What is the next step in treating otitis media that is resistant to Augmentin (amoxicillin-clavulanate)?

Treatment for Resistant Otitis Media After Augmentin Failure

For otitis media that is resistant to Augmentin (amoxicillin-clavulanate), the next step should be switching to a respiratory fluoroquinolone, parenteral ceftriaxone, or appropriate combination therapy. 1

Treatment Algorithm for Augmentin-Resistant Otitis Media

First-Line Alternative Options

1. Respiratory Fluoroquinolones

   • Gatifloxacin, levofloxacin, or moxifloxacin 2, 1
   • Appropriate for adults with treatment failure after 72 hours of initial therapy

2. Parenteral Ceftriaxone

   • Dosing: 1-2 g/day IM or IV for 5 days in adults 2, 1
   • For children: 50 mg/kg IM or IV daily for 3 days 1
   • FDA-approved for acute bacterial otitis media caused by susceptible strains of S. pneumoniae, H. influenzae, and M. catarrhalis 3

3. Combination Therapy Options

   • High-dose amoxicillin or clindamycin plus cefixime 2
   • High-dose amoxicillin or clindamycin plus rifampin 2
   • Ensures adequate gram-positive and gram-negative coverage

Special Considerations

For Patients with Penicillin Allergy

• Non-severe allergy: Cephalosporins including cefdinir (300 mg twice daily), cefuroxime (500 mg twice daily), or cefpodoxime (200 mg twice daily) for 5-7 days 1
• Severe allergy: Clindamycin (30-40 mg/kg/day in 3 divided doses for children) or respiratory fluoroquinolones 1
• Note: Macrolides (azithromycin, clarithromycin) have higher bacteriologic failure rates (20-25%) and should be used with caution 2, 1

Evaluation and Monitoring

• Failure to respond to antimicrobial therapy after 72 hours should prompt either a switch to alternate antimicrobial therapy or reevaluation of the patient 2
• Consider obtaining a CT scan, fiberoptic endoscopy, or sinus aspiration for culture if symptoms persist despite effective antibiotic therapy 2
• Treatment should continue for at least 48-72 hours beyond symptom resolution, with a minimum duration of 5-7 days 1

Important Caveats

• Avoid rifampin monotherapy: Rifampin should not be used as monotherapy as resistance emerges rapidly; limit use to 10-14 days in combination therapy 2
• Consider tympanocentesis: For persistent symptoms despite appropriate therapy, tympanocentesis can help confirm diagnosis and guide therapy based on culture results 4
• Distinguish between treatment failure and OME: 60-70% of children will have middle ear effusion at 2 weeks after successful treatment, which represents otitis media with effusion (OME), not treatment failure 1
• Prevention strategies: Ensure pneumococcal and influenza vaccinations are up-to-date and counsel on risk factor reduction including limiting daycare attendance and avoiding tobacco smoke exposure 1

When selecting the next antibiotic after Augmentin failure, consider the limitations in coverage of the initial agent and choose an option with a different mechanism of action or broader spectrum to target potentially resistant organisms.