From the Guidelines
If doxycycline hasn't cleared up an ear infection, the next medication to try would typically be amoxicillin-clavulanate (Augmentin), usually at a dose of 875/125 mg twice daily for 7-10 days for adults. This recommendation is based on the most recent and highest quality study available, which suggests that amoxicillin-clavulanate is effective against a broader spectrum of bacteria, including those that may have developed resistance to doxycycline 1.
Key Considerations
- The choice of antibiotic depends on whether the infection is in the outer ear (otitis externa) or middle ear (otitis media) 2.
- For outer ear infections, antibiotic ear drops like ciprofloxacin with dexamethasone may be more effective than oral antibiotics.
- The switch to a different antibiotic class is important because the infection may be caused by bacteria resistant to tetracyclines like doxycycline, or the infection might be fungal rather than bacterial.
Alternative Options
- For patients with penicillin allergies, alternatives include fluoroquinolones like ciprofloxacin (especially for outer ear infections) or clindamycin 2.
- If symptoms persist after a second antibiotic course, further evaluation by an ear specialist (otolaryngologist) is recommended to determine if there's an underlying issue requiring different treatment 1.
Important Notes
- Tympanocentesis should be considered, and culture of middle ear fluid should be performed for bacteriologic diagnosis and susceptibility testing when a series of antibiotic drugs have failed to improve the clinical condition 1.
- Newer antibiotics that are not approved by the FDA for treatment of AOM, such as levofloxacin or linezolid, may be indicated in cases of repeated treatment failures 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Otitis Media Refractory to Doxycycline
- The next line of treatment for otitis media that is refractory to doxycycline is not directly stated in the provided studies, as doxycycline is not mentioned as a primary treatment option for otitis media in any of the studies 3, 4, 5, 6, 7.
- However, for persistent or recurrent acute otitis media, guidelines recommend high-dose amoxicillin/clavulanate, cefdinir, cefprozil, cefpodoxime, cefuroxime, or ceftriaxone 3.
- Amoxicillin is recommended as the first-line agent to treat uncomplicated AOM, and for clinical treatment failures after 3 days of amoxicillin, recommended antimicrobial agents include oral amoxicillin/clavulanate, cefuroxime axetil, cefprozil, cefpodoxime proxetil, and intramuscular (i.m.) ceftriaxone 6.
- Twice-daily trimethoprim-sulfamethoxazole has been shown to be effective in the treatment of acute otitis media, except that caused by group A beta-streptococci 7.
Considerations for Treatment
- When selecting an agent, physicians should consider in vitro activity, particularly against drug-resistant Streptococcus pneumoniae; pharmacokinetics; adverse events; palatability of the suspension; and cost 6.
- The choice of antibiotic should also take into account the potential for antibiotic resistance, as well as the effectiveness of the antibiotic against the specific pathogens causing the infection 4, 5.