What is the recommended medication, dose, and course for an 8-year-old girl weighing 63 pounds with left otitis media and left otitis externa?

Treatment for 8-Year-Old with Concurrent Otitis Media and Otitis Externa

For this 8-year-old girl (63 lbs/28.6 kg) with both left acute otitis media and left otitis externa, treat the otitis media systemically with high-dose amoxicillin 80-90 mg/kg/day (2,290-2,575 mg/day) divided into 2 doses for 5-7 days, and treat the otitis externa topically with ciprofloxacin-dexamethasone otic drops 4 drops twice daily for 7 days. 1, 2

Systemic Treatment for Acute Otitis Media

First-Line Antibiotic Selection

• High-dose amoxicillin is the recommended first-line treatment for acute otitis media in children who have not received amoxicillin in the past 30 days and have no penicillin allergy 1
• The dosing should be 80-90 mg/kg/day divided into 2 doses 1, 3
• For this 28.6 kg child: 2,290-2,575 mg total daily dose, which translates to approximately 1,145-1,288 mg per dose twice daily 3
• Practical dosing: 1,200 mg twice daily (rounded for ease of administration using available formulations) 1

Duration of Therapy

• 5-7 days is appropriate for an 8-year-old with uncomplicated acute otitis media 3, 4
• Children under 2 years require 10 days, but older children with mild-to-moderate disease respond well to shorter courses 1, 3

Alternative if Amoxicillin Recently Used

• If amoxicillin was given in the past 30 days, switch to amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component (with 6.4 mg/kg/day clavulanate) divided into 2 doses 1
• This provides coverage against β-lactamase-producing organisms 1, 5

Penicillin Allergy Alternatives

• For non-type I hypersensitivity: cefdinir 14 mg/kg/day, cefuroxime 30 mg/kg/day, or cefpodoxime 10 mg/kg/day 1
• These second- and third-generation cephalosporins have negligible cross-reactivity with penicillin due to distinct chemical structures 1
• For type I hypersensitivity reactions: azithromycin 10 mg/kg day 1, then 5 mg/kg days 2-5, though bacteriologic failure rates of 20-25% are possible 1, 6

Topical Treatment for Otitis Externa

Otic Drop Therapy

• Ciprofloxacin-dexamethasone otic suspension: 4 drops into the affected left ear twice daily for 7 days 2
• This provides both antibacterial coverage (ciprofloxacin) and anti-inflammatory effect (dexamethasone) 2
• Warm the bottle in hand for 1-2 minutes before instillation to avoid dizziness from cold suspension 2
• Patient should lie with affected ear upward and maintain position for 60 seconds after instillation 2

Pain Management

Analgesic Recommendations

• Pain assessment and management are essential regardless of antibiotic use, especially during the first 24 hours 7, 3
• Appropriate analgesics include acetaminophen or ibuprofen dosed by weight 4
• Pain relief is a priority outcome alongside infection resolution 7

Reassessment and Treatment Failure

When to Reassess

• Reevaluate if symptoms worsen or fail to improve within 48-72 hours of starting antibiotics 1
• Signs of treatment failure include: worsening condition, persistence of symptoms beyond 48 hours, or fever continuing beyond 48-72 hours 1, 7

Second-Line Treatment Options

• If initial amoxicillin fails: switch to amoxicillin-clavulanate 90 mg/kg/day 1
• If amoxicillin-clavulanate fails: ceftriaxone 50 mg/kg IM daily for 3 days (more effective than 1-day regimen) 1
• For multiple treatment failures: consider tympanocentesis for culture and susceptibility testing 1

Important Clinical Considerations

Common Pitfalls to Avoid

• Do not underdose amoxicillin—the high-dose regimen (80-90 mg/kg/day) is critical for eradicating penicillin-resistant Streptococcus pneumoniae, the most common pathogen 1, 5
• Ensure proper diagnosis of otitis media with visualization of bulging tympanic membrane or middle ear effusion before prescribing antibiotics 1, 7
• Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole as second-line agents due to substantial pneumococcal resistance 1
• Complete the full antibiotic course even if symptoms improve before completion 7

Concurrent Infection Management

• The presence of both otitis media and otitis externa requires both systemic and topical therapy 2, 4
• The systemic antibiotic addresses the middle ear infection while topical drops treat the external ear canal infection 2
• β-lactamase-producing Haemophilus influenzae is the predominant pathogen in amoxicillin failures, accounting for 62-64% of bacteriologic failures 5