In a patient with recurrent bilateral otitis media, previously treated with amoxicillin, should I use azithromycin or amoxicillin-clavulanic acid for this episode?

Treatment Recommendation for Recurrent Bilateral Otitis Media

Use amoxicillin-clavulanate (high-dose: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) for this recurrent episode, not azithromycin. 1

Rationale for Amoxicillin-Clavulanate Over Azithromycin

Primary Evidence from Guidelines

• The 2024 WHO Essential Medicines guidelines explicitly designate amoxicillin-clavulanate as the second-choice antibiotic for acute otitis media, with amoxicillin as first choice. 1

• The 2013 American Academy of Pediatrics guidelines specifically recommend amoxicillin-clavulanate for patients who have taken amoxicillin in the previous 30 days (your patient took it 28 days ago). 1

• High-dose amoxicillin-clavulanate provides superior coverage against the two most likely resistance patterns in recurrent otitis media: β-lactamase-producing H. influenzae (58-82% of strains) and penicillin-resistant S. pneumoniae. 1, 2

Why Not Azithromycin?

• Azithromycin showed inferior bacteriologic eradication compared to amoxicillin-clavulanate in head-to-head trials, with only 82% clinical success at Day 11 versus 88% for amoxicillin-clavulanate. 3

• For S. pneumoniae specifically, azithromycin achieved only 82% presumptive bacterial eradication at Day 11 compared to 96% with high-dose amoxicillin-clavulanate. 1, 3

• Azithromycin is not recommended in any major guideline as a preferred agent for recurrent otitis media and would contribute to macrolide resistance. 1

Clinical Context: Recurrent vs. Treatment Failure

• Your patient has recurrent AOM (new episode 28 days after successful treatment), not treatment failure, but the recent amoxicillin exposure is the critical factor. 1, 4

• The bilateral presentation in an 18-year-old increases the likelihood of bacterial etiology requiring antibiotic therapy rather than observation. 1, 5

• Recurrent and persistent otitis media are predominantly caused by antibiotic-resistant S. pneumoniae and β-lactamase-producing H. influenzae, which amoxicillin-clavulanate specifically targets. 2

Dosing and Duration

• Use the 14:1 ratio formulation (90 mg/kg/day amoxicillin with 6.4 mg/kg/day clavulanate) given in 2 divided doses, which has lower diarrhea rates than other ratios. 1

• For an 18-year-old, this translates to approximately 875 mg amoxicillin/125 mg clavulanate twice daily (adjust for actual weight). 1

• Treatment duration should be 7-10 days based on guideline recommendations for recurrent episodes. 1, 4

Critical Pitfalls to Avoid

• Do not use azithromycin for recurrent otitis media when amoxicillin-clavulanate is available and the patient has no true penicillin allergy—this would be suboptimal therapy with inferior outcomes. 1, 3, 2

• Ensure this is truly AOM (bulging tympanic membrane, middle ear effusion, acute symptoms) and not otitis media with effusion, which does not require antibiotics. 1, 4

• The bilateral presentation and recent amoxicillin use are the two factors that mandate stepping up to amoxicillin-clavulanate rather than repeating plain amoxicillin. 1, 4

If Treatment Fails

• If symptoms worsen or fail to improve within 48-72 hours, consider ceftriaxone 50 mg IM/IV for 3 days as the next step. 1, 5

• Reassess to confirm the diagnosis and exclude other causes of ear pain. 1, 4