I treated a 12-month-old boy who had a three-week history of left otitis media (OM) with amoxicillin for 10 days. Follow-up on day 14 was fine, although he had increased rhinitis and congestion. On day 21, he presented to the clinic with a fever of 105°F rectally, and I sent him to the emergency department. Bilateral OM was discovered. Blood culture grew out amoxicillin-resistant Streptococcus pneumoniae. He was treated with three days of IV ceftriaxone (Rocephin). The only risk factor was his introduction to day care five weeks earlier. Immunizations are up to date, including three doses of pneumococcal 7-valent conjugate vaccine (Prevnar). Would this patient have had better immunity to the pneumococcus if he had been introduced to day care earlier (i.e., at age 6 weeks rather than 11 months)? — RENEE ANDREEFF, RPA-C, MPAS, Blasdell, N.Y.
Attendance at day-care centers during the first three years of life increases the risk of respiratory and GI infections. Although some studies have indicated that long-term day-care attendance leads to a diminished risk of infections, I don’t think this patient would have been better protected if he had started day care at a younger age. In fact, some would argue that he would have been at increased risk if he had started at age 6 weeks, when his immune system was very immature. Transmission of antibiotic-resistant bacteria in the day-care setting and recurrent OM from these resistant pathogens has been reported. Because of the risk of acute OM caused by drug-resistant S. pneumoniae, children younger than age 2 years and children in day care should be treated with amoxicillin 80-90 mg/kg daily in divided doses. In cases of treatment failure, an antibiotic that covers B-lactamase-producing Hemophilus influenzae and Moraxella catarrhalis is indicated. — JoAnn Deasy, PA-C, MPH (145-5)