Should an 8-year-old with recurrent AOM, last treated with amoxicillin 3 months ago, be treated with amoxicillin or amoxicillin-clavulanate?

Treatment of Recurrent AOM in an 8-Year-Old Child

For an 8-year-old child with recurrent acute otitis media (AOM) who was last treated with amoxicillin 3 months ago, amoxicillin-clavulanate should be prescribed rather than repeating amoxicillin. 1, 2

Rationale for Amoxicillin-Clavulanate Selection

The American Academy of Pediatrics (AAP) guidelines specifically recommend prescribing an antibiotic with additional β-lactamase coverage when:

• The child has received amoxicillin in the last 30 days
• The child has concurrent purulent conjunctivitis
• The child has a history of recurrent AOM unresponsive to amoxicillin 1

In this case, the child has recurrent AOM, which increases the likelihood of resistant pathogens, including beta-lactamase producing organisms such as H. influenzae and M. catarrhalis.

Dosing Recommendations

• For children weighing less than 40 kg: 45 mg/kg/day divided every 12 hours based on the amoxicillin component 3
• For children weighing 40 kg or more: Adult dosing applies (500 mg/125 mg tablet every 8 hours or 875 mg/125 mg tablet every 12 hours) 3
• Duration of therapy: 5 days (for children older than 2 years) 2

Pathogen Coverage Considerations

Amoxicillin-clavulanate provides coverage against:

• Penicillin-susceptible and intermediate strains of S. pneumoniae
• Beta-lactamase producing strains of H. influenzae
• M. catarrhalis 4

Studies have demonstrated high eradication rates with amoxicillin-clavulanate:

• 98% eradication of S. pneumoniae (including 91% of penicillin-resistant strains)
• 94% eradication of H. influenzae 5

Treatment Algorithm

1. First episode of AOM: Amoxicillin (if no amoxicillin use in past 30 days)
2. Recurrent AOM or recent amoxicillin use: Amoxicillin-clavulanate
3. Treatment failure with amoxicillin-clavulanate: Consider ceftriaxone or consultation with specialist 1

Monitoring and Follow-up

• Assess response within 48-72 hours of starting treatment
• If symptoms persist or worsen after 48-72 hours, reevaluate the diagnosis and consider changing antibiotics 1, 2
• No routine follow-up visit is necessary if symptoms resolve 1
• Be aware that middle ear effusion (MEE) may persist for weeks to months after successful treatment of AOM and does not require additional antibiotics 1

Common Pitfalls to Avoid

1. Overdiagnosis of AOM: Ensure accurate diagnosis with proper visualization of the tympanic membrane showing bulging or new-onset otorrhea, not just redness 1

2. Unnecessary prolonged treatment: For children over 2 years, 5 days of therapy is sufficient; longer courses increase the risk of resistance 2

3. Failure to distinguish between AOM and otitis media with effusion (OME): OME does not require antibiotics 1

4. Inappropriate use of macrolides or fluoroquinolones: These should be avoided due to increasing pneumococcal resistance 2

By selecting amoxicillin-clavulanate for this 8-year-old with recurrent AOM, you're providing optimal coverage against likely pathogens while following evidence-based guidelines for antibiotic stewardship.