From the Guidelines
The next step for a patient who has been on amoxicillin for ten days and still has ear pain is to reevaluate the patient and consider alternative causes of illness, including fungal infections, resistant bacteria, or dermatologic disorders, as suggested by the clinical practice guideline for acute otitis externa 1. When a patient fails to respond to treatment, it is essential to consider alternative causes of ear pain and associated otorrhea, such as fungi, which may be present as a co-pathogen and cause persistent infection from overgrowth in the ear canal if the flora is altered after topical antibacterial therapy 1. Some key points to consider in the reevaluation include:
- Reexamining the ear canal and tympanic membrane to detect an unrecognized foreign body, perforated tympanic membrane, or middle ear disease
- Considering dermatologic disorders such as dermatitis, psoriasis, dermatomycosis, or acne that involves the external auditory canal
- Assessing for malignant otitis externa or carcinoma of the external auditory canal, especially if granulation tissue is present
- Evaluating for allergic contact dermatitis of the external auditory canal, which can result in refractory symptoms, especially with prolonged use of antimicrobial otic drops A culture of the ear canal can identify fungi, resistant bacteria, or unusual causes of infection that require targeted topical or systemic therapy, and should be considered in cases of persistent symptoms 1. Pain management should continue with appropriate analgesics such as acetaminophen or ibuprofen. It is crucial to approach the patient's condition with a broad perspective, considering various potential causes of persistent ear pain, rather than solely focusing on antibiotic therapy.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Next Steps for Patient with Ear Pain
- The patient has been on amoxicillin for ten days and still experiences ear pain, indicating that the current treatment may not be effective.
- According to the study 2, amoxicillin-clavulanate has a high success rate for treating acute otitis media, especially for Streptococcus pneumoniae and Haemophilus influenzae.
- However, the study 3 suggests that azithromycin given over 3 days is as effective as co-amoxiclav for treatment of AOM and may result in more complete resolution of tympanic membrane disease.
- Another study 4 found that amoxicillin/clavulanate was significantly more likely to eradicate all bacterial pathogens, including Haemophilus influenzae, from middle ear fluid than azithromycin.
- A systematic review 5 concluded that amoxicillin-clavulanate should be the treatment of choice for children with AOM, but its efficacy was comparable to other antimicrobials or placebo in some studies.
Possible Actions
- Consider switching to azithromycin for 3 days, as it has been shown to be effective in treating AOM and may have a better tolerability profile 3.
- Alternatively, continue with amoxicillin-clavulanate for a longer duration or consider adding other antibiotics, such as clavulanate, to enhance its effectiveness 2, 4.
- It is essential to reassess the patient's condition and consider further diagnostic tests, such as tympanocentesis, to determine the underlying cause of the ear pain and guide further treatment decisions 4.