What are the second and third line treatments for Acute Otitis Media (AOM) in a 10-month-old infant?

From the Guidelines

For a 10-month-old with acute otitis media (AOM) requiring second-line treatment, high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component, divided twice daily for 10 days) is recommended. This is indicated when initial amoxicillin treatment fails after 48-72 hours or in cases with severe symptoms, as suggested by 1. If the child has a penicillin allergy, cefdinir (14 mg/kg/day divided once or twice daily), cefuroxime (30 mg/kg/day divided twice daily), or ceftriaxone (50 mg/kg IM or IV once daily for 1-3 days) are appropriate alternatives.

Key Considerations

• The choice of second-line treatment should be based on the anticipated clinical response and the microbiologic flora likely to be present, with amoxicillin-clavulanate being a suitable option due to its effectiveness against susceptible and intermediate resistant pneumococci, as noted in 1.
• For third-line treatment when second-line options fail, consider clindamycin (30-40 mg/kg/day divided three times daily) plus a third-generation cephalosporin, or consult with pediatric infectious disease specialists for guidance, as recommended by 1.
• Tympanocentesis may be considered to identify the causative organism and guide targeted therapy in refractory cases, allowing for more precise treatment and reducing the risk of treatment failure.

Treatment Options

• High-dose amoxicillin-clavulanate for second-line treatment
• Cefdinir, cefuroxime, or ceftriaxone for patients with penicillin allergy
• Clindamycin plus a third-generation cephalosporin for third-line treatment
• Tympanocentesis for targeted therapy in refractory cases These escalated treatments address beta-lactamase-producing organisms and resistant strains of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis that commonly cause treatment failures in infants with AOM, as discussed in 1 and 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5. For a 10-month-old patient, the dose would be calculated based on the patient's weight.

• Second and third line treatment options are not explicitly stated in the label for AOM, but azithromycin is a commonly used second or third line option.
• Dosing for 10-month-old: The patient's weight would need to be determined to calculate the dose, but for example, if the patient weighs 8 kg (approximately 17.6 lbs), the dose would be 3.75 mL (150 mg) for the 1-day regimen, or 2.5 mL (100 mg) on Day 1 and 1.25 mL (50 mg) on Days 2-5 for the 5-day regimen, or 2.5 mL (100 mg) per day for the 3-day regimen.
• Key considerations: The effectiveness of azithromycin for AOM has been established, but the label does not provide explicit guidance on second and third line treatment. 2 2

From the Research

Second and Third Line Treatment for AOM in 10 Month Old

• The treatment of acute otitis media (AOM) in children, including those around 10 months old, often involves the use of antibiotics to target the bacterial causes of the infection 3, 4, 5, 6, 7.
• First-line treatment typically involves amoxicillin, but for cases where this is not effective, second and third line treatments are considered 6.
• Second-line therapy options include high-dose amoxicillin/clavulanate (90 mg/kg/day based on the amoxicillin component) and ceftriaxone, which have demonstrated activity against penicillin-resistant S. pneumoniae and beta-lactamase-producing pathogens 6.
• The choice between these options may depend on factors such as the suspected causative pathogens, the patient's history of antibiotic use, and potential resistance patterns in the community 3, 5.
• Studies have shown that amoxicillin/clavulanate is effective and well-tolerated in the treatment of AOM in pediatric patients, including those with penicillin-resistant S. pneumoniae 3, 4.
• Other antibiotics like azithromycin and clarithromycin have also been studied for the treatment of AOM, with varying degrees of success and tolerability compared to amoxicillin/clavulanate 5, 7.
• The specific choice of second or third line treatment should be guided by clinical judgment, taking into account the individual patient's needs and the latest evidence on antibiotic efficacy and resistance patterns 6.