What is the likely diagnosis and appropriate management for a 6‑year‑old with recent Group A Streptococcus pharyngitis now presenting with hemorrhagic otorrhea?

Bloody Ear Drainage Post Strep Throat in a 6-Year-Old

Most Likely Diagnosis

This 6-year-old with recent Group A Streptococcus pharyngitis now presenting with hemorrhagic otorrhea most likely has acute otitis media (AOM) with spontaneous tympanic membrane perforation. The bloody ear drainage represents otorrhea from AOM, which is a recognized suppurative complication of streptococcal pharyngitis 1.

Diagnostic Confirmation

• Diagnose AOM when new-onset otorrhea not due to acute otitis externa is present – this is a Grade B recommendation and meets diagnostic criteria even without visualizing the tympanic membrane 1.
• The recent streptococcal pharyngitis increases suspicion for a bacterial etiology, as suppurative complications including otitis media are among the outcomes antibiotic treatment aims to prevent 1.
• Examine the ear canal to confirm the drainage is coming from the middle ear (through a perforated tympanic membrane) rather than from external otitis 1.

Immediate Management Algorithm

Step 1: Confirm the Child Completed Streptococcal Pharyngitis Treatment

• Verify the child received and completed appropriate antibiotic therapy for the streptococcal pharyngitis – typically amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days 2, 3.
• If the child did not receive antibiotics or did not complete the course, this represents inadequate treatment of the initial streptococcal infection 1.

Step 2: Prescribe Appropriate Antibiotic Coverage

• For AOM with otorrhea in a 6-year-old, prescribe amoxicillin-clavulanate rather than amoxicillin alone – the β-lactamase coverage is indicated when the child has received amoxicillin in the past 30 days or has concurrent purulent conjunctivitis 1.
• Dose amoxicillin-clavulanate at 90 mg/kg/day of the amoxicillin component divided twice daily for adequate coverage of resistant organisms 4.
• Continue treatment for 10 days to ensure adequate bacterial eradication 1.

Step 3: Provide Symptomatic Relief

• Offer acetaminophen or ibuprofen for ear pain and fever control during the first 24 hours – this provides symptomatic relief regardless of the antibacterial agent used 1, 2.
• Avoid aspirin in this 6-year-old due to Reye syndrome risk 2, 3.

Step 4: Reassess Within 48-72 Hours

• Reassess the patient if symptoms worsen or fail to respond within 48-72 hours to determine whether a change in therapy is needed 1.
• If no improvement occurs, consider alternative diagnoses or complications such as mastoiditis 1.

Special Considerations for This Case

• The hemorrhagic nature of the otorrhea does not change management – bloody drainage can occur with spontaneous perforation and does not necessarily indicate a more severe infection 1.
• Do not routinely culture the ear drainage unless the child fails to respond to first-line therapy, as empiric treatment is appropriate 1.
• The tympanic membrane perforation will typically heal spontaneously once the infection is adequately treated 1.

Penicillin Allergy Considerations

If the child has a documented penicillin allergy:

• For non-anaphylactic penicillin allergy, prescribe a first-generation cephalosporin such as cephalexin 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 2.
• For immediate/anaphylactic penicillin allergy, prescribe clindamycin 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days, which provides coverage for both streptococcal pharyngitis and otitis media pathogens 2.

Common Pitfalls to Avoid

• Do not assume the ear drainage represents treatment failure of the streptococcal pharyngitis alone – this is a new suppurative complication requiring specific otitis media treatment 1.
• Do not prescribe amoxicillin alone if the child received it within the past 30 days – use amoxicillin-clavulanate for β-lactamase coverage 1.
• Do not delay antibiotic therapy while awaiting culture results – empiric treatment is appropriate for AOM with otorrhea 1.
• Do not order routine follow-up cultures after treatment unless symptoms persist or recur 2, 3.

Prevention Context

• This case illustrates why prompt diagnosis and treatment of streptococcal pharyngitis is important – prevention of suppurative complications like otitis media is one of the primary goals of treating GAS pharyngitis 1, 3.
• Ensure the full 10-day course of antibiotics is completed to maximize bacterial eradication and minimize complications 2, 3.