Should an adult or geriatric patient with a history of recent fall and stitches, now presenting with mastoid effusion or mastoiditis, be started on IV amoxicillin-clavulanate (amoxicillin-clavulanic acid) upon return to the skilled nursing facility?

Management of Mastoid Effusion/Mastoiditis in a Skilled Nursing Facility Patient

Do not start IV amoxicillin alone—you need IV amoxicillin-clavulanate (Augmentin) immediately, and this patient requires urgent ENT consultation and imaging to rule out intracranial complications before initiating antibiotics at the skilled nursing facility. 1

Immediate Actions Required

This patient needs emergency transfer back to the hospital, not antibiotic initiation at the SNF. Mastoiditis is a serious infection requiring:

• Immediate IV broad-spectrum antibiotics upon confirmed diagnosis, not delayed initiation at a skilled nursing facility 1, 2
• Urgent ENT evaluation for possible myringotomy with or without tympanostomy tube placement 1, 2
• CT temporal bone with IV contrast if not already obtained, to assess for subperiosteal abscess, bony erosion, or intracranial complications 2
• MRI without and with IV contrast if any neurological signs are present (altered consciousness, seizures, focal deficits, neck rigidity) to evaluate for brain abscess, subdural empyema, meningitis, or sigmoid sinus thrombosis 2

Why IV Amoxicillin Alone Is Inadequate

The correct antibiotic is IV amoxicillin-clavulanate, not amoxicillin alone, because:

• Mastoiditis commonly involves beta-lactamase-producing organisms including Haemophilus influenzae and Moraxella catarrhalis, which require clavulanate for coverage 3, 4
• Staphylococcus epidermidis and Streptococcus pneumoniae are also common pathogens in mastoiditis 4
• Amoxicillin-clavulanate provides broader coverage against the polymicrobial nature of mastoiditis 1, 2

Appropriate Antibiotic Regimen

For complicated or severe mastoiditis, broader coverage is required beyond amoxicillin-clavulanate alone:

• The Infectious Diseases Society of America recommends vancomycin plus one of the following: piperacillin-tazobactam, a carbapenem, ceftriaxone plus metronidazole, or a fluoroquinolone plus metronidazole 1, 2
• If using IV amoxicillin-clavulanate, dose at 80-90 mg/kg/day of the amoxicillin component (maximum 4000 mg/day total), which translates to approximately 1333 mg IV every 8 hours or 2000 mg IV every 12 hours 1, 2

Critical Complications to Monitor

This patient is at high risk for life-threatening complications:

• Brain abscess is the most common intracranial complication of mastoiditis 1, 2
• Sigmoid sinus thrombosis occurs frequently and may require anticoagulation 1, 2
• Meningitis or subdural empyema can develop rapidly 2
• Subperiosteal abscess was present in 49% of mastoiditis cases in one series 4

Neurological warning signs include: nuchal rigidity, altered consciousness, seizures, focal neurological deficits, or visual changes 2

Why This Patient Should Not Be Managed at SNF

Several factors make SNF management inappropriate:

• 33-81% of patients with mastoiditis had already received antibiotics before admission, demonstrating that outpatient antibiotic treatment frequently fails 1, 2
• Initial conservative management requires 0-48 hours of IV antibiotics with close monitoring, followed by reassessment for surgical intervention if no improvement 1, 2
• Surgical intervention (mastoidectomy) is required in 22% of cases, and myringotomy in 68% of cases 2
• The patient requires imaging within 48 hours if not improving or immediately if deteriorating 2

Common Pitfalls to Avoid

• Do not use amoxicillin alone—clavulanate is essential for beta-lactamase-producing organisms 3, 4
• Do not delay ENT consultation—early surgical evaluation is critical 1, 2
• Do not assume prior antibiotic treatment rules out serious infection—most mastoiditis patients had received antibiotics before diagnosis 1, 2
• Do not manage at SNF without imaging—intracranial complications cannot be reliably excluded clinically 2

Recommended Course of Action

Transfer the patient back to the emergency department immediately with the following information:

1. Documented mastoid effusion/mastoiditis on prior ER imaging
2. Request urgent ENT consultation
3. Initiate IV amoxicillin-clavulanate or broader coverage (vancomycin plus piperacillin-tazobactam or carbapenem) upon arrival 1, 2
4. Obtain CT temporal bone with IV contrast if not already done 2
5. Consider MRI if any neurological signs present 2

Once clinical improvement is documented on IV therapy (typically after 48-72 hours), transition to oral high-dose amoxicillin-clavulanate (2000 mg twice daily for adults) may be considered for completion of therapy at the SNF 1, 2