Pharmacology

Otitis-Acute Otitis Media

Case Study

Patient Profile

Name: Jack

Age: 18 months

Gender: male

Current Medications

None

History of Present Illness

Jack is an 18-month-old boy with benign medical/surgical history presenting with his supportive father after picking Jack up from daycare. His father received a call saying that they were not able to console him and he is tugging at his left ear. Jack has had some nasal congestion and runny nose for the past three to four days. Jack’s father reports that it is not like him to be inconsolable; he is concerned. Jack did not want to play as much this morning, and he did eat and drink at breakfast but not as much as usual.

Jack has been urinating as usual and has had no diarrhea or constipation. Jack has received all scheduled immunizations.

Relevant Assessment

No known drug allergies

General impression: Crying, tugging on left ear, cheeks are rosy, and skin is warm to touch.

Vitals: Temperature: 39.1°C (102.4°F), hemodynamically stable, well oxygenated. Height: 32.5 inches (82.3 cm). Weight: 24 pounds, 1 ounce (10.9 kg).

HEENT: Normocephalic, atraumatic. Eyes: EOMI. PERRLA. + retinal reflexes bilaterally. No injection or drainage. Ears: Canals are clear, without erythema, tissue desquamation, swelling, or drainage bilaterally. Right ear: TM intact, pearly grey, bony landmarks and cone of light are visible. Left ear: TM erythematic and bulging. Bony landmarks and cone of light are obscured.

No other expanded review of system (subjective data) or examination (objective data) has an impact on the diagnosis reviewed in this case.

Differentials

Acute otitis media, otitis media with effusion, otitis externa, mastoiditis, temporomandibular joint pain or dental pain

Diagnosis

Acute otitis media

Diagnostic Testing

None at this time

Referrals

None at this time

Patient/Provider Collaborative Goals

Jack will have resolution of symptoms of acute otitis media by time of planned follow-up.

Therapeutic Interventions

  1. Describe a first-line pharmacologic treatment: Include drug name, dose and formulation, frequency, and length of treatment at this dose.
    Answer:

    One option is amoxicillin 500 mg/5 ml given 4.5 mL every 12 hours for 10 days.

    • Drug Mechanism of Action:
      Answer:

      Amoxicillin works by inhibiting bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs). This binding inhibits cell wall synthesis by interfering with the final transpeptidation step of peptidoglycan synthesis. This leads to cell death because the cell wall synthesis is impaired.

    • Contraindications if applicable:
      Answer:

      Hypersensitivity to amoxicillin or any of the formulation components. Allergy to other beta-lactam antimicrobials including cephalosporins. Patients with a history of beta lactam therapy within the past 30 days, acute otitis media recalcitrant to amoxicillin, or concurrent conjunctivitis should be treated with amoxicillin/clavulanate potassium. A patient with a history of cholestatic jaundice or hepatic dysfunction with amoxicillin/clavulanate potassium therapy should not take amoxicillin/clavulanate. Extended-release amoxicillin/clavulanate or high-dose amoxicillin should not be used in patients with renal impairment or hemodialysis.

  1. Therapeutic advisement and monitoring: (include any specific instructions that apply, such as when to take the medication, if there are foods to avoid, storage issues, etc; include what laboratory/other (i.e., EKG) test monitoring to expect and how often and monitoring for adverse effects both common and serious)
    Answer:

    Specific Instructions: The NP should educate the caregiver that amoxicillin/clavulanate is being used to treat a middle ear infection. Instruct the caregiver to ensure completion of the entire 10-day course of antibiotics even if the patient is feeling better. Advise that the patient’s symptoms should improve within 48-72 hours of starting the antibiotic. The NP should advise the family to store the medication in the refrigerator, to not freeze it, and to shake the medication well before use. They should measure liquid doses carefully and use the measuring device that comes with this drug.

    The NP should educate the families to call the office if the child gets diarrhea in order to evaluate the need for fluid replenishment and/or treatment of more serious colitis infections. Caregivers should also be advised to report any serious adverse effects listed below.

