What's the next step for a patient with otitis media who doesn't show improvement after 10 days of treatment with Augmentin (amoxicillin/clavulanate) twice a day?

Treatment Failure of Acute Otitis Media After Augmentin

For a patient with acute otitis media showing no improvement after 10 days of Augmentin, administer intramuscular ceftriaxone 50 mg/kg daily for 3 consecutive days. 1

Confirm the Diagnosis First

Before changing antibiotics, verify that you are truly dealing with persistent AOM rather than other conditions:

• Re-examine the tympanic membrane to confirm middle ear effusion with signs of acute inflammation (bulging, decreased mobility, purulent fluid) 1
• Rule out otitis media with effusion (OME), which is present in 60-70% of children 2 weeks after successful AOM treatment and does not require antibiotics 2
• Exclude complications such as mastoiditis, which occurs in 33-81% of cases despite prior antibiotic treatment 1
• Consider viral illness as an alternative explanation for persistent symptoms 1

Second-Line Antibiotic Therapy

If true treatment failure is confirmed:

• Administer ceftriaxone 50 mg/kg intramuscularly once daily for 3 consecutive days (not just 1 day, as the 3-day regimen is superior) 1
• This provides excellent coverage for beta-lactamase producing organisms (H. influenzae, M. catarrhalis) and drug-resistant S. pneumoniae 1

Alternative Oral Options for Non-Severe Penicillin Allergy

If the patient has a non-severe penicillin allergy or ceftriaxone is not feasible:

• Use cefdinir, cefuroxime, or cefixime as alternatives 1
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported 1

For Severe Penicillin Allergy

• Consider clindamycin if S. pneumoniae is the suspected pathogen 1
• Be aware that S. pneumoniae serotype 19A is often multidrug-resistant and may not respond to clindamycin 1

Management of Repeated Treatment Failures

If the patient fails second-line therapy:

• Perform tympanocentesis with Gram stain, culture, and antibiotic susceptibility testing 2, 1
• Consult pediatric subspecialists: an otolaryngologist for tympanocentesis/drainage and an infectious disease expert before using unconventional drugs 2
• Consider levofloxacin or linezolid for multidrug-resistant organisms, particularly S. pneumoniae serotype 19A, though neither is FDA-approved for AOM in children 1

Pain Management Throughout

• Administer oral acetaminophen or ibuprofen at age-appropriate doses immediately, regardless of antibiotic changes 1
• Consider topical analgesics for additional brief relief 1

Common Pitfalls to Avoid

• Do not mistake OME for persistent AOM: OME is extremely common after successful treatment (60-70% at 2 weeks, 40% at 1 month) and requires monitoring but not antibiotics 2
• Do not routinely re-evaluate all children at 10-14 days unless they are young, have severe symptoms, recurrent AOM, or parents specifically request it 2
• Do not use prophylactic antibiotics for children with persistent middle ear effusion or infrequent AOM episodes, as the benefit is minimal and contributes to bacterial resistance 2

Surgical Consideration for Recurrent Cases

• Consider tympanostomy tubes for recurrent AOM (3+ episodes in 6 months or 4+ episodes in 12 months), which decreases AOM frequency and allows topical rather than systemic antibiotic treatment 1