What is the recommended treatment for otitis media in a patient with a penicillin (PCN) allergy?

Treatment of Otitis Media in Patients with Penicillin Allergy

For patients with penicillin allergy, cefdinir, cefuroxime, or cefpodoxime should be used for non-Type I allergies, while azithromycin or clindamycin should be used for Type I penicillin allergies. 1

First-Line Options Based on Allergy Type

Non-Type I Penicillin Allergy (e.g., rash)

• Cephalosporins (if no history of anaphylaxis to penicillin):
  • Cefdinir: 14 mg/kg/day divided twice daily (max 600 mg/day)
  • Cefuroxime: 30 mg/kg/day divided twice daily (max 1000 mg/day)
  • Cefpodoxime: 10 mg/kg/day divided twice daily (max 400 mg/day)

Type I Penicillin Allergy (e.g., anaphylaxis)

• Azithromycin:
  • For children: 10 mg/kg once daily for 3 days OR 10 mg/kg on day 1 followed by 5 mg/kg/day on days 2-5 1, 2
  • For adults: 500 mg on day 1, followed by 250 mg once daily on days 2-5 2
• Clindamycin:
  • 7 mg/kg per dose three times daily (max 300 mg per dose) for 10 days 3

Dosing Considerations for Azithromycin in Children

Age-Based Dosing for Otitis Media

• 3-Day Regimen (10 mg/kg/day):

  Weight	Dosage
  5 kg	2.5 mL (½ tsp) of 100 mg/5 mL suspension daily
  10 kg	5 mL (1 tsp) of 100 mg/5 mL suspension daily
  20 kg	5 mL (1 tsp) of 200 mg/5 mL suspension daily
  40 kg	10 mL (2 tsp) of 200 mg/5 mL suspension daily

• 5-Day Regimen (10 mg/kg day 1, then 5 mg/kg days 2-5):

  • Day 1: Same as 3-day regimen
  • Days 2-5: Half the day 1 dose 2

Clinical Evidence Supporting Alternatives

Azithromycin has been shown to be as effective as amoxicillin/clavulanate for the treatment of otitis media in children, with clinical success rates of 74% for azithromycin compared to 69% for amoxicillin/clavulanate at day 28 4. Additionally, azithromycin has fewer gastrointestinal side effects (11%) compared to amoxicillin/clavulanate (20%) 4.

A multicentre evaluation found that a 3-day course of azithromycin had comparable clinical efficacy (93.2% satisfactory response) to a 10-day course of co-amoxiclav (97.3% satisfactory response) in pediatric patients with acute otitis media, with significantly fewer side effects in the azithromycin group (11.7% vs 22.4%) 5.

Important Considerations and Caveats

• Antibiotic Duration: For children under 2 years or with severe symptoms, a full course (typically 10 days for clindamycin, 3-5 days for azithromycin) is recommended 1

• Follow-up: Consider reassessment in 48-72 hours if symptoms do not improve or worsen

• Resistance Concerns: Be aware that S. pneumoniae may have reduced susceptibility to macrolides like azithromycin in some regions

• Side Effect Profile:

  • Azithromycin: Primarily gastrointestinal (diarrhea, nausea, abdominal pain)
  • Clindamycin: Risk of C. difficile-associated diarrhea
  • Cephalosporins: Generally well-tolerated but can cause rash or GI upset

• Treatment Failure: If no improvement after 48-72 hours, consider consultation with an infectious disease specialist or otolaryngologist for alternative therapy or tympanocentesis for culture

Preventive Measures

While treating the current infection, consider discussing these preventive measures:

• Pneumococcal vaccination
• Annual influenza vaccination
• Breastfeeding for at least 6 months
• Avoiding supine bottle feeding
• Reducing exposure to tobacco smoke

By following these evidence-based recommendations, you can effectively manage otitis media in patients with penicillin allergy while minimizing adverse effects and optimizing outcomes.