What is the next step in treating otitis media (middle ear infection) that doesn't resolve with initial antibiotic treatment and is accompanied by drainage and bumps?

Management of Persistent Otitis Media with Drainage and Bumps

For otitis media not resolved by initial antibiotics with drainage and bumps, tympanocentesis with culture and susceptibility testing should be performed, followed by appropriate antibiotic therapy based on the results. 1

Diagnosis of Treatment Failure

When evaluating persistent otitis media with drainage and bumps, consider:

• Treatment failure: Persistent symptoms and unimproved otologic findings after 48-72 hours of initial antibiotic therapy
• Possible causes:
  • Resistant bacteria (particularly S. pneumoniae, H. influenzae)
  • Combined bacterial and viral infection
  • Inadequate antibiotic penetration due to middle ear pressure
  • Superinfection with resistant organisms from the nasopharynx 2

Management Algorithm

Step 1: Assess for Complications

• Evaluate for signs of mastoiditis (postauricular swelling, erythema, tenderness)
• Look for drainage through the tympanic membrane or ear canal
• Examine the bumps (which may represent granulation tissue or polyps)

Step 2: Change Antibiotic Therapy

If the child was initially treated with:

• Amoxicillin: Switch to amoxicillin-clavulanate 1, 3
• Amoxicillin-clavulanate or oral third-generation cephalosporins: Consider intramuscular ceftriaxone (50 mg/kg) for 3 days 1

Step 3: Consider Tympanocentesis

Tympanocentesis with culture and susceptibility testing is strongly recommended when:

• Multiple antibiotics have failed
• Symptoms persist despite second-line therapy
• Drainage and bumps are present (suggesting possible complications) 1

Step 4: Targeted Therapy Based on Culture Results

If tympanocentesis is not available:

• Consider clindamycin (particularly if S. pneumoniae is suspected)
• May need to combine with coverage for H. influenzae and M. catarrhalis (cefdinir, cefixime, or cefuroxime) 1

Step 5: Consider Specialist Referral

• Consult with an otolaryngologist for possible tympanocentesis, drainage, and culture
• Consider infectious disease consultation for multidrug-resistant infections requiring unconventional antibiotics 1

Special Considerations for Drainage

If drainage is present through tympanostomy tubes:

• Topical antibiotic eardrops (ofloxacin or ciprofloxacin-dexamethasone) are more effective than oral antibiotics 1
• Clinical cure rates with topical therapy (77-96%) are superior to systemic antibiotics (30-67%) 1

Potential Complications

Persistent otitis media with drainage may indicate:

1. Acute mastoiditis: Requires prompt evaluation, IV antibiotics, and possible surgical intervention 1
2. Tympanic membrane perforation: May require surgical repair if persistent
3. Cholesteatoma: Requires surgical management
4. Intracranial complications: Rare but serious (brain abscess, meningitis, venous sinus thrombosis) 1

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure true treatment failure versus:

   • Noncompliance with initial therapy
   • Superimposed viral illness
   • Otitis media with effusion (OME) 1

2. Inadequate antibiotic selection: Avoid using trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures, as resistance rates are substantial 1

3. Insufficient duration of therapy: Complete the full course of antibiotics even if symptoms improve 1

4. Delayed specialist referral: Consider early referral after multiple treatment failures 1

5. Overlooking superinfection: Be aware that antibiotic treatment may promote superinfection with resistant organisms carried in the nasopharynx 2

The presence of drainage and bumps in persistent otitis media warrants aggressive management to prevent complications and hearing loss. Tympanocentesis with culture-directed therapy offers the best chance for resolution and improved outcomes.