What is the next best treatment for a patient with a continuing ear infection, who has a penicillin (PCN) allergy and is experiencing increased ear pain after initial treatment with Biaxin (clarithromycin)?

From the Guidelines

For a patient with an ear infection who has a penicillin allergy and is experiencing increased ear pain despite Biaxin (clarithromycin) treatment, the next best treatment option would be fluoroquinolones, specifically levofloxacin 750 mg orally once daily for 5-7 days or ciprofloxacin 500 mg orally twice daily for 7-10 days, as recommended by the guidelines for acute bacterial rhinosinusitis 1. The patient's condition warrants a change in antibiotic therapy due to the lack of improvement with clarithromycin, and fluoroquinolones offer broad-spectrum coverage against common ear pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis that may be resistant to macrolides like clarithromycin. Some key points to consider in the management of this patient include:

• The importance of completing the full course of antibiotics, even if symptoms improve before completion, to ensure eradication of the infection.
• The use of analgesics such as acetaminophen or ibuprofen for pain management.
• The need for reevaluation if symptoms worsen or do not improve within 48-72 hours of starting the new antibiotic, as the patient may require culture-directed therapy or consideration of a complicated infection requiring more aggressive management. Alternatively, if the infection is not severe, trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of 160/800 mg twice daily for 10 days could be considered, as it is listed as a switch therapy option for patients with a β-lactam allergy in the guidelines 1. However, it is essential to note that the guidelines prioritize fluoroquinolones, such as levofloxacin or ciprofloxacin, for their broad-spectrum coverage and efficacy against resistant pathogens 1.

From the FDA Drug Label

Acute Otitis Media Safety and efficacy using azithromycin 30 mg/kg given over 5 days ... The combined clinical success rate (i.e., cure and improvement) at the Day 11 visit was 88% for azithromycin and 88% for the control agent.

Protocol 2 In a non-comparative clinical and microbiologic trial performed in the United States, where significant rates of beta-lactamase producing organisms (35%) were found, 131 patients were evaluable for clinical efficacy. The combined clinical success rate (i.e., cure and improvement) at the Day 11 visit was 84% for azithromycin.

The next best treatment for a patient with a continuing ear infection, who has a penicillin (PCN) allergy and is experiencing increased ear pain after initial treatment with Biaxin (clarithromycin) is azithromycin.

• Key points:
  • Azithromycin has shown high clinical success rates in treating acute otitis media.
  • The drug has been effective against various bacteria, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
  • Azithromycin is a suitable alternative for patients with a penicillin allergy. 2

From the Research

Treatment Options for Ear Infection with PCN Allergy

Given the patient's penicillin (PCN) allergy and increased ear pain after initial treatment with Biaxin (clarithromycin), the next best treatment options can be considered as follows:

• The patient has already been treated with a macrolide (Biaxin), which is a common alternative for patients with PCN allergy 3.
• Considering the patient's increased ear pain, a different antibiotic may be necessary. Cefuroxime axetil or ceftriaxone may be considered as alternative treatments, as they have been shown to be effective in treating acute otitis media 4, 5.
• Amoxicillin/clavulanate may not be suitable due to the patient's PCN allergy, but it has been shown to be effective in treating acute otitis media in patients without allergies 4, 5.
• Other options, such as cefdinir, may also be considered, as they have been shown to be effective in treating persistent and recurrent acute otitis media 6.

Key Considerations

When selecting a treatment, it is essential to consider the following factors:

• The patient's PCN allergy, which limits the use of certain antibiotics.
• The patient's increased ear pain, which may indicate a need for a different or more potent antibiotic.
• The potential for antibiotic resistance, which may affect the efficacy of certain treatments 4, 3, 6.
• The importance of accurate diagnosis and selection of appropriate antibiotic therapy to ensure optimal management of the infection 4, 6.