What is step-up therapy for Acute Otitis Media (AOM) in children?

From the Guidelines

Step-up therapy for Acute Otitis Media (AOM) in children involves escalating antibiotic treatment to amoxicillin-clavulanate if initial treatment with amoxicillin fails, or to intramuscular ceftriaxone if amoxicillin-clavulanate or oral third-generation cephalosporins are not effective. The approach to managing AOM in children is guided by the need to balance the potential benefits of antibiotic treatment against the risks of resistance and side effects. According to the American Academy of Pediatrics 1, initial antibiotic treatment failure is defined as a lack of clinical improvement within 48 to 72 hours of starting treatment. In such cases, a change in antibiotic may be necessary, with options including amoxicillin-clavulanate or intramuscular ceftriaxone.

Key considerations in step-up therapy for AOM include:

• The choice of initial antibiotic, with amoxicillin being a common first-line option 1
• The need for close monitoring of symptoms and clinical response to treatment, with follow-up recommended if fever or ear pain persists beyond 48-72 hours 1
• The potential for resistance to initial antibiotics, particularly among common AOM pathogens like Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• The importance of completing the full course of antibiotics, even if symptoms improve, to minimize the risk of treatment failure and resistance 1

In terms of specific antibiotic regimens, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component divided twice daily for 10 days) is a recommended step-up option for children who fail initial treatment with amoxicillin. Alternatively, intramuscular ceftriaxone (50 mg/kg/day) may be used, particularly if the child has severe symptoms or has not responded to oral antibiotics 1. For penicillin-allergic patients, alternative options like azithromycin or clarithromycin may be considered, although these are not typically recommended as first-line treatments for AOM.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of cefdinir and other antibacterial drugs, cefdinir should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. Pediatric Patients Acute Bacterial Otitis Media caused by Haemophilus influenzae (including β-lactamase producing strains), Streptococcus pneumoniae (penicillin-susceptible strains only), and Moraxella catarrhalis (including β-lactamase producing strains).

The step-up therapy for Acute Otitis Media (AOM) in children is not explicitly defined in the provided drug labels. However, based on the information provided, cefdinir can be used to treat AOM caused by susceptible strains of Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis in pediatric patients 2.

• Key points:
  • Cefdinir is indicated for the treatment of AOM in pediatric patients.
  • The drug should be used to treat infections caused by susceptible bacteria.
  • Culture and susceptibility information should be considered when selecting or modifying antibacterial therapy. The FDA drug label does not provide a clear definition of step-up therapy for AOM in children.

From the Research

Step-Up Therapy for Acute Otitis Media (AOM) in Children

• Step-up therapy for AOM in children refers to the approach of initially treating the condition with a first-line antibiotic and then switching to a different antibiotic if the symptoms persist or worsen 3, 4.
• The first-line antibiotic for AOM in children is typically amoxicillin, due to its proven efficacy, cost-effectiveness, and safety profile 3, 4.
• If the child does not respond to amoxicillin within 48 to 72 hours, a second-line antibiotic such as amoxicillin/clavulanate may be used 4.
• Other second-line antibiotics that may be considered include cefprozil, cefuroxime axetil, and cefixime 3, 5.
• The choice of antibiotic should be based on factors such as the severity of symptoms, the presence of allergic reactions, and the likelihood of resistance to certain antibiotics 3, 4.

Factors to Consider in Step-Up Therapy

• The age of the child, with younger children potentially requiring more aggressive treatment 3, 4.
• The presence of underlying medical conditions, such as immune system disorders or anatomical abnormalities 4.
• The severity of symptoms, with more severe cases potentially requiring hospitalization or more intensive treatment 4.
• The likelihood of antibiotic resistance, with some bacteria becoming increasingly resistant to certain antibiotics 3, 6.

Alternative Treatment Options

• For children who do not respond to initial antibiotic treatment, alternative options such as cefdinir may be considered 6.
• Cefdinir has been shown to be effective in eradicating common causative pathogens of AOM, including penicillin-resistant Streptococcus pneumoniae 6.
• Other alternative treatment options may include tympanostomy tube placement or adenoidectomy, although these are typically reserved for more severe or recurrent cases 4, 7.