What is the next step in managing a 7-month-old infant with persistent ear infection, currently on amoxicillin-clavulanate (Augmentin) after a failed course of amoxicillin, presenting with marked middle ear effusion, erythema of the tympanic membrane (TM), irritability, and mild fever?

From the Guidelines

The next step in managing this 7-month-old infant with persistent ear infection would be to switch to a different antibiotic, specifically ceftriaxone (Rocephin) as a single intramuscular injection or cefdinir (Omnicef) at a dose of 14 mg/kg/day divided twice daily for 10 days. This change is necessary because the infant has failed two courses of antibiotics (amoxicillin and amoxicillin-clavulanate) and continues to show signs of active infection including middle ear effusion, tympanic membrane erythema, irritability, and fever, as indicated by the guidelines for the diagnosis and management of acute otitis media 1. These symptoms indicate treatment failure and possible antibiotic resistance. The American Academy of Pediatrics recommends considering tympanocentesis for culture and sensitivity testing when a series of antibiotic drugs have failed to improve the clinical condition, but if tympanocentesis is not available, a course of clindamycin may be used, with or without an antibiotic that covers nontypeable H influenzae and M catarrhalis, such as cefdinir, cefixime, or cefuroxime 1. However, given the infant's age and recurrent nature of the infection, it is essential to prioritize effective treatment and consider referral to an otolaryngologist if this third-line treatment fails. Additionally, pain management with acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) should be provided. Close follow-up within 48-72 hours is essential to monitor response to the new antibiotic. Some key points to consider in the management of this infant include:

• The importance of effective antibiotic treatment to prevent complications and improve quality of life
• The need for close follow-up to monitor response to treatment and adjust the treatment plan as necessary
• The potential benefits of referral to an otolaryngologist for further evaluation and management, particularly if the infant has recurrent or persistent infections.

From the Research

Next Steps in Management

The next step in managing a 7-month-old infant with persistent ear infection, currently on amoxicillin-clavulanate after a failed course of amoxicillin, presenting with marked middle ear effusion, erythema of the tympanic membrane (TM), irritability, and mild fever, involves considering alternative treatments or further diagnostic procedures.

• The current treatment with amoxicillin-clavulanate has been ongoing for 10 days, and the presence of persistent symptoms suggests a potential treatment failure or resistance.
• According to the study 2, twice-daily trimethoprim-sulfamethoxazole has been shown to be effective in the treatment of acute otitis media, with a higher combined rate of cure and improvement compared to amoxicillin-clavulanate.
• Another study 3 compared the efficacy of amoxicillin-clavulanate (Augmentin) with cefaclor in the treatment of acute otitis media with effusion, finding that Augmentin was superior in the acute phase but produced more adverse effects.
• A systematic review 4 assessed the efficacy of antimicrobials or placebo compared to amoxicillin-clavulanate in children with acute otitis media, concluding that amoxicillin-clavulanate should be the treatment of choice for children between 6 months and 12 years of age with AOM.
• Considering the options provided:
  • Perform tympanocentesis for culture (a) may be necessary to identify the causative pathogen and guide further treatment.
  • Prescribe clindamycin twice daily (b) could be considered as an alternative treatment, although its efficacy compared to amoxicillin-clavulanate is not well-established in this context.
  • Order a second course of amoxicillin-clavulanate (c) may not be the best option given the potential for resistance or treatment failure.
  • Refer the child to an otolaryngologist (d) may be necessary for further evaluation and management, especially if symptoms persist or worsen despite treatment.

Considerations

• The choice of next steps should be guided by the severity of symptoms, the potential for treatment failure or resistance, and the need for further diagnostic evaluation.
• Consultation with an otolaryngologist or a pediatric specialist may be necessary to determine the best course of action.
• The studies 5 and 6 provide additional context on the efficacy and safety of various antimicrobial regimens, but their relevance to this specific case is limited.