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Metronidazole (Flagyl) 15 mg/kg IV loading dose, maximal dose 1000 mg, then 7.5 mg/kg IV q6h (max 500 mg/dose) [B, contraindicated in 1st trimester] Regimen B

Cefoxitin (Mefoxin) 2 g IV q8h [B]

Clindamycin (Cleocin) 600 mg IV q8h (if penicillin allergic) [B] Ticarcillin/clavulanic acid (Timentin) 3.1 g IV q6h [B] Piperacillin/tazobactam (Zosyn) 3.375 g IV q6h [B] Ampicillin/sulbactam (Unasyn) 3 g IV q6h [B]

Organisms: Streptococcus sp., Bacteroides sp., Eikenella corrodens, polymicrobic Otitis Externa

1. Neomycin, polymyxin B, and 1% hydrocortisone otic solution (Cortisporin otic) 4 drops in affected ear tid-qid [C]; dispense 10 mL OR (for severe infection)

2. Ofloxacin 0.3% otic solution (Floxin) 10 drops in affected ear bid (use 5 drops bid if child <12 years old) [C]; dispense 10 mL If refractory:

1. Ciprofloxacin 0.2% and hydrocortisone 1% otic suspension (Cipro HC otic) 3 drops in affected ear bid * 7 days [C]; dispense 10 mL OR

2. Dicloxacillin 500 mg PO qid for S. aureus [B]

Course: 10 days (except 7 days for Cipro or Dicloxacillin as noted) Organisms: Pseudomonas, Enterobacteriaceae, S. aureus, Proteus sp.

Notes:

1. Use Cortisporin otic suspension (not solution) if TM perforated.

2. Cotton wicks placed in the canals aid absorption especially if the canal closes completely due to edema.

3. Consider malignant otitis externa, especially in immunocompromised patients or diabetics. Patients usually appear ill and require admission. Otitis Media

A. CHILDREN AGE 10 OR UNDER

1. Amoxicillin (Amoxil) 80-90 mg/kg/day PO divided bid or tid [B] Easy dose: 40 mg/kg/dose PO bid OR 30 mg/kg/dose PO tid Maximum dose 750 mg/dose bid OR 500 mg/dose tid Available in suspensions of 125 mg and 250 mg/5 mL

2. TMP/SMX (Bactrim, Septra) 6-12 mg/kg/day TMP and 30-60 mg/kg/day SMX PO divided bid [C; D in 3rd trimester] Easy dose: 1 mL/kg/day PO divided bid = 8 mg/kg/day TMP and 40 mg/kg/day SMX

Maximum: 20 mL/dose

Suspension of TMP 40 mg and SMX 200 mg/5 mL

3. Azithromycin (Zithromax) 10 mg/kg PO initial dose, then 5 mg/kg/day for 4 days [B] Maximum: 500 mg on day 1 and 250 mg on days 2-5

Available in suspensions of 100 mg and 200 mg/5 mL

4. Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg/day erythromycin and 150 mg/kg/day sulfa PO divided tid or qid [C; D in 3rd trimester] Easy dose: 1.25 mL/kg/day PO divided tid or qid

Maximum: 10 mL/dose

Suspension of erythromycin 200 mg and sulfisoxazole 600 mg/5 mL

5. Ceftriaxone (Rocephin) 50 mg/kg IM single dose [B] Maximum: 1 g/dose

If severe or refractory:

1. Amoxicillin/clavulanate (Augmentin) 80-90 mg/kg/day as amoxicillin, PO divided bid or tid [B] Easy dose: 40 mg/kg/dose as amoxicillin PO bid OR 30 mg/kg/dose as amoxicillin PO tid

Maximum: 750 mg/dose as amoxicillin bid OR 500 mg/dose as amoxicillin tid Available in suspensions of 125 mg and 250 mg amoxicillin/5 mL

2. Cefuroxime axetil (Ceftin) 20-30 mg/kg/day PO divided bid [B] Easy dose: 20 mg/kg/day = 10 mg/kg/dose PO bid Maximum: 250 mg/dose

Available in suspension of 125 mg/5 mL

3. Cefpodoxime (Vantin) 10 mg/kg/day PO in 1 dose [B] (probably effective but data limited)

Maximum: 400 mg/dose

Available in suspensions of 50 mg and 100 mg/5 mL

4. Cefprozil (Cefzil) 15 mg/kg/dose PO bid [B] (probably effective but data limited) Maximum: 250 mg/dose

Available in suspensions of 125 mg or 250 mg/5 mL

5. Ceftriaxone, 50 mg/kg IV or IM QD for 3 days

B. ADULTS AND CHILDREN OVER AGE 10

1. Amoxicillin (Amoxil) 500 mg PO tid [B]

2. TMP/SMX DS (Bactrim DS, Septra DS) 1 tablet PO bid [C; D in 3rd trimester]

3. Azithromycin (Zithromax) 500 mg PO initial dose, then 250 mg PO for 4 days [B]

4. Amoxicillin/clavulanate (Augmentin) 500 mg PO tid or 875 mg PO bid [B]

5. Cefuroxime axetil (Ceftin) 250-500 mg PO bid [B]

6. Ceftriaxone (Rocephin) 1 g IM/IV single dose [B]

Course: 10 days (except azithromycin and ceftriaxone as noted)

Organisms: S. pneumoniae (30-35%), non-typeable Haemophilus influenzae (20-25%), Moraxella (Branhamella) catarrhalis (10-15%), group A Strep, Staphylococcus aureus (1-2%) and viral (35%)

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