What is the recommended dosage for amoxicillin (Amoxicillin) in the treatment of Acute Suppurative Otitis Media (ASOM)?

Treatment of Acute Suppurative Otitis Media (ASOM)

High-dose amoxicillin at 80-90 mg/kg/day in 2 divided doses is the recommended first-line treatment for Acute Suppurative Otitis Media (ASOM). 1, 2, 3

First-Line Treatment Options

• High-dose amoxicillin (80-90 mg/kg/day divided in 2 doses) is the first-line treatment for most patients with ASOM due to its effectiveness against common bacterial pathogens, particularly Streptococcus pneumoniae 1, 2
• This dosage achieves middle ear fluid levels that exceed the minimum inhibitory concentration of intermediately resistant S. pneumoniae and many highly resistant serotypes 2, 4
• The higher dosage (80-90 mg/kg/day) is preferred over standard dosage (40-45 mg/kg/day) due to increasing antibiotic resistance patterns 5, 4

Special Considerations for Alternative First-Line Treatment

• For patients who have taken amoxicillin in the previous 30 days, those with concurrent conjunctivitis (otitis-conjunctivitis syndrome), or when coverage for Moraxella catarrhalis is desired, high-dose amoxicillin-clavulanate should be used instead 1, 2, 6
• The recommended dosage for amoxicillin-clavulanate is 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate (amoxicillin to clavulanate ratio of 14:1) in 2 divided doses 1, 6
• This 14:1 ratio formulation is less likely to cause diarrhea than other amoxicillin-clavulanate preparations 1, 7

Alternative Treatment for Penicillin-Allergic Patients

• For patients with non-type I hypersensitivity to penicillin, alternative options include:
  • Cefdinir (14 mg/kg/day in 1 or 2 doses) 1, 2
  • Cefuroxime (30 mg/kg/day in 2 divided doses) 1, 2
  • Cefpodoxime (10 mg/kg/day in 2 divided doses) 1, 2
• Recent data suggest that cross-reactivity among penicillins and cephalosporins is lower than historically reported, making these alternatives safer than previously thought 1

Management of Treatment Failure

• If initial treatment with amoxicillin fails after 48-72 hours, switch to:
  • Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1, 2, 6
  • Alternatively, ceftriaxone (50 mg IM or IV for 3 days) 1, 2
• For persistent failure after second-line antibiotics, consider clindamycin (30-40 mg/kg/day in 3 divided doses) with or without a third-generation cephalosporin 1

Important Clinical Considerations

• Bacterial pathogens in ASOM are primarily S. pneumoniae, H. influenzae, and M. catarrhalis 5, 8
• Viral co-infection may reduce antibiotic efficacy and may require higher dosing 4
• Diarrhea is the most common adverse effect of amoxicillin and amoxicillin-clavulanate treatment 7, 9
• The twice-daily dosing regimen (as opposed to three times daily) has been shown to reduce the incidence of diarrhea 7, 9

Common Pitfalls and Caveats

• Fluoroquinolones (ofloxacin, ciprofloxacin) should be avoided for ASOM as they have poor activity against S. pneumoniae 1, 6
• Cefixime should not be used as it has inadequate activity against pneumococci with decreased susceptibility to penicillin 1, 6
• Inadequate dosing of amoxicillin (standard dose of 40-45 mg/kg/day) may lead to treatment failure, particularly with resistant strains of S. pneumoniae 4, 10
• Ensure accurate diagnosis of ASOM versus otitis media with effusion, as antibiotics are indicated for ASOM but not for effusion in the absence of acute symptoms 3