What's the next step in treatment for bilateral otitis media and external otitis (inflammation of the outer ear) with purulent drainage that fails to respond to Augmentin (amoxicillin/clavulanate)?

Treatment for Bilateral Otitis Media and External Otitis with Purulent Drainage After Augmentin Failure

For bilateral otitis media and external otitis with purulent drainage that has failed treatment with Augmentin (amoxicillin/clavulanate), the next step should be topical antibiotic therapy with fluoroquinolone ear drops, with or without steroids.

Understanding Treatment Failure with Augmentin

When Augmentin fails to resolve otitis media with concurrent external otitis, several factors may be contributing:

1. Likely pathogens: The infection may be caused by organisms resistant to Augmentin, particularly:

   • Pseudomonas aeruginosa (common in external otitis and not covered by Augmentin)
   • Beta-lactamase producing organisms
   • Resistant strains of Streptococcus pneumoniae

2. Anatomical considerations: The combination of middle ear and external ear canal infection creates a challenging treatment scenario requiring both adequate middle ear penetration and external canal coverage.

Next Treatment Algorithm

Step 1: Topical Antibiotic Therapy

• First-line: Fluoroquinolone otic drops (e.g., ciprofloxacin with or without steroids) 1
  • Superior clinical cure rates (77-96%) compared to systemic antibiotics (30-67%)
  • Provides high local concentration (up to 1000× higher than systemic therapy)
  • Effective against likely pathogens including Pseudomonas
  • Avoids systemic side effects

Step 2: Proper Administration Technique

• Clean ear canal of debris before administering drops 2
  • Use tissue spears to gently clean external canal
  • Consider gentle suctioning of visible secretions
• Ensure drops can reach affected areas
• Continue for 7-10 days (do not exceed 10 days to prevent fungal superinfection)

Step 3: If Topical Therapy Fails (48-72 hours)

• Consider culture and sensitivity testing of ear drainage 2
• Alternative systemic antibiotics based on likely pathogens:
  • Ceftriaxone (50 mg IM or IV per day for 1-3 days) 2
  • Clindamycin (30-40 mg/kg/day in 3 divided doses) with or without a third-generation cephalosporin 2
  • For adults, consider respiratory fluoroquinolones (levofloxacin, moxifloxacin) 2, 1

Special Considerations

For Children

• Cephalosporins are generally safe even with reported penicillin allergy 2
  • Cefdinir (14 mg/kg/day in 1-2 doses)
  • Cefuroxime (30 mg/kg/day in 2 divided doses)
  • Cefpodoxime (10 mg/kg/day in 2 divided doses)

For Persistent Cases

• Consider referral to otolaryngology for:
  • Thorough cleaning/debridement of ear canal
  • Placement of ear wicks to improve medication delivery in cases of severe canal edema
  • Evaluation for possible tympanostomy tubes if recurrent episodes

Important Caveats

1. Only use otic drops approved for middle ear use - avoid aminoglycoside-containing drops due to potential ototoxicity 2

2. Reassess within 48-72 hours if symptoms worsen or fail to improve 2, 1

3. Tissue spears technique for cleaning ear canal:

   • Twist (don't roll) corner of tissue paper
   • Insert with slight twist until resistance is met
   • Leave briefly to absorb discharge, then remove
   • Repeat until spear comes out dry 2

4. Avoid water exposure during treatment to prevent worsening of external otitis

By following this algorithm, most cases of bilateral otitis media with external otitis that have failed Augmentin therapy should respond to appropriate topical therapy, with systemic antibiotics reserved for cases that don't improve with topical treatment alone.