Cefdinir for Ear Infections (Acute Otitis Media)
Cefdinir is NOT first-line therapy for acute otitis media—use it only for penicillin-allergic patients (non-Type I reactions) or after amoxicillin failure, at a dose of 14 mg/kg/day given once daily or divided twice daily for 5-10 days. 1, 2
First-Line Treatment Hierarchy
High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) remains the gold standard initial treatment due to superior effectiveness against common bacterial pathogens (S. pneumoniae, H. influenzae, M. catarrhalis), excellent safety profile, low cost, and narrow microbiologic spectrum. 1
For patients who received amoxicillin in the previous 30 days or have concurrent conjunctivitis, initiate high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) instead. 1
When Cefdinir Is Appropriate
Use cefdinir specifically for:
Penicillin-allergic patients with non-Type I hypersensitivity reactions (rash without anaphylaxis, angioedema, or urticaria)—the cross-reactivity risk is negligible at approximately 0.1% due to distinct chemical structures between cefdinir and penicillins. 1, 3
Treatment failure after 48-72 hours of amoxicillin therapy, though amoxicillin-clavulanate is generally preferred in this scenario. 1
Recommended Dosing Regimen
Pediatric Patients (≥6 months through 12 years):
- 14 mg/kg/day administered once daily OR 7 mg/kg twice daily 1, 2
- Duration: 5-10 days (10-day course preferred for once-daily dosing) 1, 2
- Maximum daily dose: 600 mg 2
- May be administered without regard to meals 2
Adults and Adolescents:
Renal Insufficiency:
- For creatinine clearance <30 mL/min: 7 mg/kg (up to 300 mg) once daily 2
- Hemodialysis patients: 300 mg (or 7 mg/kg) every other day, with an additional dose after each dialysis session 2
Clinical Algorithm for Treatment Failure
If no improvement after 48-72 hours of cefdinir:
Reassess the diagnosis to confirm acute otitis media and exclude other causes of illness 3, 4
Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1, 3, 4
Consider intramuscular/IV ceftriaxone (50 mg/kg for 3 days) if oral therapy continues to fail 1, 3, 4
Consider tympanocentesis with culture after multiple antibiotic failures to guide targeted therapy 1, 4
Efficacy Considerations
Cefdinir demonstrates 72% eradication rates for recurrent AOM caused by H. influenzae. 1 However, amoxicillin-clavulanate is significantly more effective than cefdinir for bona fide AOM, with cure rates of 86.5% versus 71.0% (p=0.001) in head-to-head comparison. 5
Important finding: Cefdinir efficacy decreases as children increase in age between 6-24 months, while amoxicillin-clavulanate maintains stable cure rates across all ages. 5 This age-related decline in cefdinir effectiveness may relate to weight-based dosing inadequacy in older/heavier children. 5
Critical Pitfalls to Avoid
Do NOT use cefdinir as first-line therapy in non-allergic patients—this contributes to antibiotic resistance and provides inferior outcomes compared to amoxicillin. 4, 5
Distinguish Type I hypersensitivity reactions (anaphylaxis, angioedema, urticaria) from non-serious reactions (rash)—cefdinir is safe only for the latter, NOT for true Type I reactions. 1, 3, 4
Switch antibiotics rather than extending the same ineffective therapy if no improvement after 72 hours. 4
Do NOT prescribe cefdinir for patients who failed amoxicillin-clavulanate—use parenteral ceftriaxone instead. 4
Monitor for diarrhea, the most common adverse effect, though cefdinir causes significantly less diarrhea than amoxicillin-clavulanate (10-13% vs. 35%). 6