What is a recommended treatment for acute otitis media in a patient with a Penicillin (PCN) allergy?

From the Guidelines

For patients with a penicillin allergy who have acute otitis media, the recommended treatment is typically cefdinir (14 mg/kg per day in 1 or 2 doses) or cefuroxime (30 mg/kg per day in 2 divided doses), as these cephalosporins have a low cross-reactivity with penicillin 1. The choice of antibiotic should be based on the anticipated clinical response and the microbiologic flora likely to be present. According to the American Academy of Pediatrics, cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin allergy due to their distinct chemical structures 1. Some key points to consider when treating acute otitis media in patients with a penicillin allergy include:

• The use of cefdinir or cefuroxime as alternative treatments in cases of non-severe penicillin allergy 1
• The importance of considering local resistance patterns when selecting an antibiotic 1
• The need to continue treatment for the full course, even if symptoms improve earlier, to ensure complete eradication of the infection
• The use of supportive care with pain management using acetaminophen or ibuprofen 1. It is also important to note that the previously cited rate of cross-sensitivity to cephalosporins among penicillin-allergic patients is likely an overestimate, and many patients who present with a history of penicillin allergy do not have an immunologic reaction to penicillin 1. In general, the treatment of acute otitis media in patients with a penicillin allergy should be individualized based on the severity of the allergy, the specific antibiotic chosen, and the patient's overall health status. The American Academy of Pediatrics recommends that the choice of a first-line treatment should be based on the anticipated clinical response and the microbiologic flora likely to be present, and that amoxicillin is recommended as first-line therapy for AOM because it is generally effective when used in sufficient doses against susceptible and intermediate resistant pneumococci, although this may not be suitable for patients with a penicillin allergy 1.

From the FDA Drug Label

The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

For a patient with a Penicillin (PCN) allergy, azithromycin is a recommended treatment option for acute otitis media. The dosage for pediatric patients is:

• 30 mg/kg as a single dose
• 10 mg/kg once daily for 3 days
• 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5 No dosage adjustment is recommended for patients with renal impairment (GFR ≤80 mL/min). However, caution should be exercised when azithromycin is administered to subjects with severe renal impairment 2.

From the Research

Treatment Options for Acute Otitis Media in Patients with PCN Allergy

• For patients allergic to penicillin, alternative antibiotics such as erythromycin ethylsuccinate and sulfisoxazole or TMP-SMZ can be used as first-line treatment for uncomplicated acute otitis media 3.
• Trimethoprim/sulfamethoxazole (TMP/SMX) is also considered an appropriate intervention for acute otitis media in patients with a reported penicillin allergy, due to its efficacy, safety, and cost 4.
• In cases of suspected penicillin-resistant pneumococcus, high-dose amoxicillin, with or without clavulanate, or clindamycin may be considered, although this may not be suitable for patients with a PCN allergy 3.
• For patients with a PCN allergy, a macrolide antibiotic may be recommended as an alternative to amoxicillin 5.
• Single-dose azithromycin has also been proposed as a potential treatment option for acute otitis media, due to its pharmacokinetic and pharmacodynamic properties 6.
• However, the most recent guidelines recommend a "watchful waiting" approach, with amoxicillin-clavulanic acid or second-generation cephalosporins reserved for specific cases, and macrolides or other alternatives considered for patients with a PCN allergy 7.

Key Considerations

• The need for antibiotics in acute otitis media remains controversial, and treatment decisions should be made on a case-by-case basis 4, 5.
• Reported penicillin allergies may be an unreliable indicator of a potentially serious reaction, and alternative treatments should be considered accordingly 4.
• The choice of antibiotic should be guided by factors such as the severity of the infection, the patient's age and health status, and the likelihood of antibiotic resistance 3, 5, 7.