Can a pediatric patient with a recent history of streptococcal pharyngitis treated with amoxicillin be given amoxicillin again for bilateral Acute Otitis Media?

Can You Give Amoxicillin Again for Bilateral AOM After Recent Strep Treatment?

Yes, you can give amoxicillin again for bilateral acute otitis media (AOM) if the strep pharyngitis treatment was completed more than 30 days ago. 1

Antibiotic Selection Based on Timing

The critical decision point is the interval since the last amoxicillin course:

• If >30 days since last amoxicillin dose: Use high-dose amoxicillin (80-90 mg/kg/day divided into 2 doses) as first-line therapy 1, 2
• If ≤30 days since last amoxicillin dose: Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate, using 14:1 ratio formulation) 1, 2, 3

The American Academy of Pediatrics specifically recommends high-dose amoxicillin when the child received amoxicillin more than 30 days ago, as resistance risk is lower and the narrower spectrum antibiotic is preferred 1. The American Academy of Otolaryngology-Head and Neck Surgery supports this approach, noting that amoxicillin remains effective due to its safety profile, low cost, acceptable taste, and narrow microbiologic spectrum 2.

Why Bilateral AOM Matters

Bilateral AOM in young children has higher treatment failure rates and warrants immediate antibiotic therapy rather than observation. 4

Key evidence supporting immediate treatment:

• Treatment failure rates for bilateral AOM were 21.7% with amoxicillin-clavulanate versus 46.3% with placebo (NNT = 4) 4
• For children 6-23 months with bilateral AOM, the American Academy of Pediatrics recommends immediate antibiotic therapy regardless of symptom severity 2
• Observation without antibiotics is only appropriate for unilateral AOM in children ≥6 months with non-severe symptoms 2

Treatment Duration and Dosing

For bilateral AOM, treatment duration depends on age:

• Children <2 years: 10-day course 2, 3
• Children 2-5 years with mild-moderate symptoms: 7-day course 2
• Children ≥6 years: 5-7 day course for mild-moderate symptoms 2

Maximum single dose is 2000 mg of amoxicillin 3

Common Pitfalls to Avoid

Do not use leftover amoxicillin from the strep treatment. The American Academy of Pediatrics advises against this because potency cannot be guaranteed and dosing will be incorrect for current weight 1. Always obtain a fresh prescription with weight-based dosing.

Do not prescribe amoxicillin-clavulanate as first-line when the last course was >30 days ago. This unnecessarily increases gastrointestinal side effects (diarrhea in 52.8% vs 36.1% with placebo) without improving outcomes 4, 1. The American Academy of Pediatrics specifically warns against this practice 1.

Do not use standard-dose amoxicillin (40-45 mg/kg/day). High-dose regimens (80-90 mg/kg/day) are essential for eradicating resistant Streptococcus pneumoniae, which accounts for approximately 35% of isolates in some regions 1, 2. Recent data show that despite increasing prevalence of beta-lactamase-producing bacteria (65.8% of children had one or more beta-lactamase-producing bacteria), treatment failure with amoxicillin remains uncommon at 5.4% 5.

Pain Management

Initiate immediate pain control with acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) regardless of antibiotic choice. 1, 2 Pain management is mandatory and should not be delayed, as antibiotics do not provide symptomatic relief in the first 24 hours 2.

Reassessment Strategy

Reassess at 48-72 hours if symptoms worsen or fail to improve. 1, 2 If treatment failure occurs:

• Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) if initially on amoxicillin 1, 2
• Switch to ceftriaxone 50 mg/kg IM/IV daily for 1-3 days if amoxicillin-clavulanate fails 2, 3
• A 3-day course of ceftriaxone is superior to a 1-day regimen for treatment failures 2