A 4-year-old girl is brought to the pediatric clinic by her father with right ear pain and fever for the past 4 days. She has been pulling her left ear frequently for relief. She did have a sore throat and fever last year which was treated with antibiotics. The patient's father reports urticaria occurred following treatment with penicillin. Her temperature today is 38°C (100.4°F), pulse is 100 beats/min, respirations are 22/min, and blood pressure is 100/60 mm Hg. Physical examination shows an opaque, bulging tympanic membrane with diminished light reflex.
Which of the following is the most appropriate treatment for the patient's condition?
A) Oral amoxicillin
B) Oral amoxicillin-clavulanate
C) Oral azithromycin
D) Topical ciprofloxacin
E) Tympanic tube placement
C) Oral azithromycin
Acute Otitis Media (AOM) often presents with fever and ear pain that is relieved with pulling on the pinna. AOM is most often caused by Streptococcus pneumoniae. Otoscopy shows an opaque, bulging tympanic membrane with diminished light reflex which are signs of fluid behind the ear. Treatment is predominantly supportive. And acute symptoms and signs of AOM often resolve within three days whether antibiotics are used or not. However, in children with otorrhea, bilateral AOM, signs of worsening illness, or prolonged symptoms, antibiotics can be considered. The child in this vignette has already had symptoms for 4 days. Amoxicillin is the first line agent for AOM. In patients with a penicillin allergy like the child in the vignette, a macrolide such as azithromycin is the treatment of choice. For cases of AOM refractory to amoxicillin, amoxicillin-clavulanate can be used. In AOM refractory to medical treatment or recurrent AOM, tympanic tubes should be considered.
Key Learning Point
If an antibiotic is prescribed for a patient with acute otitis media and a history of penicillin allergy, a macrolide is the treatment of choice.
