Cefdinir for Otitis Media
Recommended Dosage and Treatment Duration
For acute otitis media in pediatric patients, cefdinir should be dosed at 14 mg/kg per day (up to 600 mg maximum) given either once daily for 10 days or divided as 7 mg/kg every 12 hours for 5-10 days. 1
Position in Treatment Algorithm
Cefdinir is not a first-line agent for acute otitis media. High-dose amoxicillin (80-90 mg/kg per day in 2 divided doses) remains the recommended initial treatment for most patients due to its effectiveness against common AOM pathogens, safety profile, low cost, and narrow microbiologic spectrum. 2, 3
When to Use Cefdinir
Cefdinir is indicated as an alternative agent in the following specific scenarios:
Penicillin allergy (non-type I hypersensitivity): Cefdinir 14 mg/kg per day in 1 or 2 doses is an appropriate alternative, as cross-reactivity between penicillins and cephalosporins is lower than historically reported (previously overestimated at ~10%). 2, 3
Recent amoxicillin exposure: If the patient has received amoxicillin within the previous 30 days, high-dose amoxicillin-clavulanate is preferred over cefdinir. 2
Concurrent purulent conjunctivitis: This suggests H. influenzae infection; amoxicillin-clavulanate or other agents are preferred over cefdinir in this scenario. 2
Efficacy Considerations and Important Caveats
Critical Limitation with Pneumococcal Coverage
A major caveat is that cefdinir shows significantly reduced efficacy against Streptococcus pneumoniae compared to amoxicillin-clavulanate. In a head-to-head trial, presumptive eradication rates for S. pneumoniae were only 55.2% with cefdinir BID versus 89.5% with amoxicillin-clavulanate (p=0.0019). 4 Another study demonstrated that 10 days of high-dose amoxicillin-clavulanate achieved an 86.5% clinical cure rate compared to only 71.0% with 5 days of cefdinir (p=0.001). 5
Age-Related Effectiveness Decline
Cefdinir effectiveness decreases as children increase in age between 6-24 months (odds ratio 0.932 per month, p=0.01), while amoxicillin-clavulanate maintains stable cure rates across all ages. 5 This age effect correlates with child weight, suggesting the standard 14 mg/kg dose may be inadequate in older/heavier children.
Inadequate for Resistant Pneumococcus
Even at higher doses (25 mg/kg daily), cefdinir remains ineffective against penicillin-nonsusceptible S. pneumoniae. Pharmacodynamic studies show the time above MIC is <40% of the dosing interval, insufficient for bacteriologic effectiveness against resistant strains. 6 The current FDA-approved dose of 14 mg/kg is only appropriate for penicillin-susceptible S. pneumoniae. 1, 6
Dosing Specifics
Pediatric Dosing (6 months through 12 years)
Two equivalent regimens are available: 1
- Once-daily: 14 mg/kg every 24 hours for 10 days
- Twice-daily: 7 mg/kg every 12 hours for 5-10 days
Weight-based dosing examples (using 250 mg/5 mL suspension): 1
- 18 kg (40 lbs): 2.5 mL every 12 hours OR 5 mL every 24 hours
- 27 kg (60 lbs): 3.75 mL every 12 hours OR 7.5 mL every 24 hours
- 36 kg (80 lbs): 5 mL every 12 hours OR 10 mL every 24 hours
- ≥43 kg (95 lbs): 6 mL every 12 hours OR 12 mL every 24 hours (maximum 600 mg/day)
Renal Impairment
For patients with creatinine clearance <30 mL/min/1.73 m², reduce dose to 7 mg/kg (up to 300 mg) once daily. 1 For patients on hemodialysis, give 300 mg or 7 mg/kg every other day, with an additional dose after each dialysis session. 1
Tolerability Profile
Diarrhea is the most common adverse event but occurs significantly less frequently with cefdinir (10-13%) compared to amoxicillin-clavulanate (35%, p<0.001). 4 However, at the higher 25 mg/kg dose, diarrhea incidence increases to 20%. 6
Clinical Bottom Line
Cefdinir should be reserved for penicillin-allergic patients or as a second-line option when first-line therapy is contraindicated. Its inferior efficacy against S. pneumoniae—the most important AOM pathogen—makes it a suboptimal choice when amoxicillin or amoxicillin-clavulanate can be used. 2, 5, 4 The standard 10-day course at 14 mg/kg daily (or 7 mg/kg BID) represents the evidence-based regimen, though clinical outcomes remain inferior to high-dose amoxicillin-clavulanate. 1, 5