What is the recommended dosage of cefuroxime (Cefuroxime axetil) for the treatment of acute otitis media?

Cefuroxime for Acute Otitis Media

Primary Recommendation

Cefuroxime is NOT recommended as a first-line or second-line agent for acute otitis media; it should be reserved only as an alternative treatment in penicillin-allergic patients. 1

Current Guideline Position

The most recent WHO guidelines (2024) explicitly exclude cefuroxime from recommended treatment options for acute otitis media, despite it being proposed by their working group. 1 The Expert Committee made this decision to:

• Reduce emphasis on routinely treating penicillin-resistant Streptococcus pneumoniae 1
• Favor oral options with narrower spectrum 1
• Promote antimicrobial stewardship by limiting Watch category antibiotics 1

Recommended Treatment Algorithm

First-Line Treatment

• Amoxicillin 80-90 mg/kg/day divided into 2 doses 1, 2
• This remains the gold standard due to effectiveness, safety, low cost, acceptable taste, and narrow spectrum 1

Second-Line Treatment

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day clavulanate in 2 divided doses) 1
• Use when: amoxicillin taken in previous 30 days, concurrent purulent conjunctivitis, or coverage for β-lactamase producers needed 1, 2

Penicillin Allergy Alternative (Non-Type I Hypersensitivity)

Only in this specific scenario is cefuroxime appropriate:

• Cefuroxime axetil 30 mg/kg/day in 2 divided doses 1
• Cefuroxime has negligible cross-reactivity with penicillin due to its distinct chemical structure as a second-generation cephalosporin 1
• Other alternatives include cefdinir (14 mg/kg/day) or cefpodoxime (10 mg/kg/day) 1

Dosing Specifics When Cefuroxime Is Used

• Children under 2 years: 125 mg twice daily 3
• Children 2 years and older: 250 mg twice daily 3
• Weight-based dosing: 30 mg/kg/day divided into 2 doses 1, 4
• Duration: 5-10 days (typically 8-10 days based on clinical trials) 5, 4, 3

Clinical Efficacy Evidence

While older research studies (1990s) demonstrated cefuroxime's comparable efficacy to amoxicillin with cure rates of 74-94% 5, 4, 3, current guidelines have deliberately moved away from recommending it due to antimicrobial stewardship concerns. 1

Important Caveat on Resistance

• Cefuroxime shows increased treatment failure risk when penicillin MIC ≥2 mg/L for S. pneumoniae 6
• This limitation further supports its demotion from routine use 6

Reassessment Criteria

• Evaluate treatment response at 48-72 hours 1, 2
• If no improvement on cefuroxime, switch to ceftriaxone (50 mg IM/IV for 3 days) or consider tympanocentesis 1

Key Clinical Pitfall

The most common error is using cefuroxime as a first-line agent when amoxicillin is appropriate. This contributes to unnecessary use of broader-spectrum antibiotics and promotes resistance. 1 Reserve cefuroxime strictly for documented penicillin allergy (non-type I) or as a second-line agent after amoxicillin failure in allergic patients. 1