Recommendations include amoxicillin at 80-90 mg/kg/day (divided t.i.d.) and, for more severe cases, amoxicillin-clavulanate (at 90 mg/kg/day of the amoxicillin component) dosed twice daily. Alternatives include cefdinir 14 mg/kg/day (in one or two doses per day); cefpodoxime 10 mg/kg daily; and cefuroxime 30 mg/kg/day (divided b.i.d.). Patients with serious beta lactam allergy can be treated with clindamycin 30-40 mg/kg/day in divided doses; a macrolide (azithromycin or clarithromycin); or trimethoprim/sulfamethoxazole, alone or in combination with erythromycin.¹

CRITICAL DECISION

Is a single dose of ceftriaxone appropriate stand-alone treatment for AOM in any situation?

Because of the growing problem of S. pneumoniae resistance, it has been shown that a single dose of ceftriaxone, like the previously acceptable lower doses of amoxicillin (40 mg/kg divided three times daily), is not an adequate therapy.¹⁵ However, ceftriaxone may be used to initiate treatment in the emergency department when a patient is vomiting or unable to tolerate the taste of oral medication. The clinician should consider prescribing a full 10-day course of oral antibiotics to begin the following morning, by which time the patient should be showing signs of improvement. If patients have had recurrent episodes of AOM despite multiple courses of oral antibiotics, refer them to their pediatricians to receive a second and third ceftriaxone injection over the next two days.^1,16

CRITICAL DECISION

When should observation be considered in a child with AOM rather than initiation of antibiotic treatment?

It is important to remember that viruses are the most common cause of upper respiratory tract infection. The rates of serious bacterial infection, including mastoiditis, have not been found to increase when a less severely ill older child with AOM is observed initially, rather than immediately treated with antibiotics.^1,17 This does not apply to neonates (younger than 1 month) found to have AOM. Because of a neonate’s higher risk of serious bacterial infection, evaluation for possible sepsis with hospitalization and intravenous antibiotics is recommended.¹⁸

Case Resolution

The 18-month-old boy who came in with vomiting and congestion fulfilled the diagnostic criteria for AOM. At his age, treatment with an appropriate antibiotic is recommended. Because he had been vomiting and did not tolerate oral medications well, ceftriaxone, 50 mg/kg x 1, was injected intramuscularly in the emergency department. He was able to tolerate a Popsicle and some juice during the visit. He was sent home with a prescription for a full 10-day course of amoxicillin to start the next morning, and the parents were instructed to follow up with the pediatrician within two to three weeks to document resolution of the ear infection or sooner if vomiting continued and he was not able to hold down the oral medication. The patient was seen for recheck at the pediatrician’s office in two weeks and was doing fine.

Summary

In recent years, the AAP and the AAFP have developed specific criteria to help in making a certain diagnosis of AOM. Over the past two decades, pathogen shifts and the development of bacterial resistance among common pathogens of AOM have necessitated updating treatment recommendations. Although amoxicillin remains the treatment of choice, higher doses are required to overcome bacterial resistance, and some previously accepted antibiotic choices for AOM are no longer effective. If a child is old enough and not severely ill, it is reasonable to refrain from prescribing antibiotics and have the patient follow up with a pediatrician if symptoms persist or worsen over the next two to three days.