase-producing organisms or where first-line treatment with amoxicillin has failed 2.
From the Research
Treatment Options for Acute Otitis Media
The nurse practitioner is presented with a 3-year-old child who has had a recent episode of acute otitis media (AOM) 3 weeks prior, treated with amoxicillin, and now presents with fever, bulging tympanic membrane, and a type B tympanogram. The treatment options for this child include:
- Amoxicillin twice daily
- Intramuscular ceftriaxone
- A referral for tympanocentesis
- Amoxicillin-clavulanate twice daily
Evidence-Based Treatment
Based on the evidence, amoxicillin-clavulanate is a well-established broad-spectrum antibacterial treatment that is effective and well-tolerated in the treatment of AOM in pediatric patients 3. The high-dose combination of amoxicillin-clavulanate (90/6.4 mg/kg/day in two divided doses) has been shown to eradicate a high proportion of penicillin-resistant S. pneumoniae 4, 3.
Comparison of Treatment Options
Some studies have compared the effectiveness of different antibiotic regimens for the treatment of AOM. For example, one study found that amoxicillin-clavulanate was more effective than azithromycin in eradicating S. pneumoniae and H. influenzae 4. Another study found that twice-daily trimethoprim-sulfamethoxazole was more effective than twice-daily amoxicillin-clavulanate in the treatment of AOM 5.
Recommended Treatment
Given the child's recent episode of AOM and the presence of a bulging tympanic membrane and type B tympanogram, the nurse practitioner may consider ordering amoxicillin-clavulanate twice daily, as it is a well-established treatment for AOM and has been shown to be effective in eradicating penicillin-resistant S. pneumoniae 4, 3. This treatment option is supported by the evidence, which suggests that amoxicillin-clavulanate is a effective and well-tolerated treatment for AOM in pediatric patients 6, 7, 3.