    • Therapeutic Monitoring: The nurse practitioner should monitor for improvement or deterioration of the patient’s otitis symptoms and any reported concerns of watery, foul-smelling diarrhea.
    • Serious Adverse Effects:
      • Antibiotic Associated Diarrhea/GI Distress (non-Clostridioides difficile): Symptoms include diarrhea, nausea, and vomiting. This is the most common side effect which will usually resolve without medical intervention, but it is important to ensure hydration is maintained.
      • Clostridioides Difficile Infection: Symptoms include foul watery smelling diarrhea, fever, and abdominal pain/cramping. Risk factors include prolonged antibiotic use/exposure, recent or recurrent hospitalizations, geriatric patients, immunocompromised patients, surgical gastrointestinal procedures, or patients receiving chemotherapy. This condition requires medical attention and monitoring.
      • Drug Induced Enterocolitis Syndrome: Non-IgE mediated hypersensitivity reaction. This is defined as vomiting lasting one to four hours after taking amoxicillin/clavulanate with at least three of the following: Extreme lethargy, marked pallor, need for emergency department visit, need for IV fluid support, diarrhea in 24 hours after ingestion of the drug, hypotension, hypothermia, and leukocytosis with neutrophilia, WITHOUT symptoms consistent with IgE mediated hypersensitivity like hives, wheezing, or respiratory distress.
      • Drug Induced Liver Injury: Most commonly presents as cholestatic hepatitis. Risk factors include geriatric, male, Caucasian, serious comorbidities, and polypharmacy.
      • Hypersensitivity Reactions: Hives, angioedema, and anaphylaxis. This is a life-threatening emergency requiring immediate medical attention.
      • Skin Problems: Erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) can occur. Monitor patients for any skin rashes including blisters or peeling skin. If present, the patient should be evaluated immediately, especially if the patient has a fever. These may occur without a fever as well.
  1. Planned follow-up should consider adverse effect monitoring, dose adjustment considerations, and decisions about continuing versus discontinuing. In this case, planned follow-up would be:
    Answer:

    A phone call follow-up in three days to ensure improvement. If worsening or no improvement, see patient in office to determine if diagnosis is accurate and consider changing to an alternate agent.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. You are examining a patient who has a history of allergic rhinitis and reports ear fullness with muffled hearing but no pain. On examination, his tympanic membranes are intact, pearly gray with muted cones of light, mild injection, and serous effusions. There is no erythema, bulging, or retractions of either tympanic membrane. Which of the following represents an appropriate treatment for this scenario?
    1. Watchful waiting without any other intervention
    2. Amoxicillin/clavulanate
    3. Cefdinir
    4. Fluticasone nasal spray
    5. All of the above
Answer:

D. Fluticasone nasal spray

Feedback: The following describes otitis media with effusion: history of allergic rhinitis and reports ear fullness with muffled hearing but no pain. On examination, his tympanic membranes are intact, pearly gray with muted cones of light, mild injections, and serous effusions. There is no erythema, bulging, or retractions of either tympanic membrane.

  1. Jack is an 18-month-old male with benign medical/surgical history who has a fever, tugging at his left ear, crying, decreased intake but still eating and drinking, and is not as active as usual. On the exam the left tympanic membrane is erythematic and bulging. Which of the following is an appropriate treatment?
    1. Watchful waiting without any other intervention
    2. Amoxicillin
    3. Cefazolin
    4. Fluticasone nasal spray
    5. All of the above
Answer:

B. Amoxicillin

Feedback: The patient in this scenario is less than two years old and the patient has a fever with examination findings associated with acute otitis media. The patient has no known drug allergies. Amoxicillin is a reasonable first choice antibiotic. While third generation cephalosporins are useful in penicillin allergic patients, this patient has no allergies and cefazolin is intravenous only.

  1. Which of the following patients would be appropriate for 48 to 72 hours of watchful waiting (observation) and pain management?
    1. A three-year-old female with benign medical history with one day history of right ear pain who has supportive/attentive parents.
    2. A three-year-old female with benign medical history with one day history of right ear pain who has a single parent who works and reports they are on duty for the next four days with an older sibling not of driving age watching the three-year-old while the parent is at work.
    3. A one-month-old female with benign medical history with one day history of fussiness, decreased intake and tugging at her right ear.
    4. A four-year-old with recurrent otitis media infections with right ear pain and fever.
Answer:

A. A three-year-old female with benign medical history with one day history of right ear pain who has supportive/attentive parents.

