Antibiotic Regimen for Adult AOM and Paronychia
For an adult presenting with both acute otitis media and paronychia, treat each infection separately: use amoxicillin-clavulanate 875 mg/125 mg twice daily (or high-dose 2000 mg/125 mg twice daily for moderate disease) for 5-7 days for the AOM, and address the paronychia with warm soaks plus oral antibiotics covering Staphylococcus aureus if there is significant cellulitis or abscess formation. 1
Treatment of Adult Acute Otitis Media
First-Line Antibiotic Selection
Amoxicillin-clavulanate is the preferred first-line agent for adult AOM because it provides coverage against beta-lactamase-producing Haemophilus influenzae (17-34% of strains) and Moraxella catarrhalis (100% of strains), as well as resistant Streptococcus pneumoniae—the three primary pathogens in adult AOM. 1
The standard dose is amoxicillin-clavulanate 875 mg/125 mg twice daily (total 1.75 g amoxicillin/250 mg clavulanate per day) for mild to moderate disease without recent antibiotic exposure. 1, 2
For patients with recent antibiotic use within 4-6 weeks or moderate disease severity, use high-dose amoxicillin-clavulanate 2000 mg/125 mg twice daily (total 4 g amoxicillin/250 mg clavulanate per day). 1
Treatment duration should be 5-7 days for uncomplicated adult AOM, which is shorter than the 10-day course recommended for young children, as adults have different immune responses and lower risk of treatment failure. 1
Alternative Regimens for Penicillin Allergy
For patients with non-type I penicillin allergy, use cefdinir, cefpodoxime, or cefuroxime as alternative first-line options. 3, 1
For patients with type I penicillin hypersensitivity (anaphylaxis, urticaria, angioedema), respiratory fluoroquinolones (levofloxacin or moxifloxacin) provide 90-92% predicted clinical efficacy and are superior to macrolides. 1, 2
Azithromycin or clarithromycin may be used but have significant limitations with bacteriologic failure rates of 20-25% and predicted clinical efficacy of only 77-81% due to inadequate coverage against resistant S. pneumoniae. 3, 2
Pain Management
Address pain immediately with oral analgesics (acetaminophen or ibuprofen) regardless of antibiotic decision, as pain management is paramount and should not be considered peripheral to treatment. 1, 2
Topical analgesics may reduce ear pain within 10-30 minutes, though evidence quality is low. 2
Management of Treatment Failure
Reassess at 48-72 hours if symptoms worsen or fail to improve to confirm the AOM diagnosis and exclude other causes of illness. 1, 2
For confirmed treatment failure after initial amoxicillin-clavulanate, switch to a respiratory fluoroquinolone (levofloxacin or moxifloxacin) or consider ceftriaxone rather than simply extending the original regimen. 1
Do not continue the same antibiotic beyond 72 hours without improvement—reassess and change therapy. 2
Treatment of Paronychia
Assessment and Initial Management
Paronychia is typically caused by Staphylococcus aureus (including MRSA in some regions) and occasionally by Streptococcus species or polymicrobial infection.
Early-stage paronychia without significant cellulitis or abscess can be managed with warm water soaks 3-4 times daily and elevation.
If there is an abscess present, incision and drainage is the primary treatment and may be sufficient without antibiotics.
Antibiotic Indications and Selection
Oral antibiotics are indicated when there is significant surrounding cellulitis, failure to improve with drainage alone, or systemic signs of infection.
For empiric coverage of S. aureus including community-acquired MRSA, use trimethoprim-sulfamethoxazole DS twice daily, doxycycline 100 mg twice daily, or clindamycin 300-450 mg three times daily for 5-7 days.
If MRSA is unlikely (no risk factors, no prior MRSA infection), cephalexin 500 mg four times daily or dicloxacillin 500 mg four times daily for 5-7 days provides adequate coverage for methicillin-sensitive S. aureus.
Critical Clinical Pitfalls to Avoid
Do not diagnose AOM based solely on tympanic membrane redness with normal landmarks—this is insufficient for diagnosis and does not warrant antibiotic therapy. 1
Do not confuse otitis media with effusion (OME) for acute otitis media, as isolated middle ear fluid without acute inflammation does not require antibiotics. 1
Avoid fluoroquinolones as first-line therapy for AOM due to concerns about antimicrobial resistance and side effects; reserve them for penicillin-allergic patients or treatment failures. 3, 1
Do not rely on NSAIDs at anti-inflammatory doses or corticosteroids as primary therapy for AOM, as they have not demonstrated efficacy for treatment. 1
For paronychia, do not prescribe antibiotics without drainage if an abscess is present—drainage is the definitive treatment and antibiotics alone will fail.
Monitoring and Follow-Up
Clinical improvement for AOM should occur within 48-72 hours of initiating appropriate therapy, with predicted clinical efficacy of 90-92% for amoxicillin-clavulanate. 1
If no improvement occurs by 48-72 hours, reassess to confirm the diagnosis and consider switching to a different antibiotic class rather than increasing the dose. 2
For paronychia, reassess in 48-72 hours to ensure improvement; if worsening or spreading cellulitis occurs, consider MRSA coverage if not already provided or evaluate for deeper infection.