What are the next steps for a patient with a persistent ear infection and upper respiratory infection (URI) who remains symptomatic 7 days after treatment with Augmentin (amoxicillin-clavulanate)?

Management of Persistent Ear Infection and URI After Augmentin Failure

For a patient with persistent symptoms 7 days after Augmentin treatment, you should switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component in two divided doses) if not already on this formulation, or escalate to intramuscular ceftriaxone 50 mg/kg for 3 consecutive days if the patient was already on appropriate high-dose therapy. 1, 2

Initial Reassessment Steps

Before changing antibiotics, you must confirm the diagnosis and rule out common pitfalls:

• Re-examine the tympanic membrane to verify middle ear effusion with bulging or inflammation, as isolated erythema can occur with viral pharyngitis alone 2
• Assess medication adherence, as patients commonly over-administer when pain is severe and under-administer as symptoms improve, leading to apparent treatment failure 2
• Consider viral superinfection or carrier state, particularly for throat symptoms, as up to 20% of school-aged children are group A streptococcal carriers who can experience intercurrent viral pharyngitis 2

Antibiotic Treatment Failure Criteria

Treatment failure is defined as 3:

• Worsening of the patient's condition
• Persistence of symptoms for more than 48 hours after initiating antibiotic therapy
• Recurrence of functional and systemic signs with otoscopic evidence of purulent acute otitis media within 4 days of treatment discontinuation

Antibiotic Escalation Algorithm

If Patient Was on Standard-Dose Augmentin:

Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component divided into two doses), which provides enhanced coverage against beta-lactamase producing organisms and penicillin-resistant Streptococcus pneumoniae 1, 4

• This formulation is specifically designed to cover penicillin-resistant S. pneumoniae (MIC ≤2 mg/L), Haemophilus influenzae, and Moraxella catarrhalis 4
• Reassess in 48-72 hours to confirm clinical improvement 1

If Patient Fails High-Dose Amoxicillin-Clavulanate or Has Severe Symptoms:

Administer intramuscular ceftriaxone 50 mg/kg for 3 consecutive days 2

• This covers resistant S. pneumoniae and beta-lactamase-producing H. influenzae and M. catarrhalis 2
• Three-day regimens are superior to single-dose ceftriaxone for treatment-resistant cases 2

Alternative Oral Options (if IM therapy not feasible):

• Cefdinir 14 mg/kg/day in 1-2 doses, which provides excellent coverage against all three major pathogens 2
• Clindamycin 30-40 mg/kg/day in 3 divided doses (children) or 300 mg four times daily (adults) for 10 days, though this lacks coverage for H. influenzae and M. catarrhalis unless combined with another agent 2

Critical Pitfalls to Avoid

• Do not use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole, as pneumococcal resistance to these agents is substantial 2
• Do not repeat azithromycin or other macrolides given their already demonstrated failure and lower efficacy rates against S. pneumoniae 1, 2
• Avoid empiric treatment without obtaining culture if symptoms persist beyond 7 days, as this may lead to unnecessary treatment of culture-negative patients 3

Treatment Duration

• 8-10 days for children under 2 years of age 3, 2
• 5 days for older children and adults 3, 2

When to Refer to ENT

Consider specialist referral if 2:

• Patient fails to respond after multiple appropriate antibiotic courses
• Tympanocentesis is needed for culture-directed therapy
• Severe refractory symptoms suggest complications (mastoiditis, malignant otitis externa)
• Recurrent episodes warrant evaluation for anatomic abnormalities or immunodeficiency

Upper Respiratory Infection Component

For the URI component, recognize that 3:

• Most URIs are viral and self-limited
• Acute bacterial rhinosinusitis is suspected only if symptoms persist >10 days without improvement, are severe (fever >39°C, purulent discharge, facial pain >3 consecutive days), or worsen after initial improvement ("double sickening")
• If bacterial sinusitis is confirmed, amoxicillin-clavulanate remains first-line, with doxycycline or respiratory fluoroquinolones as alternatives 3
• Adjunctive therapy with intranasal saline irrigation or intranasal corticosteroids may alleviate symptoms 3