Amoxicillin elixir

An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

Middle ear effusion can be detected with the combined use of otoscopy, pneumatic otoscopy, and tympanometry.

Adequate analgesia is recommended for all children with AOM. Deferring antibiotic therapy for lower-risk children with AOM should be considered. High-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is the first choice for initial antibiotic therapy in children with AOM. Children with middle ear effusion and anatomic damage or evidence of hearing loss or language delay should be referred to an otolaryngologist.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.

For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort .

An AOM diagnosis requires moderate to severe bulging of the tympanic membrane, new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (less than 48 hours) or erythema.

Middle ear effusion can be detected with the combined use of otoscopy, pneumatic otoscopy, and tympanometry.

Adequate analgesia is recommended for all children with AOM. Deferring antibiotic therapy for lower-risk children with AOM should be considered. High-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is the first choice for initial antibiotic therapy in children with AOM.

Children with middle ear effusion and anatomic damage or evidence of hearing loss or language delay should be referred to an otolaryngologist. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.

For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort . Abstract Etiology and Risk Factors Diagnosis Management of Acute Otitis Media Management of OME Tympanostomy Tube Placement Special Populations References.

Usually, AOM is a complication of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection.

Bacteria can be isolated from middle ear fluid cultures in 50% to 90% of cases of AOM and OME.

Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the most common organisms.3 , 4 H. influenzae has become amoxicillin for skin abscess the most prevalent organism amoxicillin 500mg over the counter among children with severe or refractory AOM following the introduction of the pneumococcal conjugate vaccine.5 – 7 Risk factors for AOM are listed in Table 1 .8 , 9.

Exposure to environmental smoke or other respiratory irritants.

Exposure to environmental smoke or other respiratory irritants. Abstract Etiology and Risk Factors Diagnosis Management of Acute Otitis Media Management of OME Tympanostomy Tube Placement Special Populations References.

Previous diagnostic criteria for AOM were based on symptomatology without otoscopic findings of inflammation. The updated American Academy of Pediatrics

guideline

Erythema and bulging of the tympanic membrane with loss of normal landmarks are noted.

Erythema and bulging of the tympanic membrane with loss of normal landmarks are noted. OME is defined as middle ear effusion in the absence of acute symptoms.10 , 11 If OME is suspected and the presence of effusion on otoscopy is not evident by loss of landmarks, pneumatic otoscopy, tympanometry, or both should be used.11 Pneumatic otoscopy is a useful technique for the diagnosis of AOM and OME8 – 12 and is 70% to 90% sensitive and specific for determining the presence of middle ear effusion. By comparison, simple otoscopy is 60% to 70% accurate.10 , 11 Inflammation with bulging of the tympanic membrane on otoscopy is highly predictive of AOM.7 , 8 , 12 Pneumatic otoscopy is most helpful when cerumen is removed from the external auditory canal. Tympanometry and acoustic reflectometry are valuable adjuncts to otoscopy or pneumatic otoscopy.8 , 10 , 11 Tympanometry has a sensitivity and specificity of 70% to 90% for the detection of middle ear fluid, but is dependent on patient cooperation.13 Combined with normal otoscopy findings, a normal tympanometry result may be helpful to predict absence of middle ear effusion.

Acoustic reflectometry has lower sensitivity and specificity in detecting middle ear effusion

and

Children six months or older with otorrhea or severe signs or symptoms (moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or higher): antibiotic therapy for 10 days.

Children six to 23 months of age with bilateral acute otitis media without severe signs or symptoms: antibiotic therapy for 10 days. Children six to 23 months of age with unilateral acute otitis media without severe signs or symptoms: observation or antibiotic therapy for 10 days.

Children two years or older without severe signs or symptoms: observation or antibiotic therapy for five to seven days. Persistent symptoms (48 to 72 hours) Repeat ear examination for signs of otitis media. If otitis media is present, initiate or change antibiotic

therapy

If symptoms persist despite appropriate antibiotic therapy, consider intramuscular ceftriaxone (Rocephin), clindamycin, or tympanocentesis. Diagnosis established by physical examination findings and presence of symptoms. Children six months or older with otorrhea or severe signs or symptoms (moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or higher): antibiotic therapy for 10 days. Children six to 23 months of age with bilateral acute otitis media without severe signs or symptoms: antibiotic therapy for 10 days. Children six to 23 months of age with unilateral acute otitis media without severe signs or symptoms: observation or antibiotic therapy for 10 days.

