What are the doses of Amoxiclav and Avamys for a 4-year-old with Serous Otitis Media who failed high-dose Amoxicillin?

Amoxicillin-Clavulanate Dosing for Treatment Failure in Pediatric Serous Otitis Media

For a 4-year-old who has failed high-dose amoxicillin for serous otitis media, switch to high-dose amoxicillin-clavulanate at 90 mg/kg/day (amoxicillin component) with 6.4 mg/kg/day clavulanate, divided into two doses daily for 10 days. 1, 2

Amoxicillin-Clavulanate (Amoxiclav) Dosing After Amoxicillin Failure

High-Dose Regimen Specification

• The recommended dose is 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, given in two divided doses (approximately every 12 hours). 1, 2
• This provides a 14:1 ratio of amoxicillin to clavulanate, which minimizes gastrointestinal side effects while maintaining efficacy against resistant pathogens. 2, 3
• For a typical 4-year-old weighing approximately 16-18 kg, this translates to roughly 720-810 mg of amoxicillin twice daily. 2

Duration of Treatment

• Continue therapy for 10 days for otitis media. 1, 4

Rationale for High-Dose Regimen After Failure

• When amoxicillin fails, the primary concern is beta-lactamase-producing organisms (H. influenzae, M. catarrhalis) or penicillin-resistant S. pneumoniae. 1, 5
• High-dose amoxicillin-clavulanate achieves middle ear fluid concentrations adequate to overcome penicillin-resistant S. pneumoniae (MIC ≤2-4 mcg/mL) and covers beta-lactamase producers. 2, 4
• Studies demonstrate 91-98% eradication rates for penicillin-resistant S. pneumoniae and 94% eradication for H. influenzae with this regimen. 4

Critical Pitfall to Avoid

• Do not use standard-dose amoxicillin-clavulanate (40-45 mg/kg/day) after high-dose amoxicillin failure, as this provides inadequate coverage and promotes resistance. 2
• Using subtherapeutic doses leads to inevitable treatment failure with resistant organisms. 2

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Fluticasone Furoate Nasal Spray (Avamys) Dosing for Eustachian Tube Dysfunction

Important Clinical Context

Serous otitis media (otitis media with effusion) does not routinely require intranasal corticosteroids as first-line therapy. 1

• Current guidelines emphasize watchful waiting as the initial management strategy for otitis media with effusion, unless the child has bilateral disease lasting >3 months, hearing loss >25-40 dB, or significant impact on development. 1
• Medical treatment including intranasal steroids is discouraged in most guidelines for routine OME management. 1

Avamys Dosing (If Clinically Indicated)

If intranasal corticosteroids are deemed necessary for concurrent allergic rhinitis or specific Eustachian tube dysfunction:

• For children 2-11 years: 1 spray (27.5 mcg) per nostril once daily (total 55 mcg/day)
• For children ≥12 years: 2 sprays (55 mcg) per nostril once daily initially, then reduce to 1 spray per nostril for maintenance

When to Consider Intranasal Steroids

• Concurrent allergic rhinitis contributing to Eustachian tube dysfunction
• Adenoidal hypertrophy with nasal obstruction
• Persistent OME with documented hearing loss after appropriate observation period

What NOT to Do

• Do not prescribe intranasal steroids as routine treatment for uncomplicated serous otitis media. 1
• Do not delay appropriate antibiotic therapy if bacterial infection is suspected while relying solely on nasal steroids.
• Surgical intervention (tympanostomy tubes) is recommended over prolonged medical management for persistent bilateral OME >3 months with hearing impairment. 1