From the Guidelines
For patients with acute otitis media who have an anaphylactic allergy to penicillin, the best alternative treatment is cefdinir, given its effectiveness and low risk of cross-reactivity with penicillin 1. The recommended dosage for cefdinir is 14 mg/kg per day in 1 or 2 doses, as outlined in the treatment guidelines for acute otitis media 1. Other alternatives, such as cefuroxime (30 mg/kg per day in 2 divided doses) or ceftriaxone (50 mg IM or IV per day for 1 or 3 d), may also be considered, but cefdinir is preferred due to its oral administration route and once-daily dosing convenience. Key points to consider when selecting an alternative treatment for acute otitis media in patients with a penicillin allergy include:
- The risk of cross-reactivity between penicillins and cephalosporins is lower than historically reported, especially with second- and third-generation cephalosporins like cefdinir 1.
- Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin due to their distinct chemical structures 1.
- Symptom management with analgesics such as acetaminophen or ibuprofen is also important to alleviate pain and discomfort associated with acute otitis media. If symptoms worsen or don't improve within 48-72 hours, the patient should seek follow-up care as antibiotic resistance may necessitate a different treatment approach 1.
From the FDA Drug Label
The most common side effects were diarrhea/loose stools (2% azithromycin vs. 29% control) For the 366 patients who were evaluated for clinical efficacy at the Day 12 visit, the clinical success rate (i.e., cure plus improvement) was 83% for azithromycin and 88% for the control agent. Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates 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.
The best alternative treatment for acute otitis media in a patient with an anaphylactic allergy to penicillin is Zithromax 500 mg on day 1, and then 250 mg daily for 4 days or Zithromax 30 mg/kg as a single dose.
- Azithromycin is effective against the most common bacteria that cause acute otitis media.
- The dosage of azithromycin for the treatment of acute otitis media in pediatric patients is 30 mg/kg as a single dose or 10 mg/kg once daily for 3 days.
- Azithromycin has been shown to be clinically and microbiologically effective in the treatment of acute otitis media, with a clinical success rate of 83% at Day 12.
- The most common side effects of azithromycin are diarrhea/loose stools, vomiting, and abdominal pain. 2 2 2
From the Research
Treatment Options for Acute Otitis Media with Penicillin Allergy
Given the patient's anaphylactic allergy to penicillin, the following treatment options can be considered:
- Cefixime (Suprax): A third-generation cephalosporin antibiotic, which is a suitable alternative for patients with penicillin allergy 3. The recommended dosage is 400 mg daily for 7 days.
- Azithromycin (Zithromax): A macrolide antibiotic, which can be used as an alternative treatment for acute otitis media in patients with penicillin allergy 4. The recommended dosage is 500 mg on day 1, followed by 250 mg daily for 4 days.
Unsuitable Options
The following options are not suitable due to the patient's penicillin allergy:
- Amoxicillin: A penicillin-type antibiotic, which is contraindicated in patients with penicillin allergy.
- Augmentin: A combination of amoxicillin and clavulanate, which is also contraindicated in patients with penicillin allergy.
Evidence Summary
Studies have shown that macrolide antibiotics, such as azithromycin, may be associated with increased clinical failures in the treatment of acute otitis media 5. However, they can still be considered as an alternative treatment option for patients with penicillin allergy. Cefixime, a third-generation cephalosporin, is also a suitable alternative, with a lower risk of cross-reactivity with penicillin 3.