Which antibiotic is appropriate for an 8‑year‑old male (weight 24 kg) with acute otitis media, hyperthermia (39.5 °C), bulging erythematous tympanic membrane, recent amoxicillin course completed 14 days ago, and documented intolerance to bitter‑tasting antibiotic suspensions?

Prescribe Co-amoxiclav (Amoxicillin-Clavulanate) Suspension

For this 8-year-old with severe acute otitis media who completed amoxicillin just 14 days ago, co-amoxiclav suspension at 90 mg/kg/day of the amoxicillin component divided into 2 doses for 7 days is the definitive choice. 1

Why Co-amoxiclav is Required in This Case

This patient meets three specific criteria that mandate amoxicillin-clavulanate over plain amoxicillin:

• Recent amoxicillin exposure within 30 days (completed 14 days ago) significantly increases the risk of β-lactamase-producing organisms, making clavulanate coverage essential 1, 2
• Severe presentation with high fever (39.5°C), bulging tympanic membrane, and significant symptoms requires immediate broad-spectrum coverage 1
• The American Academy of Pediatrics explicitly recommends amoxicillin-clavulanate as first-line when amoxicillin was used in the previous 30 days 1

Why NOT Cefuroxime

• Cefuroxime at 20 mg/kg/day is underdosed for acute otitis media—the recommended dose is 30 mg/kg/day divided twice daily 1
• Second-generation cephalosporins are reserved for penicillin-allergic patients, not as first-line therapy when recent amoxicillin use mandates β-lactamase coverage 1
• The patient has no penicillin allergy, so there is no indication to use a less-effective alternative 1

Why NOT Azithromycin

• Macrolide resistance in Streptococcus pneumoniae exceeds 40% in the United States, resulting in bacterial failure rates of 20-25% 1
• Azithromycin achieves only 67% clinical success against macrolide-resistant pneumococcus compared to 90% with β-lactams 3
• The FDA label shows azithromycin's clinical success rate at Day 30 was only 73% versus 88% for amoxicillin-clavulanate 4
• Azithromycin is explicitly not recommended as first-line therapy for acute otitis media by current guidelines 1

Addressing the Palatability Concern

• Twice-daily amoxicillin-clavulanate causes significantly less diarrhea than three-times-daily dosing while maintaining equivalent efficacy 1
• The 600 mg/5 mL preparation allows for smaller volumes (approximately 3.6 mL per dose for this 24 kg child), which may improve tolerability
• Modern amoxicillin-clavulanate suspensions have improved taste formulations compared to older preparations
• The severe symptoms (39.5°C fever, bulging TM) justify prioritizing microbiologic efficacy over palatability concerns—untreated or inadequately treated severe AOM carries significant morbidity risk 1

Specific Prescription Details

For a 24 kg child:

• Dose calculation: 90 mg/kg/day = 2,160 mg/day of amoxicillin component
• Per-dose amount: 1,080 mg amoxicillin per dose (twice daily)
• Volume per dose: 9 mL of the 600 mg/5 mL preparation
• Total volume for 7 days: 126 mL (dispense 150 mL bottle)
• Duration: 7 days is appropriate for this age group with severe symptoms 1

Critical Management Points

• Reassess at 48-72 hours—if symptoms worsen or fail to improve, escalate to intramuscular ceftriaxone 50 mg/kg once daily for 3 consecutive days 1
• Aggressive pain control with weight-based ibuprofen or acetaminophen is mandatory and should be initiated immediately, as antibiotics provide no symptomatic relief in the first 24 hours 1
• Expected middle-ear effusion will persist in 60-70% of children at 2 weeks post-treatment; this does not indicate treatment failure and requires monitoring only 1

Common Pitfall to Avoid

Do not use azithromycin simply because of palatability concerns when the clinical scenario demands β-lactamase coverage—the 20-25% bacterial failure rate with macrolides in this setting poses unacceptable risk of treatment failure, potential complications, and need for rescue therapy 1.