What is the most appropriate treatment plan for a 3-year-old child with acute otitis media (AOM) who has been taking amoxicillin (amoxicillin) for 3 days and still has symptoms?

Treatment of Persistent Acute Otitis Media After Initial Amoxicillin Therapy

The most appropriate treatment for GM's acute otitis media is to discontinue amoxicillin and start amoxicillin/clavulanate 650 mg orally twice daily for 10 days with acetaminophen 220 mg orally every 4 hours as needed for ear pain. 1

Assessment of Treatment Failure

GM presents with clear signs of treatment failure on amoxicillin:

• Persistent fever (103°F)
• Continued ear pain
• Increased irritability
• Decreased appetite
• Symptoms persisting after 3 days of appropriate amoxicillin therapy

The American Academy of Pediatrics (AAP) clinical practice guideline specifically addresses this situation in Key Action Statement 4C, which states that clinicians should reassess patients who fail to respond to initial antibiotic treatment within 48-72 hours and determine whether a change in therapy is needed 1.

Rationale for Switching to Amoxicillin/Clavulanate

The AAP guideline (Key Action Statement 4B) recommends prescribing an antibiotic with additional β-lactamase coverage when:

• The child has received amoxicillin in the past 30 days
• The child has concurrent purulent conjunctivitis
• The child has a history of recurrent AOM unresponsive to amoxicillin 1

In this case, GM is clearly unresponsive to amoxicillin after 3 days of therapy, which meets the criteria for changing to a β-lactamase stable antibiotic.

Dosing Considerations

For a 14.6 kg child:

• The recommended high-dose amoxicillin/clavulanate dosage is 90 mg/kg/day of the amoxicillin component 2
• This equals approximately 1,314 mg daily of amoxicillin, or 657 mg twice daily
• The prescribed dose of 650 mg twice daily is appropriate

Pain Management

The addition of acetaminophen for pain management is appropriate and supported by guidelines:

• Pain assessment is crucial in all children with AOM
• Appropriate analgesia should be provided if pain is present
• Options include acetaminophen or ibuprofen for systemic relief 2

The recommended dose of acetaminophen (220 mg every 4 hours as needed) is appropriate for GM's weight of 14.6 kg (15 mg/kg/dose).

Why Other Options Are Not Optimal

1. Clindamycin with ibuprofen: While clindamycin has activity against resistant pneumococci, it lacks coverage against H. influenzae and M. catarrhalis, which are common pathogens in AOM 1. It should be reserved for patients with penicillin allergy.

2. Continuing amoxicillin with ibuprofen: Continuing the same antibiotic that has failed after 72 hours contradicts the AAP guideline recommendation to change therapy when symptoms worsen or fail to respond within 48-72 hours 1.

3. Ceftriaxone with acetaminophen: While ceftriaxone is effective, intramuscular administration should be reserved for severe cases or when compliance is a concern 3. Oral therapy is preferred when possible for a 3-year-old child.

Duration of Therapy

The 10-day course is appropriate for a child under 6 years of age with severe symptoms, as recommended by the AAP guideline 2.

Potential Side Effects to Monitor

• Diarrhea is more common with amoxicillin-clavulanate than with other antibiotics 2
• Probiotic supplements taken 2 hours before or after antibiotics may help reduce gastrointestinal side effects 2

Follow-up Recommendations

• If symptoms persist after 48-72 hours on amoxicillin/clavulanate, further evaluation may be necessary
• Consider referral for tympanocentesis if multiple courses of antibiotics fail 4
• Document the laterality and duration of any persistent effusion at follow-up visits 2

Following these evidence-based recommendations will provide GM with the most appropriate treatment for persistent acute otitis media after initial amoxicillin failure.