What is the recommended antibiotic, dose, and treatment duration for an 11‑year‑old boy (≈35–40 kg) with acute otitis media?

Antibiotic Treatment for Acute Otitis Media in an 11-Year-Old Boy

For an 11-year-old boy (≈35–40 kg) with acute otitis media, prescribe high-dose amoxicillin 80–90 mg/kg/day (approximately 3,000–3,500 mg/day, maximum 4,000 mg/day) divided into two or three doses for 5–7 days if symptoms are mild-to-moderate, or 10 days if symptoms are severe. 1

First-Line Antibiotic Selection

• Amoxicillin is the first-line antibiotic for acute otitis media due to its effectiveness against the most common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), excellent safety profile, low cost, and narrow microbiologic spectrum. 1

• High-dose amoxicillin (80–90 mg/kg/day) is essential to overcome penicillin-resistant S. pneumoniae, which accounts for approximately 35% of isolates in some regions. 1, 2

• For this 11-year-old patient weighing approximately 35–40 kg, the total daily dose would be 2,800–3,600 mg/day, divided into two or three equal doses (e.g., 1,400–1,800 mg twice daily or 933–1,200 mg three times daily). 1

• The maximum single dose is 2,000 mg, so ensure individual doses do not exceed this limit. 1

Treatment Duration by Age and Severity

• For children ≥6 years with mild-to-moderate symptoms, a 5–7 day course is appropriate. 1

• For severe acute otitis media (defined as moderate-to-severe otalgia, otalgia lasting ≥48 hours, or fever ≥39°C/102.2°F), prescribe a full 10-day course regardless of age. 1

• The shorter 5–7 day course for older children with non-severe disease is supported by evidence showing equivalent efficacy to 10-day regimens in this age group. 1

When to Use Amoxicillin-Clavulanate Instead

Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component + 6.4 mg/kg/day of clavulanate, divided twice daily) if any of the following apply: 1

• The child received amoxicillin within the previous 30 days

• Concurrent purulent conjunctivitis is present (suggests H. influenzae)

• History of recurrent AOM unresponsive to amoxicillin

• Attendance at daycare or high local prevalence of β-lactamase-producing organisms

• Twice-daily dosing of amoxicillin-clavulanate causes significantly less diarrhea than three-times-daily dosing while maintaining equivalent efficacy. 1

Penicillin Allergy Alternatives

For non-severe (non-IgE-mediated) penicillin allergy, use one of the following: 1

• Cefdinir 14 mg/kg/day in 1–2 doses (preferred for convenience)

• Cefuroxime 30 mg/kg/day in 2 divided doses

• Cefpodoxime 10 mg/kg/day in 2 divided doses

• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported, making these options generally safe for non-severe penicillin allergies. 1

Management of Treatment Failure

Reassess the patient at 48–72 hours if symptoms worsen or fail to improve. 1

Treatment Failure Algorithm:

1. If amoxicillin fails, switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component). 1

2. If amoxicillin-clavulanate fails, administer intramuscular ceftriaxone 50 mg/kg once daily for 3 consecutive days (maximum 1–2 grams per dose). 1

3. A 3-day ceftriaxone course is superior to a single-dose regimen for treatment-unresponsive AOM. 1

4. After multiple treatment failures, consider tympanocentesis with culture and susceptibility testing to guide further therapy. 1

5. Do NOT use trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures due to substantial pneumococcal resistance. 1

Pain Management

• Initiate acetaminophen or ibuprofen immediately in age-appropriate doses, regardless of antibiotic decision. 1

• Pain management is critical because antibiotics provide no symptomatic relief in the first 24 hours, and even after 3–7 days of therapy, approximately 30% of children may have persistent pain or fever. 1

Post-Treatment Expectations

• Middle ear effusion persists in 60–70% of children at 2 weeks after successful treatment, declining to 40% at 1 month and 10–25% at 3 months. 1

• Persistent effusion without acute symptoms (otitis media with effusion) requires monitoring but NOT antibiotics unless it persists >3 months with documented hearing loss. 1

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics for isolated tympanic membrane redness without middle ear effusion—this does not constitute acute otitis media. 1

• Do NOT use macrolides (azithromycin, clarithromycin) as they have bacterial failure rates of 20–25% due to rising pneumococcal resistance. 1

• Ensure proper visualization of the tympanic membrane with pneumatic otoscopy to confirm the diagnosis before prescribing antibiotics. 1

• Complete the full antibiotic course even if symptoms improve earlier, to prevent recurrence and resistance. 1