From the Guidelines
For patients with penicillin allergies, the most effective treatment options for otitis media and pneumonia are azithromycin or a respiratory fluoroquinolone like levofloxacin, as they provide broad coverage against common pathogens while minimizing the risk of allergic reactions. When considering treatment options, it's crucial to assess the severity of the penicillin allergy, as this will guide the choice of antibiotic. For otitis media, azithromycin (10 mg/kg on day 1, then 5 mg/kg daily for 4 days) or clarithromycin (15 mg/kg/day divided twice daily for 10 days) are suitable alternatives 1.
For pneumonia, the guidelines recommend using a respiratory fluoroquinolone like levofloxacin (750 mg daily for 5 days) or azithromycin (500 mg on day 1, then 250 mg daily for 4 days) as first-line treatments for patients with penicillin allergies 1. Doxycycline (100 mg twice daily for 7-10 days) is another alternative for adults. It's essential to note that if the patient has a severe penicillin allergy, aztreonam can be used instead of β-lactam-based antibiotics, but this should be accompanied by coverage for MSSA 1.
The choice of antibiotic should be based on the severity of the infection, the likelihood of resistant organisms, and the patient's allergy history. In general, a respiratory fluoroquinolone or azithromycin should be the first choice for patients with penicillin allergies, as they provide effective coverage against common pathogens while minimizing the risk of allergic reactions. Symptomatic relief with analgesics and antipyretics should also be provided as needed.
From the FDA Drug Label
Azithromycin tablets are a macrolide antibacterial drug indicated for the treatment of patients with mild to moderate infections caused by susceptible strains of the designated microorganisms in the specific conditions listed below.
1.2 Pediatric Patients • Acute otitis media (>6 months of age) caused by Haemophilus influenzae , Moraxella catarrhalis, or Streptococcus pneumoniae. • Community-acquired pneumonia (>6 months of age) due to Chlamydophila pneumoniae , Haemophilus influenzae , Myroplasma pneumoniae , or Streptococcus pneumoniae in patients appropriate for oral therapy
The best treatment options for otitis media and pneumonia in a patient with a penicillin allergy are:
- Azithromycin for patients with mild to moderate infections caused by susceptible strains of the designated microorganisms.
- The recommended dose for otitis media is 30 mg/kg as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on Day 1 followed by 5 mg/kg/day on Days 2 through 5.
- The recommended dose for community-acquired pneumonia is 10 mg/kg as a single dose on Day 1 followed by 5 mg/kg once daily on Days 2 through 5 2.
From the Research
Treatment Options for Otitis Media and Pneumonia with a Penicillin Allergy
- For patients with otitis media or pneumonia and a penicillin allergy, alternative antibiotics can be used as first-line treatment 3.
- Erythromycin ethylsuccinate and sulfisoxazole or TMP-SMZ are suitable options for patients allergic to penicillin 3.
- In cases of suspected penicillin-resistant pneumococcus, high-dose amoxicillin, with or without clavulanate, or clindamycin can be considered 3.
- For acute otitis media, amoxicillin at conventional or high doses remains an appropriate choice for first-line therapy, but alternative antibiotics should be used in patients with a penicillin allergy 4.
- Second-line therapy options, such as high-dose amoxicillin/clavulanate and ceftriaxone, may be considered for patients who do not respond to first-line treatment, but these should be chosen based on the patient's allergy status and the suspected causative pathogen 4.
- Trimethoprim/sulfamethoxazole (TMP/SMX) is a suitable alternative for patients with a reported penicillin allergy, as it has been found to be effective and well-tolerated in the treatment of acute otitis media 5.
- The choice of antibiotic should be based on individual clinical findings and underlying health status, and the need for antibiotics in acute otitis media remains controversial 6, 7.