What are the recommended antibiotics for acute otitis media in an adult with a penicillin (Penicillin) allergy?

From the Guidelines

For adults with acute otitis media who have a penicillin allergy, I recommend doxycycline 100 mg twice daily for 7-10 days as the first-line treatment. This recommendation is based on the guidelines for antimicrobial treatment of acute bacterial rhinosinusitis, which also applies to acute otitis media, as both conditions are caused by similar pathogens 1. According to the guidelines, doxycycline has a calculated clinical efficacy of 81% and bacteriologic efficacy of 80%, making it a suitable option for patients with penicillin allergy.

Other alternatives for patients with penicillin allergy include azithromycin, clarithromycin, and telithromycin, with calculated clinical efficacies ranging from 77% to 77% 1. However, doxycycline is preferred due to its broader spectrum of activity and lower risk of resistance.

Key considerations when choosing an antibiotic for acute otitis media in adults with penicillin allergy include:

• The severity of symptoms and the likelihood of treatment failure
• The presence of risk factors for infection with resistant pathogens, such as recent antibiotic use
• The potential for adverse reactions and interactions with other medications

Symptom management with analgesics like acetaminophen or ibuprofen is also important to alleviate pain and discomfort. If symptoms don't improve within 48-72 hours of starting antibiotics, the patient should follow up for reassessment as this may indicate antibiotic resistance or a complication requiring different management.

From the FDA Drug Label

In a non-comparative clinical and microbiological trial, 248 patients from 6 months to 12 years of age with documented acute otitis media were dosed with a single oral dose of azithromycin (30 mg/kg on Day 1). Presumed Bacteriologic Eradication Day 10Day 24–28 S. pneumoniae70/76 (92%)67/76 (88%) H. influenzae30/42 (71%)28/44 (64%) M catarrhalis10/10 (100%)10/10 (100%) Overall110/128 (86%)105/130 (81%)

Azithromycin can be considered for the treatment of acute otitis media in adults with a penicillin allergy.

• The clinical success rate and bacteriologic efficacy rates support the use of azithromycin in the treatment of acute otitis media.
• However, the provided studies are primarily in pediatric patients, and there is limited information on the use of azithromycin in adult patients with acute otitis media.
• The dose of azithromycin used in the studies is not specified for adult patients, but it can be considered based on the recommended dose for other infections.
• It is essential to note that the FDA drug label does not provide direct information on the use of azithromycin in adult patients with acute otitis media and a penicillin allergy.
• Therefore, the decision to use azithromycin in this scenario should be made with caution and based on individual patient factors 2.

From the Research

Antibiotic Recommendations for Acute Otitis Media in Adults with Penicillin Allergy

• For adults with a penicillin allergy, alternative antibiotics should be considered for the treatment of acute otitis media.
• According to 3, trimethoprim/sulfamethoxazole (TMP/SMX) is an appropriate alternative to amoxicillin in patients with a reported penicillin allergy.
• Other options may include macrolides, such as azithromycin or clarithromycin, as mentioned in 4 and 5.
• It is essential to note that the reliability of reported penicillin allergies can be unreliable, as stated in 3.
• The choice of antibiotic should be based on factors such as efficacy, safety, cost, and patient compliance, as discussed in 6 and 7.

Considerations for Antibiotic Selection

• The prevalence of drug-resistant pathogens, such as Streptococcus pneumoniae, should be considered when selecting an antibiotic, as mentioned in 7.
• Pharmacokinetic/pharmacodynamic principles should also be taken into account, as discussed in 7.
• The potential for antibiotic resistance and the need for antibiotic stewardship should be considered when selecting an antibiotic, as implied in 7 and 5.

Additional Considerations

• The diagnosis and treatment of acute otitis media can vary depending on the patient's age, medical history, and other factors, as discussed in 4.
• Adequate analgesia should be prescribed in all cases, as recommended in 4.
• Routine antibiotic prescription should be avoided in mild to moderate cases, unless there is a clear indication for antibiotic therapy, as suggested in 4.