TABLE 58.1 ANTIBIOTIC TREATMENT OF AOM First line Amoxicillin 80–90 mg/kg/day in two doses Amoxicillin-clavulanate 90 mg/kg/day amox in two doses Penicillin allergy Cefdinir 14 mg/kg/day in one or two doses Cefpodoxime 10 mg/kg/day in two doses Cefuroxime 30 mg/kg/day in two doses Ceftriaxone 50 mg IM or IV for days Treatment failure (after 48–72 hrs) Amoxicillin-clavulanate 90 mg/kg/day amox in two doses Ceftriaxone 50 mg IM or IV for days Alternative Clindamycin 30–40 mg/kg/day in three doses plus third-generation cephalosporin Tympanocentesis and culture High-dose amoxicillin (80 to 90 mg/kg/day in two divided doses) is the initial drug of choice for AOM provided the patient is not penicillin-allergic, has not taken amoxicillin during the preceding 30 days, does not have concurrent purulent conjunctivitis (H influenza more likely), and does not have a history of AOM treatment failure with amoxicillin ( Table 58.1 ) Amoxicillin-clavulanate (80 to 90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate in two divided doses) is recommended for antibiotic treatment failure, defined as worsening or persistent symptoms after 48 to 72 hours Alternatives for treatment failure are ceftriaxone (50 mg IM or IV for or days) or clindamycin (30 to 40 mg/kg/day in three divided doses) plus a third-generation cephalosporin Tympanocentesis and culture may be indicated after multiple antibiotic failures in persistently symptomatic patients Patients with a history of penicillin allergy may be treated with cefdinir (14 mg/kg/day in one or two divided doses), cefpodoxime (10 mg/kg/day in two divided doses), cefuroxime (30 mg/kg/day in two divided doses), or ceftriaxone (50 mg IM or IV for or days) These specific cephalosporins not share similar side-chain structure with penicillin, ampicillin, or amoxicillin, and therefore pose little risk of allergic reaction in penicillin-allergic patients