What is a suitable antibiotic for otalgia (ear ache) in a patient with a hypersensitivity to penicillin (Penicillin allergy)?

From the Guidelines

For a patient with a penicillin allergy, cefdinir is a suitable antibiotic choice for otalgia, with a dosage of 14 mg/kg per day in 1 or 2 doses, due to its low risk of cross-reactivity with penicillin and effectiveness against common ear infection pathogens 1. When considering antibiotic treatment for otalgia in a patient with a penicillin allergy, it's essential to choose an antibiotic with a low risk of cross-reactivity and high efficacy against the likely causative pathogens.

• The patient's allergy to penicillin limits the treatment options, but cefdinir, cefuroxime, and cefpodoxime are suitable alternatives, as they have distinct chemical structures that minimize the risk of cross-reactivity with penicillin 1.
• Cefdinir, in particular, has been shown to be effective in treating ear infections, including those caused by Haemophilus influenzae, with an eradication rate of 72% in patients with recurrent AOM 1.
• The dosage of cefdinir should be 14 mg/kg per day in 1 or 2 doses, as recommended by the American Academy of Pediatrics 1.
• It's crucial to note that the risk of cross-reactivity between penicillins and cephalosporins is lower than historically reported, and cefdinir is highly unlikely to be associated with cross-reactivity with penicillin 1.
• Completing the full course of antibiotics is vital, even if symptoms improve before finishing treatment, to ensure the infection is fully cleared and reduce the risk of antibiotic resistance.

From the FDA Drug Label

In a non-comparative clinical and microbiological trial, 248 patients from 6 months to 12 years of age with documented acute otitis media were dosed with a single oral dose of azithromycin (30 mg/kg on Day 1). For the 240 patients who were evaluable for clinical modified Intent-to-Treat (MITT) analysis, the clinical success rate (i.e., cure plus improvement) at Day 10 was 89% and for the 242 patients evaluable at Day 24 to 28, the clinical success rate (cure) was 85%. Presumed Bacteriologic Eradication Day 10Day 24–28 S. pneumoniae70/76 (92%)67/76 (88%) H. influenzae30/42 (71%)28/44 (64%) M catarrhalis10/10 (100%)10/10 (100%) Overall110/128 (86%)105/130 (81%)

Azithromycin is a suitable antibiotic for otalgia (ear ache) in a patient with a hypersensitivity to penicillin, as it has shown clinical success rates of 89% at Day 10 and 85% at Day 24 to 28 in the treatment of acute otitis media 2.

• The bacteriologic eradication rates for the most common pathogens were:
  • S. pneumoniae: 92% at Day 10 and 88% at Day 24-28
  • H. influenzae: 71% at Day 10 and 64% at Day 24-28
  • M catarrhalis: 100% at both Day 10 and Day 24-28
• The overall bacteriologic eradication rate was 86% at Day 10 and 81% at Day 24-28.

From the Research

Suitable Antibiotics for Otalgia in Patients with Penicillin Allergy

• For patients with a hypersensitivity to penicillin, alternative antibiotics should be considered to treat otalgia (ear ache) 3, 4, 5.
• Aztreonam is a semisynthetic penicillin that may be safely used in penicillin-allergic patients 4.
• Cephalosporins may be used for patients with a vague history of penicillin allergy, but not for those with a convincing history of penicillin allergy 6.
• Macrolide antibiotics, such as azithromycin or clarithromycin, may be used to treat acute otitis media, but are associated with an increased risk of clinical failure compared to amoxicillin or amoxicillin/clavulanate 7.
• Vancomycin may be considered for patients with a convincing history of penicillin allergy and severe disease 6.
• Erythromycin may be considered for patients with a convincing history of penicillin allergy and mild disease 6.
• Quinolones may be considered for patients with a convincing history of penicillin allergy and moderate disease 6.

Considerations for Antibiotic Selection

• The type of penicillin allergic reaction (e.g. unknown, possible, drug fever, rash, hives, anaphylactic reactions) should be considered when selecting an antibiotic 3, 4, 5.
• Skin testing may be used to exclude the risk of IgE-mediated reactions to penicillin and to guide antibiotic selection 4, 5, 6.
• The severity of the disease process to be treated should also be considered when selecting an antibiotic 6.