What is the recommended treatment and dosage for otitis media in a 23-month-old infant weighing 12.3 kilograms?

Prescription for Acute Otitis Media in a 23-Month-Old

For a 23-month-old infant weighing 12.3 kg (27 lbs) with acute otitis media, prescribe amoxicillin 45 mg/kg/day divided into two doses (approximately 275 mg twice daily) for 5 days. 1

Weight-Based Dosing Calculation

• This child weighs 12.3 kg, which falls into the ≤15 kg weight category for standard pediatric dosing 1
• The recommended dose is 80-90 mg/kg/day divided into two doses 1, 2, 3
• Calculation: 12.3 kg × 80 mg/kg = 984 mg/day ÷ 2 = 492 mg per dose (round to 500 mg twice daily for practical dosing)
• Alternatively, using 45 mg/kg per dose: 12.3 kg × 45 mg/kg = 553 mg per dose (round to 550 mg twice daily)

Practical Prescription Format

Amoxicillin oral suspension 400 mg/5 mL

• Dose: 7 mL (560 mg) by mouth twice daily
• Duration: 5 days
• Total volume needed: Approximately 70 mL

This provides approximately 91 mg/kg/day, which falls within the recommended high-dose range of 80-90 mg/kg/day. 1, 2, 3

First-Line Therapy Rationale

• Amoxicillin is the first-line antibiotic for acute otitis media in children without recent antibiotic exposure (within 30 days), without concurrent purulent conjunctivitis, and without penicillin allergy 1, 2, 3
• High-dose amoxicillin (80-90 mg/kg/day) provides adequate coverage against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, the most common bacterial pathogens 1, 3, 4
• The high-dose regimen addresses increasing pneumococcal resistance patterns 1, 2

Alternative Antibiotics (Second-Line)

Use amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) if: 1

• The child received amoxicillin in the past 30 days 1
• Concurrent purulent conjunctivitis is present 1
• History of recurrent AOM unresponsive to amoxicillin 1

For penicillin allergy: 1, 2

• Cefdinir or azithromycin should be first-line based on risk of cephalosporin cross-reactivity 2
• Azithromycin dosing: 10 mg/kg once daily for 3 days (123 mg daily) 5

Pain Management

• Adequate analgesia should be provided regardless of antibiotic decision 1, 3
• Options include acetaminophen or ibuprofen at weight-appropriate doses 1

Follow-Up and Reassessment

• Reassess if symptoms worsen or fail to improve within 48-72 hours of initiating antibiotic therapy 1, 2
• If treatment failure occurs, switch to amoxicillin-clavulanate or another second-line agent 1, 3

Critical Pitfalls to Avoid

• Do not use standard-dose amoxicillin (40-45 mg/kg/day) as it provides inadequate coverage against resistant S. pneumoniae 1, 2
• Do not prescribe antibiotics for otitis media with effusion (asymptomatic middle ear fluid), as antibiotics do not hasten clearance 1, 3, 4
• Ensure accurate diagnosis with moderate-to-severe tympanic membrane bulging or new-onset otorrhea, plus acute symptoms 1, 2
• Do not round down the dose to convenient volumes if it results in subtherapeutic dosing 1

Observation Option (Not Applicable Here)

• Observation without immediate antibiotics can be considered for children ≥2 years with mild symptoms and unilateral disease 1, 2
• Since this child is 23 months old (under 2 years), immediate antibiotic therapy is recommended regardless of symptom severity 1, 2