What is the recommended treatment plan for a 6-year-old female with bullous impetigo and bilateral otitis media?

Treatment Plan for a 6-Year-Old Female with Bullous Impetigo and Bilateral Otitis Media

Recommended Treatment Plan

For a 6-year-old female with both bullous impetigo and bilateral otitis media, the recommended treatment is high-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 7-10 days for the otitis media, plus topical mupirocin for the impetigo. If the patient has risk factors for resistant organisms, amoxicillin-clavulanate should be used instead of amoxicillin alone 1.

Otitis Media Management

Antibiotic Selection

• First-line therapy: High-dose amoxicillin (80-90 mg/kg/day divided twice daily) for 5-7 days

  • This higher dosage is necessary to overcome potential resistant Streptococcus pneumoniae 1, 2
  • For a 6-year-old (approximately 20 kg), this would be approximately 800-900 mg twice daily

• If treatment failure occurs (symptoms persist after 48-72 hours):

  • Switch to amoxicillin-clavulanate (90/6.4 mg/kg/day in two divided doses) 3
  • Alternative: Cefuroxime or intramuscular ceftriaxone for severe cases 2

Pain Management

• Acetaminophen or ibuprofen at age-appropriate doses for pain control
• Topical analgesics may provide additional relief 1

Monitoring

• Follow-up in 2-3 weeks to ensure resolution of middle ear effusion
• If effusion persists beyond 3 months, hearing testing is recommended 4
• Monitor for complications such as persistent pain, vertigo, or facial weakness 1

Impetigo Management

Topical Antibiotic

• First-line therapy: Topical mupirocin 2% ointment applied to affected areas three times daily for 5-7 days 5, 6
  • Particularly effective for bullous impetigo caused by Staphylococcus aureus
  • Apply to all lesions after gentle cleansing with soap and water

Alternative Options

• If extensive lesions or impractical to use topical therapy:
  • Oral cephalexin (25-50 mg/kg/day divided twice daily) 5
  • Clindamycin if MRSA is suspected 5

Hygiene Measures

• Daily bathing with antibacterial soap
• Use separate towels and linens
• Keep fingernails short and clean to prevent spread
• Avoid sharing personal items

Important Considerations

Antibiotic Resistance

• Be aware of increasing prevalence of resistant organisms:
  • Beta-lactamase producing H. influenzae and B. catarrhalis 7
  • MRSA in impetigo 5
  • Penicillin-resistant S. pneumoniae in otitis media 3

Risk Factors for Resistant Pathogens

• Recent antibiotic treatment
• Daycare attendance
• Winter season infections
• Age less than 2 years (not applicable in this case) 2

Avoid Ineffective Treatments

• Antihistamines and decongestants are ineffective for otitis media and should not be used 4
• Topical disinfectants are inferior to antibiotics for impetigo and should not be used 5, 6
• Oral steroids are not recommended for routine management of otitis media 4

Follow-up Recommendations

• Reassess in 48-72 hours if symptoms worsen
• Complete follow-up examination in 2-3 weeks to ensure resolution
• If otitis media persists beyond 3 months, refer for hearing evaluation 4, 1

Treatment Success Indicators

• Resolution of impetigo lesions within 7-10 days
• Improvement in ear pain and fever within 48-72 hours
• Complete resolution of otitis media symptoms within 10-14 days
• No new impetigo lesions after 48 hours of treatment

Remember that bullous impetigo is highly contagious, so proper hygiene measures are essential to prevent spread to other family members or classmates.