Feedback: Patients with ear pain may undergo a period of 48-72 hours of watchful waiting (observation) with pain management if the patient is greater than two-years-old, has temperature of less than 39 degrees Celsius, pain improvement with analgesics, one ear infected, no bulging of the tympanic membrane, and less than 72 hours of symptoms.

  1. Which of the following are risk factors for antibiotic-resistant acute otitis media? (Select all that apply)
    1. Attending church
    2. Age greater than 2 years
    3. Age younger than 2 years
    4. Attending day care
    5. Exposure to antibiotics in the past 1-3 months
    6. Fall and summer seasons
    7. Exposure to antibiotics in the past 1-3 days
    8. Winter and spring seasons
Answer:

C. Age younger than 2 years; D) Attending day care; E) Exposure to antibiotics in the past 1-3 months; H) Winter and spring seasons

Feedback: Risk factors for development of resistant acute otitis media include age less than 2 years, day care attendance, antibiotic use in the past 1-3 months, and infections in the winter and spring.

  1. Which oral medications are appropriate for acute otitis externa when the infection extends beyond the pinna?
    1. Ciprodex
    2. Ciprofloxacin
    3. Erythromycin
    4. Doxycycline
Answer:

B. Ciprofloxacin

Feedback: When acute otitis externa extends beyond the pinna (cellulitis) and/or fever, fluoroquinolones, like ciprofloxacin, is a good choice for adults. However, fluoroquinolones should be avoided in those less than 18 years of age due to the Food and Drug Administration boxed warning for risk of tendon rupture. For children, cephalexin (Keflex) is the favored choice. With these more extensive presentations, both topical otic drops and oral antibiotic therapy is appropriate.

  1. A geriatric patient was correctly diagnosed and treated with amoxicillin/clavulanate for acute otitis media. The patient developed fever, watery foul-smelling diarrhea, and abdominal cramps. This condition is self-limiting and does not require any intervention. True or False?
    1. True
    2. False
Answer:

B. False

Feedback: Fever, watery foul-smelling diarrhea, and abdominal cramps should raise suspicion for clostridium difficile colitis infection which can be life threatening.

  1. A 10-year-old patient with a history of previous otitis media infections took his first dose of a beta lactam antibiotic today and developed hives, angioedema, and wheezing. The patient’s parents call the office to ask for advice. The most appropriate action is:
    1. Instruct the parents that this is a common side effect and it should resolve on its own.
    2. Instruct the parents to put the child in the car and drive to the nearest urgent care or emergency room.
    3. Instruct the parents to call 911 for immediate medical attention.
    4. None of the above.
Answer:

C. Instruct the parents to call 911 for immediate medical attention.

Feedback: Hives, angioedema, and wheezing are symptoms and signs of an anaphylactic reaction and require immediate lifesaving intervention with epinephrine. This type of reaction should prompt the nurse practitioner to ensure the patient has a prescription for an Epipen moving forward.

  1. Patient education for antibiotic therapy for otitis media should include that symptoms are expected to be better:
    1. Within 4 hours of therapy initiation.
    2. Within 24 hours of therapy initiation.
    3. Within 72 hours of therapy initiation.
    4. Within 96 hours of therapy initiation.
Answer:

C. Within 72 hours of therapy initiation.

Feedback: Response to antibiotic therapy is expected within 48-72 hours. It is good to inform your patients of this, so they know when to expect to feel better; however, make it clear to patients that they should complete their antibiotics even when feeling better. Also educate the patient that if they feel progressively worse despite initiation of antibiotic therapy, they should reach out for further evaluation.

References

Condina Leik, M. T. (2025). Head, eyes, ears, nose, and throat review. In FNP Certification Intensive Review (pp. 91–122). Springer Publishing.

Messner, A. H. (2025). Acute otitis externa in children and adolescents. UpToDate®. Retrieved June 12, 2025 from https://www.uptodate.com/contents/acute-otitis-externa-in-children-and-adolescents

Rosenthal, L. D., & Burchum, J. R. (2026). Drugs for disorders of the ear. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 855–861). Elsevier.

Tähtinen, P. (2025). Acute otitis media in children: Treatment. UpToDate®. Retrieved June 12, 2025 from https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment

Up To Date®. (2025). Amoxicillin/clavulanate: Drug information. LexidrugTM. Retrieved June 12, 2025 from https://www.uptodate.com/contents/amoxicillin-and-clavulanate-drug-information

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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