Children two years or older without severe signs or symptoms: observation or antibiotic therapy for five to seven days.

Persistent symptoms (48 to 72 hours) Repeat ear examination for signs of otitis media.

If otitis media is present, initiate or change antibiotic therapy. If symptoms persist despite appropriate antibiotic therapy, consider intramuscular ceftriaxone (Rocephin), clindamycin, or tympanocentesis. Analgesics are recommended for symptoms of ear pain, fever, and irritability.8 , 15 Analgesics are particularly important at bedtime because disrupted sleep is one of the most common symptoms motivating parents to seek care.2 Ibuprofen and acetaminophen have been shown to be effective.16 Ibuprofen is preferred, given its longer duration of action and its lower toxicity in the event of overdose.2 Topical analgesics, such as benzocaine, can also be helpful.17. Antibiotic-resistant bacteria remain a major public health challenge. A widely endorsed strategy for improving the management of AOM involves deferring antibiotic therapy in patients least likely to benefit from antibiotics.18 Antibiotics should be routinely prescribed for children with AOM who are six months or older with severe signs or symptoms (i.e., moderate or severe otalgia, otalgia for at least 48 hours, or temperature of 102.2°F [39°C] or higher), and for children younger than two years with bilateral AOM regardless of additional signs or symptoms.8. Among children with mild symptoms, observation may be an option in those six to 23 months of age with unilateral AOM, or in those two years or older with bilateral or unilateral AOM.8 , 10 , 19 A large prospective study of this strategy found that two out of three children will recover without antibiotics.20 Recently, the American Academy of Family Physicians recommended not prescribing antibiotics for otitis media in children two to 12 years of age with nonsevere symptoms if observation is a reasonable option.21 , 22 If observation is chosen, a mechanism must be in place to ensure appropriate treatment if symptoms persist for more than 48 to 72 hours.

Strategies include a scheduled follow-up visit or providing patients with a backup antibiotic prescription to be filled only if symptoms persist.8 , 20 , 23. [ corrected] Table 3 summarizes the antibiotic options for children with AOM.8 High-dose amoxicillin should be the initial treatment in the absence of a known allergy.8 , 10 , 24 The advantages of amoxicillin include low cost, acceptable taste, safety, effectiveness, and a narrow microbiologic spectrum. Children who have taken amoxicillin in the past 30 days, who have conjunctivitis, or who need coverage for ?-lactamase–positive organisms should be treated with high-dose amoxicillin/clavulanate (Augmentin).8.

Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have Failed Initial Antibiotic Therapy.

Amoxicillin (80 to 90 mg/kg per day in 2 divided doses) Amoxicillin-clavulanate* (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate [amoxicillin to clavulanate ratio, 14:1] in 2 divided doses) Cefdinir (14 mg/kg per day in 1 or 2 doses) Cefuroxime (30 mg/kg per day in 2 divided doses) Cefpodoxime (10 mg/kg per day in 2 divided doses) Ceftriaxone (50 mg/kg IM or IV per day for 1 or 3 days, not to exceed 1 g per day) Amoxicillin-clavulanate* (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses) Ceftriaxone (50 mg/kg IM or IV per day for 1 or 3 days, not to exceed 1 g per day) Ceftriaxone, 3 d clindamycin (30–40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin.

Clindamycin (30–40 mg/kg per day in 3 divided doses) plus third-generation cephalosporin.

NOTE : Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin allergy on the basis of their distinct chemical structures . *— May be considered in patients who have received amoxicillin in the previous 30 d or who have the otitis-conjunctivitis syndrome .

†— Perform tympanocentesis/drainage if skilled in the procedure, or seek a consultation from an otolaryngologist for tympanocentesis/drainage. If the tympanocentesis reveals multidrug-resistant bacteria, seek an infectious disease specialist consultation . Reprinted with permission from Lieberthal AS, Carroll AE, Chonmaitree T, et al.

