What to do for ear pain persisting after 8 days of strep (streptococcal) antibiotics?

Ear Pain After 8 Days of Strep Antibiotics

You need to reassess the patient immediately to confirm the diagnosis, as ear pain persisting after 8 days of streptococcal pharyngitis treatment suggests either a new complication (acute otitis media or acute otitis externa) or treatment failure requiring different management.

Immediate Diagnostic Reassessment

The first priority is distinguishing between acute otitis media (AOM) and acute otitis externa (AOE), as these require completely different treatments. 1

Key Examination Findings to Differentiate:

• For AOM: Look for middle ear effusion confirmed by pneumatic otoscopy or tympanometry, bulging tympanic membrane, and signs of middle ear inflammation 1, 2
• For AOE: Look for ear canal inflammation, debris in the canal, pain with tragal pressure or pinna manipulation, and assess if the tympanic membrane is intact 1
• Critical pitfall: Isolated tympanic membrane redness with normal landmarks does NOT indicate AOM and should not be treated with antibiotics 1, 2

If Acute Otitis Media is Confirmed

Switch to high-dose amoxicillin-clavulanate 90 mg/kg/day (of amoxicillin component) divided into 2 doses for 5 days in adults and children over 2 years. 3, 2 This is necessary because:

• The bacteria causing AOM (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) differ from Group A Streptococcus causing pharyngitis 1, 3, 4
• Standard penicillin or amoxicillin used for strep throat provides inadequate coverage for beta-lactamase-producing organisms common in AOM 3
• Treatment failure is defined as persistence of symptoms beyond 48 hours after starting appropriate antibiotics 1, 2

Alternative Antibiotics for Penicillin Allergy:

• Non-type I hypersensitivity: Use cefdinir, cefpodoxime, or cefuroxime 2
• Type I hypersensitivity: Consider macrolides, though these have 20-25% bacteriologic failure rates due to resistance 3

If Acute Otitis Externa is Confirmed

Prescribe topical antibiotic-steroid drops (non-ototoxic if tympanic membrane perforation is suspected or tympanostomy tube present) rather than systemic antibiotics. 1

• Topical therapy is the primary treatment for uncomplicated AOE, not systemic antibiotics 1, 5
• If the ear canal is obstructed with debris, aural toilet or wick placement may be necessary before drops can be effective 1
• Patients should show improvement within 48-72 hours of starting topical therapy 1

Pain Management is Mandatory

Initiate immediate analgesic therapy with acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) regardless of which diagnosis is confirmed. 2 Pain relief should not be delayed while awaiting diagnostic clarification or antibiotic effect 1, 2.

Critical Reassessment Timeline

If symptoms do not improve within 48-72 hours of starting appropriate treatment, reassess again to:

• Reconsider the diagnosis 1
• Evaluate for suppurative complications (peritonsillar abscess, mastoiditis, acute sinusitis) 1
• Consider need for aural toilet if AOE 1
• Switch to alternative antibiotic if AOM treatment failure 1, 2

Common Pitfalls to Avoid

• Do not simply continue or extend the original strep throat antibiotic – this will not adequately treat AOM if present 3, 2
• Do not prescribe antibiotics for isolated TM redness without confirmed middle ear effusion 1, 2
• Do not use systemic antibiotics alone for uncomplicated AOE – topical therapy is superior 1, 5
• Do not assume the strep throat treatment failed – this is likely a new, separate infection requiring different management 1, 3