What is the management of acute otitis media (AOM) in a pediatric patient weighing 40 kilograms who requires oral antibiotics and has no penicillin (PCN) allergy?

From the Guidelines

For a 40 kg pediatric patient with acute otitis media (AOM) and no penicillin allergy, I recommend amoxicillin as first-line therapy at a dose of 90 mg/kg/day divided twice daily (approximately 1800 mg/day or 900 mg twice daily for this 40 kg child) for 10 days, as supported by the most recent and highest quality study 1. This recommendation is based on the effectiveness of amoxicillin against Streptococcus pneumoniae, the most common bacterial cause of AOM, while providing good coverage against other common pathogens like Haemophilus influenzae and Moraxella catarrhalis. Some key points to consider in the management of AOM include:

• If the child has severe symptoms or risk factors for resistant organisms, amoxicillin-clavulanate would be more appropriate at 90 mg/kg/day of the amoxicillin component divided twice daily 1.
• For patients with recent antibiotic use within 30 days, consider starting with amoxicillin-clavulanate instead 1.
• If the patient doesn't respond to initial therapy within 48-72 hours, reassessment is needed, and alternative options such as cefdinir (14 mg/kg/day divided once or twice daily, maximum 600 mg/day) or cefuroxime (30 mg/kg/day divided twice daily, maximum 1000 mg/day) can be considered 1.
• Pain management is also important, and acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) can be recommended as needed. The choice of antibiotic should be based on the anticipated clinical response and the microbiologic flora likely to be present, as well as considerations of safety, cost, and taste 2. It's worth noting that the optimal duration of therapy for patients with AOM is uncertain, but 10 days is a commonly recommended duration 2, 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

For a pediatric patient weighing 40 kg, the recommended dose would be:

• 30 mg/kg as a single dose: 30 mg/kg x 40 kg = 1200 mg
• 10 mg/kg once daily for 3 days: 10 mg/kg x 40 kg = 400 mg/day for 3 days
• 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5: 10 mg/kg x 40 kg = 400 mg on Day 1, then 5 mg/kg x 40 kg = 200 mg/day on Days 2-5

The patient can be given 1200 mg of azithromycin as a single dose, or 400 mg on the first day followed by 200 mg on Days 2-5, or 400 mg once daily for 3 days. 3

From the Research

Management of Acute Otitis Media (AOM) in Pediatric Patients

Overview of AOM Management

• AOM is a common bacterial infection in children, and the most common indication for antibiotic prescriptions 4.
• The Centers for Disease Control and the American Academy of Pediatrics promote the judicious use of antibiotics in the treatment of AOM, emphasizing the importance of distinguishing AOM from otitis media with effusion and minimizing the use of antibiotics 4.

First-Line Treatment Options

• Amoxicillin is the treatment of choice for AOM, but resistance to pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis is increasing 4, 5.
• For patients who are not allergic to penicillin, amoxicillin at conventional or high doses (80-90 mg/kg/day) remains an appropriate choice for first-line therapy for AOM 5.

Second-Line Treatment Options

• For patients in whom amoxicillin is unsuccessful, second-line therapy should have demonstrated activity against penicillin-resistant S. pneumoniae as well as beta-lactamase-producing pathogens 5.
• Cefuroxime axetil, cefdinir, and cefpodoxime proxetil are alternative options for second-line therapy, offering a broad spectrum of activity and convenient once- or twice-daily dosing schedules 4.
• Macrolide antibiotics, such as clarithromycin, may be considered for patients who are allergic to penicillin or have failed first-line therapy, but their use is associated with an increased risk of clinical failure 6.

Treatment of AOM in Pediatric Patients 40 kg or More

• For a pediatric patient weighing 40 kg or more with no penicillin allergy, amoxicillin or amoxicillin-clavulanate may be considered as first-line treatment options 5.
• If the patient has failed first-line therapy or has a history of recurrent AOM, second-line treatment options such as cefuroxime axetil, cefdinir, or cefpodoxime proxetil may be considered 4, 5.

Oral Antibiotic Options

• Amoxicillin, amoxicillin-clavulanate, cefuroxime axetil, cefdinir, and cefpodoxime proxetil are available in oral formulations and may be considered for the treatment of AOM in pediatric patients 4, 5, 7.
• Clarithromycin is also available in an oral formulation, but its use is associated with an increased risk of clinical failure and should be reserved for patients who cannot receive amoxicillin or amoxicillin-clavulanate 6.