The diagnosis and management of acute otitis media . Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have Failed Initial Antibiotic Therapy. Amoxicillin (80 to 90 mg/kg per day in 2 divided doses) Amoxicillin-clavulanate* (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate [amoxicillin to clavulanate ratio, 14:1] in 2 divided doses) Cefdinir (14 mg/kg per day in 1 or 2 doses) Cefuroxime (30 mg/kg per day in 2 divided doses) Cefpodoxime (10 mg/kg per day in 2 divided doses) Ceftriaxone (50 mg/kg IM or IV per day for 1 or 3 days, not to exceed 1 g per day) Amoxicillin-clavulanate* (90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses) Ceftriaxone (50 mg/kg IM or IV per day for 1 or 3 days, not to exceed 1 g per day) Ceftriaxone, 3 d clindamycin (30–40 mg/kg per day in 3 divided doses), with or without third-generation cephalosporin. Clindamycin (30–40 mg/kg per day in 3 divided doses) plus third-generation cephalosporin. NOTE : Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin allergy on the basis of their distinct chemical structures .

*— May be considered in patients who have received amoxicillin in the previous 30 d or who have the otitis-conjunctivitis syndrome .

†— Perform tympanocentesis/drainage if skilled in the procedure, or seek a consultation from an otolaryngologist for tympanocentesis/drainage.

If the tympanocentesis reveals multidrug-resistant bacteria, seek an infectious disease specialist consultation . Reprinted with permission from Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media . Oral cephalosporins, such as cefuroxime (Ceftin), may be used in children who are allergic to penicillin. Recent research indicates that the degree of cross reactivity between penicillin and second- and third-generation cephalosporins is low (less than 10% to 15%), and avoidance is no longer recommended.25 Because of their broad-spectrum coverage, third-generation cephalosporins in particular may have an increased risk of selection of resistant bacteria in the community.26 High-dose azithromycin (Zithromax; 30 mg per kg, single dose) appears to be more effective than the commonly used five-day course, and has a similar cure rate as high-dose amoxicillin/clavulanate.8 , 27 , 28 However, excessive use of azithromycin is associated with increased resistance, and routine use is not recommended.8 Trimethoprim/sulfamethoxazole is no longer effective for the treatment of AOM due to evidence of S. Intramuscular or intravenous ceftriaxone (Rocephin) should be reserved for episodes of treatment failure or when a serious comorbid bacterial infection is suspected.2 One dose of ceftriaxone may be used in children who cannot tolerate oral antibiotics because it has been shown to have similar effectiveness as high-dose amoxicillin.30 , 31 A three-day course of ceftriaxone is superior to a one-day course in the treatment of nonresponsive AOM caused by penicillin-resistant S.

pneumoniae .31 Although some children will likely benefit from intramuscular ceftriaxone, overuse of this agent may significantly increase high-level penicillin resistance in the community.2 High-level penicillin-resistant pneumococci are also resistant to first- and third-generation cephalosporins.

Antibiotic therapy for AOM is often associated with diarrhea.8 , 10 , 32 Probiotics and yogurts containing active cultures reduce the incidence of diarrhea and should be suggested for children receiving

antibiotics

Children with persistent, significant AOM symptoms despite at least 48 to 72 hours of antibiotic therapy should be reexamined.8 If a bulging, inflamed tympanic membrane is observed, therapy should be changed to a second-line agent.2 For children initially on amoxicillin, high-dose amoxicillin/clavulanate is recommended.8 , 10 , 28.

For children with an amoxicillin allergy who do not improve with an oral cephalosporin, intramuscular ceftriaxone, clindamycin, or tympanocentesis may be considered.4 , 8 If symptoms recur more than one month after the initial diagnosis of AOM, a new and unrelated episode of AOM should be assumed.10 For children with recurrent AOM (i.e., three or more episodes in six months, or four episodes within 12 months with at least one episode during the preceding six months) with middle ear effusion, tympanostomy tubes may be considered to reduce the need for systemic antibiotics in favor of observation, or topical antibiotics for tube otorrhea.8 , 10 However, tympanostomy tubes may increase the risk of long-term tympanic membrane abnormalities and reduced hearing compared with medical therapy.33 Other strategies may help prevent recurrence (Table 4) .34 – 37.