What are alternative antibiotics in syrup form for acute otitis media (AOM) in children?

Alternative Antibiotics in Syrup Form for Acute Otitis Media in Children

For children with acute otitis media who cannot take amoxicillin or amoxicillin-clavulanate, the recommended alternative antibiotics in syrup form include cefdinir (14 mg/kg/day in 1-2 doses), cefuroxime (30 mg/kg/day in 2 divided doses), and cefpodoxime (10 mg/kg/day in 2 divided doses). 1

First-Line Treatment (For Reference)

• High-dose amoxicillin (80-90 mg/kg/day) is the first-line treatment for uncomplicated AOM
• High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) in 2 divided doses for cases with suspected beta-lactamase producing organisms 1

Alternative Antibiotics in Syrup Form

For Non-Type I Penicillin Allergy:

1. Cefdinir

   • Dosage: 14 mg/kg/day in 1-2 doses 1
   • Available as oral suspension (125 mg/5 mL or 250 mg/5 mL)
   • Advantages: Once-daily dosing option improves compliance 2
   • Duration: 10 days for children <2 years; 5-7 days for children ≥2 years 1

2. Cefuroxime axetil

   • Dosage: 30 mg/kg/day in 2 divided doses 1
   • Available as oral suspension (125 mg/5 mL or 250 mg/5 mL)
   • Duration: 10 days for children <2 years; 5-7 days for children ≥2 years 3

3. Cefpodoxime proxetil

   • Dosage: 10 mg/kg/day in 2 divided doses 1
   • Available as oral suspension (50 mg/5 mL or 100 mg/5 mL)
   • Duration: 5-10 days depending on age and severity 3

For Type I/Severe Penicillin Allergy:

1. Azithromycin

   • Dosage options 4:
     • 30 mg/kg as a single dose, or
     • 10 mg/kg once daily for 3 days, or
     • 10 mg/kg on day 1, then 5 mg/kg/day on days 2-5
   • Available as oral suspension (100 mg/5 mL or 200 mg/5 mL)
   • Note: Less effective against resistant S. pneumoniae

2. Clindamycin

   • Dosage: 30-40 mg/kg/day in 3 divided doses 1
   • Available as oral solution (75 mg/5 mL)
   • Duration: 10 days
   • Note: Effective against S. pneumoniae but not against H. influenzae or M. catarrhalis

Selection Algorithm Based on Clinical Scenario

1. For children with non-Type I penicillin allergy:

   • First choice: Cefdinir (once-daily dosing improves compliance) 2
   • Alternative: Cefuroxime or cefpodoxime (if cefdinir unavailable)

2. For children with Type I/severe penicillin allergy:

   • First choice: Azithromycin (convenient dosing schedule) 4
   • Alternative: Clindamycin (if S. pneumoniae is strongly suspected) 1

3. For treatment failure with amoxicillin:

   • Switch to amoxicillin-clavulanate or cefdinir if beta-lactamase producing organisms are suspected 3, 1

Special Considerations

Age-Based Considerations

• Children <2 years: Longer treatment duration (10 days) recommended 1
• Children ≥2 years with mild/moderate symptoms: Shorter course (5-7 days) may be sufficient 1

Pathogen-Specific Considerations

• For suspected H. influenzae or M. catarrhalis: Cefdinir, cefuroxime, or cefpodoxime provide good coverage 2
• For suspected resistant S. pneumoniae: Standard dose cefdinir (14 mg/kg/day) may be insufficient 5

Compliance Considerations

• Once-daily dosing (cefdinir, azithromycin) may improve adherence in children 2
• Palatability affects compliance - cefdinir has better taste acceptance than some alternatives 6

Monitoring and Follow-up

• Reassess after 48-72 hours of therapy if symptoms persist 1
• If no improvement after 72 hours, consider changing to an alternative antibiotic 1
• Monitor for common side effects: diarrhea (more common with amoxicillin-clavulanate than cefdinir) 6

Pitfalls and Caveats

• Standard dose cefdinir (14 mg/kg/day) may be ineffective against penicillin-nonsusceptible S. pneumoniae 5
• Azithromycin has increasing resistance rates and should be used judiciously 7
• Cefixime has excellent activity against H. influenzae and M. catarrhalis but relatively poor activity against S. pneumoniae 8
• Taking antibiotics with food can reduce gastrointestinal side effects 1

By following this structured approach to selecting alternative antibiotics in syrup form for AOM, clinicians can provide effective treatment while considering factors such as allergy status, suspected pathogens, and medication adherence.