What antibiotic is recommended for a 21-month-old female with bilateral otitis media and strep throat who cannot tolerate amoxicillin (amoxicillin) and has symptoms of nausea and vomiting?

Antibiotic Treatment for Bilateral Otitis Media and Strep Throat in a 21-Month-Old with Amoxicillin Intolerance

For a 21-month-old female with bilateral otitis media and strep throat who cannot tolerate amoxicillin due to nausea and vomiting, azithromycin is the recommended antibiotic treatment.

Rationale for Recommendation

When a child cannot tolerate amoxicillin due to gastrointestinal side effects, alternative antibiotics must be considered. The decision-making process involves:

1. Identifying the common pathogens in both conditions
2. Selecting an antibiotic that covers these pathogens
3. Choosing an option that minimizes gastrointestinal side effects
4. Considering age-appropriate dosing and compliance

Bilateral Otitis Media Considerations

For acute otitis media (AOM), the American Academy of Pediatrics recommends:

• First-line: Amoxicillin (not tolerated in this case) 1
• For patients with penicillin allergy or intolerance, alternatives include:
  • Cephalosporins (if no severe penicillin allergy)
  • Macrolides like azithromycin
  • Clindamycin 1, 2

In this case, immediate antibiotic therapy is indicated because:

• The patient is under 24 months of age
• The infection is bilateral
• There are concurrent symptoms (nausea/vomiting) 1

Strep Throat Considerations

For group A streptococcal pharyngitis, the Infectious Diseases Society of America recommends:

• First-line: Penicillin or amoxicillin (not tolerated in this case)
• For patients with penicillin allergy, alternatives include:
  • Cephalosporins (if no immediate hypersensitivity)
  • Clindamycin
  • Clarithromycin
  • Azithromycin 1

Recommended Treatment

Azithromycin Regimen

• Dosage: 10 mg/kg once daily for 3 days OR 12 mg/kg once daily for 5 days 1, 3
• The 5-day regimen at 12 mg/kg/day is preferred for streptococcal pharyngitis to reduce recurrence risk 1, 4

Rationale for Azithromycin Selection

1. Coverage for both conditions: Azithromycin is effective against common pathogens in both otitis media and streptococcal pharyngitis 3, 4
2. Gastrointestinal tolerance: Azithromycin has a lower incidence of gastrointestinal side effects compared to amoxicillin-clavulanate and other alternatives 3, 5
3. Compliance advantage: Once-daily dosing for a shorter duration improves compliance compared to multiple daily doses for 10 days 5
4. Clinical efficacy: Studies show comparable clinical success rates between azithromycin and amoxicillin for both conditions 3, 5

Alternative Options (If Azithromycin Cannot Be Used)

For Non-Severe Penicillin Allergy

• Cefdinir: 14 mg/kg/day in 1-2 doses
• Cefuroxime: 30 mg/kg/day in 2 divided doses
• Cefpodoxime: 10 mg/kg/day in 2 divided doses 2

For Severe Penicillin Allergy

• Clindamycin: 30-40 mg/kg/day in 3 divided doses 2

Important Considerations and Monitoring

• Assess response to therapy within 48-72 hours
• If symptoms worsen or fail to improve within this timeframe, reevaluate and consider changing antibiotics 1
• Monitor for side effects of azithromycin, which may include:
  • Diarrhea (less common than with amoxicillin)
  • Abdominal pain
  • Vomiting (though less frequent than with amoxicillin) 3
• Provide appropriate pain management with acetaminophen or ibuprofen regardless of antibiotic choice 2

Caution and Pitfalls

• Macrolide resistance in S. pneumoniae can occur, though rates in the US are generally <5% 1
• First-generation cephalosporins like cephalexin have poor coverage for H. influenzae (a common otitis media pathogen) and should be avoided 2
• Avoid trimethoprim-sulfamethoxazole due to high bacteriologic failure rates (20-25%) 2
• Follow-up post-treatment testing for strep throat is not routinely recommended 1

Azithromycin offers the best balance of efficacy, tolerability, and compliance for this young patient with dual infections who cannot tolerate amoxicillin.