What is the next antibiotic to try for otitis media after 10 days of Amoxicillin (amoxicillin) treatment with no cure?

Next Antibiotic for Otitis Media After Failed Amoxicillin Treatment

After 10 days of amoxicillin treatment with no cure for otitis media, amoxicillin-clavulanate should be used as the second-line antibiotic therapy. 1

Rationale for Amoxicillin-Clavulanate as Second-Line Therapy

When initial treatment with amoxicillin fails, this typically indicates one of the following scenarios:

1. Infection with β-lactamase-producing organisms (H. influenzae or M. catarrhalis)
2. Resistant Streptococcus pneumoniae
3. Poor medication adherence
4. Incorrect initial diagnosis

Amoxicillin-clavulanate is specifically recommended as the second-line therapy because:

• It provides coverage against β-lactamase-producing organisms while maintaining activity against S. pneumoniae 2
• The clavulanate component inhibits β-lactamase enzymes that would otherwise inactivate amoxicillin 1
• Guidelines consistently recommend this as the appropriate step-up therapy after amoxicillin failure 2, 1

Dosing Recommendations

• For children: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate divided into two doses 2, 1
• For adults: High-dose formulation (2000 mg amoxicillin/125 mg clavulanate twice daily) 1

Alternative Options Based on Clinical Scenario

If amoxicillin-clavulanate cannot be used due to allergy or other contraindications, consider:

For Non-Type I Penicillin Allergy:

• Cefdinir (14 mg/kg/day in 1-2 doses)
• Cefuroxime (30 mg/kg/day in 2 doses)
• Cefpodoxime (10 mg/kg/day in 2 doses) 2, 1

For Type I Penicillin Allergy:

• Clindamycin (10-13 mg/kg/dose every 6-8 hours for children; 300-450 mg three times daily for adults) - particularly if MRSA or resistant pneumococci are suspected 2, 1
• Azithromycin may be considered, though it has lower efficacy rates (clinical success rates of 82-88% at day 11 and 74-82% at day 30) 3

When to Consider Tympanocentesis

If there is treatment failure with second-line therapy, especially in:

• Children under 2 years of age
• Patients with severe symptoms
• Cases with complications

Tympanocentesis with bacterial culture and susceptibility testing should be considered to guide further antibiotic selection 2

Duration of Treatment

• For children under 2 years or those with severe symptoms: 10-day course
• For children 2-5 years with mild/moderate symptoms: 7-day course
• For children 6 years and older: 10-day course 2

Important Considerations

• Pain management should be addressed regardless of antibiotic choice (acetaminophen or ibuprofen) 1
• Reassess within 48-72 hours if symptoms worsen or fail to improve 1
• Monitor for adverse effects, particularly diarrhea with amoxicillin-clavulanate (occurs in approximately 20-30% of patients) 1, 4
• Contrary to common practice, using a broader-spectrum antibiotic for a new episode following a previous treatment failure does not result in better outcomes than returning to first-line therapy if the episodes are separated by more than 90 days 5

Remember that persistent middle ear effusion without symptoms (otitis media with effusion) is common after successful antibiotic treatment and does not require additional antibiotics 2.