What is the plan of care for a 12-month-old with recurrent acute otitis media (AOM) being treated with cefdinir (14 mg/kg/day x 7 days), and who has developed hives after ingestion of whole milk and peanut butter, with a history of allergic reaction to amoxicillin (amox)?

Plan of Care for 12-Month-Old with Recurrent AOM, Amoxicillin Rash, and New-Onset Hives

Immediate Action: Discontinue Cefdinir and Reassess Allergies

Stop cefdinir immediately and do not restart it—this child has a documented penicillin allergy (amoxicillin rash), and cephalosporins carry cross-reactivity risk that should not be ignored in a child who has now developed hives after multiple exposures. 1, 2

Critical Allergy Assessment

• The amoxicillin rash at 7 days was likely a true allergic reaction, not a benign viral exanthem, especially given the subsequent hives after cefdinir exposure 1
• Cross-reactivity between penicillins and cephalosporins occurs in up to 10% of penicillin-allergic patients, though newer data suggest lower rates with second/third-generation cephalosporins 1, 2
• However, the FDA label explicitly warns that cefdinir should be given with caution to penicillin-sensitive patients 2
• The hives may be from cefdinir (cross-reactivity), peanut butter (first exposure), or whole milk (new allergen at 12 months) 1

Immediate Management Steps

1. Allergy Workup:

• Refer to pediatric allergist urgently for formal evaluation of penicillin allergy, peanut allergy, and milk allergy 1
• Document the exact nature of the amoxicillin reaction (timing, distribution, associated symptoms) 2
• Hold all new food introductions until allergy evaluation is complete 1

2. Alternative Antibiotic for Current AOM:

Switch to azithromycin 10 mg/kg on day 1, then 5 mg/kg daily for days 2-5 (total 5 days), as this is the safest non-beta-lactam option for a child with documented penicillin allergy and suspected cephalosporin cross-reactivity 1, 3

• Azithromycin is recommended for type I hypersensitivity reactions to penicillin 3
• While macrolides have higher pneumococcal resistance rates, they are the appropriate choice when beta-lactams are contraindicated 3
• For a 12-month-old child, a 10-day antibiotic course is required per AAP guidelines 1, 4

3. Correct the Dosing Error:

• The prescribed cefdinir dose of 14 mg/kg/day for 7 days was incorrect on two counts:
  • Children under 2 years require 10 days of therapy, not 7 days 1, 4
  • The 14 mg/kg/day dose is appropriate, but duration was inadequate 2

Management of Recurrent AOM

This child meets criteria for recurrent AOM if there have been 3+ episodes in 6 months or 4+ episodes in 12 months with at least 1 in the preceding 6 months 1

Recurrent AOM Prevention Strategy

1. Risk Factor Modification (implement immediately):

• Eliminate tobacco smoke exposure completely 1, 4
• Reduce or eliminate pacifier use after 6 months of age 4
• Avoid supine bottle feeding 4
• Consider reducing daycare attendance if feasible 1, 4
• Ensure pneumococcal (PCV-13) and annual influenza vaccination are up to date 4

2. Avoid Antibiotic Prophylaxis:

• Do not use prophylactic antibiotics—the AAP explicitly recommends against this due to minimal benefit, adverse effects, and contribution to bacterial resistance 1, 4
• Prophylaxis prevents only 1 episode per child-year and has no lasting benefit after cessation 1

3. Consider Tympanostomy Tubes:

• Refer to pediatric otolaryngology for evaluation for tympanostomy tube placement if recurrent AOM criteria are met 1
• Tubes reduce AOM episodes during the 6-month period they remain patent 1
• This is an option, not a mandate—requires shared decision-making with parents 1

Follow-Up Protocol

1. Short-term (48-72 hours):

• Reassess clinical response to azithromycin 1, 3
• If no improvement, consider tympanocentesis with culture to guide therapy, or empiric switch to intramuscular ceftriaxone 50 mg/kg daily for 3 days (if allergy evaluation suggests cephalosporin is safe) 1, 4

2. Medium-term (2-4 weeks):

• Complete allergy evaluation with allergist 1
• Confirm resolution of middle ear effusion (60-70% will have persistent effusion at 2 weeks, which is normal and does not require antibiotics) 1
• Document whether this episode qualifies as recurrent AOM based on total episode count 1

3. Long-term:

• If recurrent AOM is confirmed, proceed with ENT referral for tube consideration 1
• Establish clear antibiotic allergy list based on formal testing 1
• Reintroduce peanut butter and whole milk only after allergy clearance 1

Critical Pitfalls to Avoid

• Never use cefdinir or other cephalosporins again until formal allergy testing confirms safety 1, 2
• Do not use 7-day antibiotic courses in children under 2 years—this increases treatment failure risk 1, 4
• Do not prescribe prophylactic antibiotics for recurrent AOM—this is explicitly not recommended 1, 4
• Do not ignore the hives—this requires urgent allergy evaluation to determine the culprit (drug vs. food) 1, 2
• Do not assume middle ear effusion at 2-4 weeks post-treatment represents treatment failure—this is otitis media with effusion (OME) and requires monitoring, not antibiotics 1