What is the recommended treatment for Acute Otitis Media (AOM) with Augmentin (amoxicillin-clavulanate)?

Augmentin (Amoxicillin-Clavulanate) Treatment for Acute Otitis Media

For acute otitis media (AOM), amoxicillin-clavulanate (Augmentin) is recommended as second-line therapy after amoxicillin failure, or as first-line therapy in cases with recent amoxicillin use, recurrent AOM, or when beta-lactamase producing organisms are suspected. 1

Indications for Augmentin in AOM

Augmentin should be used in the following scenarios:

• After failure of first-line amoxicillin therapy
• When patient has used amoxicillin in the past 30 days
• For recurrent episodes of AOM
• When beta-lactamase producing organisms are suspected (e.g., AOM with conjunctivitis, suggesting H. influenzae)

Dosing Recommendations

• Children: 90/6.4 mg/kg/day based on the amoxicillin component, divided into two doses daily 1, 2
• Adults: 1500-3000 mg/day divided into two doses 1
• Duration: 10 days for children under 2 years; 5-7 days for older children and adults 3, 1

Rationale for Augmentin Use

Augmentin combines amoxicillin with clavulanic acid (a beta-lactamase inhibitor), providing coverage against:

• Penicillin-susceptible and intermediate S. pneumoniae
• Beta-lactamase producing H. influenzae and M. catarrhalis 2

The high-dose formulation (90/6.4 mg/kg/day) is particularly effective against penicillin-resistant S. pneumoniae while maintaining activity against beta-lactamase producing organisms 2, 4.

Treatment Algorithm

1. First episode of AOM:

   • Use amoxicillin 80-90 mg/kg/day as first-line therapy
   • Reserve Augmentin for treatment failure

2. Recurrent AOM or recent amoxicillin use:

   • Use Augmentin as first-line therapy

3. Treatment failure with Augmentin:

   • Consider ceftriaxone or specialist consultation 1

Special Considerations

Penicillin Allergy

• For non-anaphylactoid reactions: cefdinir, cefpodoxime, or cefuroxime
• For severe penicillin allergy: Consider respiratory fluoroquinolones (adults) or specialist consultation (children) 1

Monitoring

• Clinical improvement should be noted within 48-72 hours of starting therapy
• If no improvement after 72 hours, consider treatment failure and change antibiotics 1

Side Effects and Management

The most common side effect is diarrhea, which occurs less frequently with twice-daily dosing (9.6%) compared to three-times-daily dosing (26.7%) 5. The newer formulations of Augmentin with higher amoxicillin-to-clavulanate ratios have shown improved gastrointestinal tolerability.

Common Pitfalls to Avoid

1. Inappropriate use as first-line therapy: Reserve Augmentin for specific indications rather than using it empirically for all AOM cases to prevent resistance development.

2. Inadequate dosing: Using conventional doses rather than high-dose formulations may lead to treatment failure against resistant organisms.

3. Failure to distinguish AOM from otitis media with effusion (OME): Ensure proper diagnosis of AOM using the criteria of acute onset, middle ear effusion, and signs of middle ear inflammation 3.

4. Overlooking prevention strategies: Advise on preventive measures including pneumococcal vaccination, limiting pacifier use after 6 months, breastfeeding for at least 6 months, avoiding supine bottle feeding, and reducing daycare-related respiratory infections 1.

Augmentin remains a valuable antibiotic for AOM, particularly for cases where first-line therapy with amoxicillin is inappropriate or has failed, providing effective coverage against the common pathogens involved in AOM, including resistant strains.