What antibiotic to use for a 15-month-old child with recurrent otitis media after previous treatment with high-dose Augmentin (amoxicillin-clavulanate)?

From the Guidelines

For a 15-month-old child with recurrent otitis media who has previously been treated with high-dose Augmentin, the most appropriate antibiotic option is ceftriaxone, given its effectiveness against resistant organisms that may have survived the initial treatment, as recommended by the American Academy of Pediatrics 1. When considering the management of recurrent otitis media, it's crucial to select an antibiotic that targets the likely causative pathogens, including beta-lactamase-producing bacteria and resistant Streptococcus pneumoniae.

• Ceftriaxone can be administered as a single intramuscular injection (50 mg/kg) or as a 3-day course, offering a convenient and effective treatment option.
• Alternatively, oral cefdinir at 14 mg/kg/day divided into one or two doses for 10 days is also effective, providing a suitable alternative for patients who may not tolerate intramuscular injections.
• For children with penicillin allergy, clindamycin at 30-40 mg/kg/day divided into three doses for 10 days is recommended, as it covers penicillin-resistant S pneumoniae, although its use should be guided by local resistance patterns 1. Key considerations in the management of recurrent otitis media include:
• Tympanocentesis for culture may be considered in severe or persistent cases to guide targeted therapy.
• Addressing risk factors such as pacifier use, exposure to secondhand smoke, and considering tympanostomy tubes for children with frequent recurrences (typically three episodes in six months or four in one year) is important for comprehensive management. The choice of antibiotic should be guided by the most recent and highest quality evidence, with consideration of local resistance patterns and patient-specific factors, such as allergy history and previous antibiotic use 1.

From the FDA Drug Label

For the 366 patients who were evaluated for clinical efficacy at the Day 12 visit, the clinical success rate (i.e., cure plus improvement) was 83% for azithromycin and 88% for the control agent. For the 362 patients who were evaluated at the Days 24 to 28 visit, the clinical success rate was 74% for azithromycin and 69% for the control agent. In a double-blind, controlled, randomized clinical study of acute otitis media in pediatric patients from 6 months to 12 years of age, azithromycin (10 mg/kg per day for 3 days) was compared to amoxicillin/clavulanate potassium (7:1) in divided doses q12h for 10 days.

The antibiotic to use for a 15-month-old child with recurrent otitis media after previous treatment with high-dose Augmentin (amoxicillin-clavulanate) could be azithromycin.

• Key points:
  • Azithromycin has shown clinical success rates of 83% at the Day 12 visit and 74% at the Days 24 to 28 visit in pediatric patients with acute otitis media.
  • The drug was compared to amoxicillin/clavulanate potassium in a clinical study.
  • Azithromycin may be considered as an alternative treatment option for recurrent otitis media in pediatric patients who have previously been treated with amoxicillin/clavulanate. 2

From the Research

Treatment Options for Recurrent Otitis Media

The child in question has already been treated with high-dose Augmentin (amoxicillin-clavulanate) for otitis media and is now experiencing a recurrence. Considering the previous treatment, the following options can be considered:

• Cefuroxime axetil (standard dose, 30 mg/kg/day) 3
• Ceftriaxone (possibly requiring up to three injections to optimize clinical success) 3
• High-dose amoxicillin/clavulanic acid can also be considered for recurrent or persistent pediatric AOM, especially where involvement of resistant pathogens is suspected 4

Pathogens and Antibiotic Resistance

The predominant pathogens of recurrent and persistent acute otitis media are antibiotic-resistant Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae 3. Therefore, the selection of appropriate antibiotic therapy should take into account these major pathogens and the occurrence of antibiotic resistance.

Considerations for Antibiotic Choice

When choosing an antibiotic, considerations should include proven efficacy, cost, side effect profile, compliance issues, spectrum of coverage, and the age of the child 5. The decision should be made based on the specific circumstances of the child and the suspected or confirmed pathogens involved.

Additional Management Options

For children with recurrent infections, antibiotic prophylaxis may be beneficial 5. In cases of chronic middle ear effusion that persists beyond three months, referral for insertion of tympanostomy tubes may be appropriate, especially for patients with documented language delay and/or significant medical complications 5, 6.