What is the next step in managing recurrent otitis media in a pediatric patient who has failed treatment with Amoxicillin (Amox) and Augmentin (Amoxicillin-Clavulanate)?

From the Guidelines

For recurrent otitis media in a pediatric patient who has failed both amoxicillin and amoxicillin-clavulanate (Augmentin), I recommend switching to ceftriaxone intramuscular injection (50 mg/kg/day for 3 days) or oral cefdinir (14 mg/kg/day divided twice daily for 10 days) as the next step in management, as these options target resistant organisms like beta-lactamase-producing Haemophilus influenzae or penicillin-resistant Streptococcus pneumoniae that may be causing treatment failure, according to the most recent and highest quality study available 1.

Rationale for Recommendation

The recommendation is based on the most recent clinical practice guideline for tympanostomy tubes in children, which suggests that tympanostomy tube insertion can be beneficial for children with recurrent AOM, especially those with persistent middle ear effusion (MEE) 1. However, the primary focus for a patient who has failed initial antibiotic treatment is to switch to a different antibiotic that covers resistant organisms.

Antibiotic Options

• Ceftriaxone intramuscular injection (50 mg/kg/day for 3 days) is a recommended option for patients who have failed initial antibiotic treatment, as it provides broad coverage against common pathogens, including beta-lactamase-producing Haemophilus influenzae and penicillin-resistant Streptococcus pneumoniae 1.
• Oral cefdinir (14 mg/kg/day divided twice daily for 10 days) is another option, which has been shown to be effective against Haemophilus influenzae, including beta-lactamase-producing strains 1.
• Clindamycin (30-40 mg/kg/day divided three times daily for 10 days) can be used as an alternative option if the child has no beta-lactam allergy, although its effectiveness against Haemophilus influenzae is lower compared to ceftriaxone or cefdinir.

Additional Considerations

• Tympanocentesis for culture should be considered if available to guide targeted therapy, especially if the patient has a history of recurrent AOM or has failed multiple antibiotic treatments 1.
• The patient should be reevaluated in 48-72 hours to ensure clinical improvement, and if symptoms persist despite appropriate antibiotic therapy, referral to an otolaryngologist is warranted to evaluate for possible tympanostomy tube placement, especially if this represents the third episode in 6 months or fourth episode in 12 months 1.
• Contributing factors such as daycare attendance, secondhand smoke exposure, or anatomical issues that may predispose to recurrent infections should be assessed and addressed to prevent future episodes of AOM.

From the Research

Next Steps in Managing Recurrent Otitis Media

The next step in managing recurrent otitis media in a pediatric patient who has failed treatment with Amoxicillin (Amox) and Augmentin (Amoxicillin-Clavulanate) involves considering alternative antibiotic therapies.

• The patient's history of treatment failure with first-line antibiotics suggests the possibility of antibiotic-resistant pathogens such as Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae 2, 3.
• According to the recommendations, second-line therapy options should have demonstrated activity against penicillin-resistant S. pneumoniae as well as beta-lactamase-producing pathogens 4.
• Appropriate options for second-line therapy include:
  • High-dose amoxicillin/clavulanate (90 mg/kg/day based on the amoxicillin component)
  • Ceftriaxone
  • Cefuroxime axetil (standard dose, 30 mg/kg/day) 2, 4.
• Tympanocentesis may be useful for identifying the causative pathogen, particularly for patients who have failed multiple courses of antibiotics 4.
• The pneumococcal conjugate vaccine should be administered to all children less than 2 years old and those at risk for recurrent AOM 4.

Considerations for Antibiotic Selection

When selecting an antibiotic, the physician should consider:

• Proven efficacy
• Cost
• Side effect profile
• Compliance issues
• Spectrum of coverage
• The age of the child 5.
• The use of pharmacokinetic/pharmacodynamic principles in designing treatment strategies is also important 4.

Additional Management Strategies

For children with recurrent infections, antibiotic prophylaxis may be beneficial 5. Referral for insertion of tympanostomy tubes is most appropriate for patients with documented language delay and/or significant medical complications 5.