What is the most appropriate next step in managing a 9-month-old girl with fever, ear discharge, and seizure, diagnosed with acute otitis media (inflammation of the middle ear) and mastoiditis (infection of the mastoid bone), presenting with hyperthermia (elevated body temperature), erythema (redness), and purulent otorrhea (discharge from the ear)?

From the Guidelines

The most appropriate next step in management for this 9-month-old girl is oral amoxicillin therapy. This child presents with signs of acute otitis media (AOM), as evidenced by the bulging and cloudy tympanic membrane with oozing pus, fever, and ear discharge. The presence of postauricular erythema, tenderness, and displacement of the auricle suggests possible mastoiditis, a complication of AOM. According to the guidelines for AOM management 1, children with severe AOM, such as this patient, should be treated with antibiotics. The American Academy of Otolaryngology-Head and Neck Surgery recommends high-dose amoxicillin (80-90 mg/kg/d) as the first-line antibiotic for AOM treatment 1. While the child's recent seizure raises concern for intracranial complications, the initial management should focus on treating the underlying infection with antibiotics.

Some may argue that an MRI of the brain is necessary to rule out intracranial complications, but given the clinical presentation of AOM and possible mastoiditis, oral amoxicillin therapy is the most appropriate next step. The child's history of untreated ear infection three weeks ago, followed by the current presentation with fever, ear discharge, and seizure, suggests progression of infection beyond the middle ear, making antibiotic treatment crucial.

Key points to consider in this case include:

• The child's age and clinical presentation, which suggest AOM and possible mastoiditis
• The need for prompt antibiotic treatment to prevent further complications
• The recommendation for high-dose amoxicillin as the first-line antibiotic for AOM treatment
• The potential for intracranial complications, which may require further evaluation and management after initiating antibiotic therapy.

In summary, oral amoxicillin therapy is the most appropriate next step in management for this 9-month-old girl with signs of AOM and possible mastoiditis, as it addresses the underlying infection and prevents further complications.

From the FDA Drug Label

Ceftriaxone for injection USP is indicated for the treatment of the following infections when caused by susceptible organisms: Acute Bacterial Otitis Media caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase producing strains) or Moraxella catarrhalis (including beta-lactamase producing strains).

The most appropriate next step in management is Oral amoxicillin therapy or another appropriate antibiotic, as the patient has symptoms of acute bacterial otitis media, including a bulging and cloudy tympanic membrane with oozing pus, and a fever.

• The patient's presentation is consistent with Acute Bacterial Otitis Media.
• Ceftriaxone may be considered in some cases, but it is typically reserved for more severe infections or those that do not respond to first-line therapy.
• Topical ciprofloxacin therapy may be used for external ear infections, but it is not the most appropriate choice for acute bacterial otitis media.
• Myringotomy and tympanostomy tube placement may be necessary in some cases, but it is not typically the first line of treatment.
• Electroencephalography and MRI of the brain may be considered to evaluate the cause of the seizure, but they are not directly related to the treatment of the ear infection 2 2.