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M catarrhalis and some strains of H influenzae are more likely to be amoxicillin-resistant (ie, are more likely to produce beta-lactamases) but they are less common pathogens, and AOM caused by either bacteria is more likely to resolve spontaneously. Amoxicillin has excellent middle ear penetration (so may still be effective despite in vitro resistance), is inexpensive, well tolerated and has a relatively narrow antimicrobial spectrum. Given in an adequate oral dose, amoxicillin is more likely than other oral antimicrobials to be effective against penicillin-susceptible – and some penicillin-resistant – S pneumoniae , beta-lactamase-negative H influenzae and GAS. For clinical cure of AOM, the levels of amoxicillin in the middle ear should be adequate for over 50% of the day. Administering 45 mg/kg/day to 60 mg/kg/day of amoxicillin in three divided doses will achieve adequate middle ear levels, whereas a twice per day dosing regimen requires higher total daily doses of 75 mg/kg/day to 90 mg/kg/day to maintain adequate levels for amoxicillin 650 mg a comparable percentage of the day (Table 1).[40] There are certain clinical situations in which other antimicrobials should be considered as first-line. In the setting of AOM with purulent conjunctivitis (otitis-conjunctivitis syndrome), H influenzae and M catarrhalis are common pathogens and, therefore, treatment with a beta-lactamase inhibitor-amoxicillin combination (eg, amoxicillin-clavulanate) or a second-generation cephalosporin (eg, cefuroxime-axetil) is preferred.[41] Bacterial cultures of purulent conjunctival discharge should be performed when the infection is slow to resolve. It may also be prudent to use amoxicillin-clavulanate if the child has had a recent treatment with amoxicillin – within the previous 30 days – or infection that suggests a relapse of a recent infection or nonresponse to amoxicillin. If the child has a history of a hypersensitivity reaction to amoxicillin or penicillin, using the second-generation cephalosporins (cefprozil or cefuroxime-axetil) or a third-generation cephalosporin is acceptable, unless the previous reaction was life-threatening (ie, associated with angioedema, bronchospasm or hypotension).[42] Alternatively, using a macrolide/azalide (clarithromycin or azithromycin) or clindamycin is an option; however, these antibiotics generally have inferior bacterial killing capabilities, especially for S pneumoniae and H influenzae , compared with the beta-lactams (eg, penicillins or cephalosporins). Only rarely are other medications indicated, such as doxycycline in children ?8 years of age or quinolones; however, such alternatives should only be considered in consultation with an infectious disease physician. Symptoms should improve within 24 h and resolve within two to three days of starting antimicrobials. If symptoms persist or worsen, the patient should be evaluated again to assess for either complications or persistent AOM. If the AOM persists despite amoxicillin given in recommended doses with good compliance, H influenzae and M catarrhalis may be causing the AOM. In this setting, treatment should be changed to amoxicillin-clavulanate, reserving intravenous or intramuscular ceftriaxone for cases where oral drugs are not tolerated or amoxicillin-clavulanate failed (Table 1). In this latter uncommon situation, ceftriaxone should be administered for a period of three days because the drug’s half-life is longer (approximately 12 h to 24 h), and sampling the middle ear fluid should also be considered. Middle ear effusions may persist for months, despite clinical and bacteriological resolution. The presence of MEE does not necessitate a change in antimicrobials. Appropriate duration of antimicrobial therapy for AOM. Five days of antimicrobial treatment with oral amoxicillin has been shown to be at least as effective as 10 days of therapy in most children ?2 years of age with uncomplicated disease.[43] - [45] Ten days of oral antimicrobial treatment courses are appropriate for children 35 kg, 500 mg tablets orally three times a day for 10 days. If a patient is unable to tolerate oral antimicrobials or if treatment with amoxicillin-clavulanate fails, a course of ceftriaxone – 50 mg/kg/day intramuscularly (or intravenously) once per day for three days – could be considered. Alternatively, referral to an otolaryngologist for tympanocentesis may be considered to determine the etiological agent and guide therapy. To diagnose AOM, there must be acute onset of symptoms such as otalgia (or nonspecific symptoms in nonverbal children), signs of a middle ear effusion associated with inflammation of the middle ear (ie, a TM that is bulging and, usually, very erythematous or hemorrhagic, and yellow or cloudy in colour) or a TM that has ruptured. For otherwise healthy children ?6 months of age who have mild illness with appropriately diagnosed AOM criteria or children who do not fully meet diagnostic criteria, a watchful waiting approach for 48 h is an option if follow-up can be assured. It is recommended to: reassess the child within 24 h to 48 h to document the clinical course; OR have the caregiver return if the child does not improve or worsens anytime within 48 h; OR provide an antimicrobial prescription to be filled if the child does not improve.
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