What is the next best antibiotic treatment for a 13-year-old with an ear infection that didn't improve with amoxicillin (875 mg), Augmentin (amoxicillin-clavulanate) or other alternatives?

Treatment for Ear Infection After Failed Amoxicillin Therapy in a 13-Year-Old

High-dose amoxicillin-clavulanate (Augmentin) is the recommended next treatment for a 13-year-old with an ear infection that did not respond to amoxicillin 875 mg. 1

Rationale for Amoxicillin-Clavulanate

When initial amoxicillin therapy fails to resolve an ear infection, the most likely causes are:

1. Beta-lactamase producing organisms (particularly H. influenzae and M. catarrhalis)
2. Penicillin-resistant Streptococcus pneumoniae
3. Poor compliance with the medication regimen

Amoxicillin-clavulanate addresses these issues by:

• Adding clavulanic acid to inhibit beta-lactamase enzymes
• Using a higher dose to overcome intermediate resistance
• Providing coverage against both common pathogens 1, 2

Dosing Recommendations

• Recommended dose: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into two doses daily 1
• For a 13-year-old (likely adult-sized or near adult-sized), the typical dose would be 875 mg amoxicillin/125 mg clavulanate twice daily
• Treatment duration: 10 days 1

Alternative Options

If the patient has a penicillin allergy:

• Non-Type I allergy: Cefuroxime axetil or cefpodoxime proxetil 1, 3
• Type I/severe allergy: Clindamycin (if S. pneumoniae is suspected) 1

For severe infections or treatment failures:

• Intramuscular ceftriaxone (50 mg/kg/day for 3-5 days) 1

Expected Outcomes

• Clinical success rates with amoxicillin-clavulanate are approximately 80-90% 2, 4
• Improvement should be seen within 48-72 hours of starting the new antibiotic 3, 1
• If no improvement after 72 hours on amoxicillin-clavulanate, reassessment is needed 1

Important Considerations

• Take with food to reduce gastrointestinal side effects 1
• Most common side effect is diarrhea, which is generally less frequent with twice-daily dosing compared to three-times-daily dosing 2, 5
• Probiotics may help reduce antibiotic-associated diarrhea 1
• If the patient has tympanostomy tubes and visible drainage, antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) would be preferred over oral antibiotics 3

Follow-up Recommendations

• Reassess in 48-72 hours if symptoms persist or worsen 1
• Complete the full course of antibiotics even if symptoms improve quickly
• If no improvement after 72 hours on the new antibiotic, consider:
  • Tympanocentesis for culture and susceptibility testing
  • Alternative antibiotic therapy
  • Evaluation for complications or alternative diagnoses 1

Prevention of Future Episodes

• Ensure pneumococcal and influenza vaccinations are up to date
• Reduce risk factors such as limiting tobacco smoke exposure
• Consider evaluation for underlying conditions if infections are recurrent 1

Remember that persistent middle ear effusion is common after treatment and does not require additional antibiotics if the child is asymptomatic.