What is the treatment for mastoiditis in a patient with a hypersensitivity reaction to penicillin (antibiotic)?

From the Guidelines

For patients with mastoiditis who are allergic to penicillin, the most appropriate treatment involves the use of non-beta-lactam antibiotics, such as ciprofloxacin plus clindamycin or aztreonam plus vancomycin, as recommended by the Infectious Diseases Society of America 1.

Key Considerations

• The choice of antibiotic should be guided by the severity of the allergic reaction to penicillin, with those having a history of immediate-type hypersensitivity reactions requiring avoidance of beta-lactams and carbapenems.
• Treatment typically involves administering these medications for 10-14 days, often starting with intravenous therapy and potentially transitioning to oral antibiotics once clinical improvement occurs.
• Surgical intervention, including myringotomy with tympanostomy tube placement or mastoidectomy, may be necessary alongside antibiotics for severe cases or those not responding to medical therapy.
• Pain management with acetaminophen or NSAIDs is also crucial for patient comfort and recovery.

Antibiotic Options

• Ciprofloxacin plus clindamycin: This combination is effective against a broad range of pathogens, including Streptococcus pneumoniae, Staphylococcus aureus, and anaerobes.
• Aztreonam plus vancomycin: This combination provides coverage against gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA).

Important Notes

• The Infectious Diseases Society of America recommends avoiding beta-lactams and carbapenems in patients with a history of immediate-type hypersensitivity reactions to penicillin 1.
• Local resistance patterns and culture results from ear drainage or surgical specimens should guide the choice of antibiotic when possible.
• While cephalosporins, such as cefdinir, cefuroxime, and ceftriaxone, have a low risk of cross-reactivity with penicillin, they should be used with caution in patients with a severe penicillin allergy 1.

From the FDA Drug Label

Vancomycin Hydrochloride for Injection, USP is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (β-lactam-resistant) staphylococci It is indicated for penicillin-allergic patients, for patients who cannot receive or who have failed to respond to other drugs, including the penicillins or cephalosporins, and for infections caused by vancomycin-susceptible organisms that are resistant to other antimicrobial drugs Vancomycin Hydrochloride for Injection, USP has been reported to be effective alone or in combination with an aminoglycoside for endocarditis caused by S. viridans or S. bovis.

The treatment for mastoiditis with an allergy to penicillin may include vancomycin, as it is indicated for penicillin-allergic patients. However, the label does not explicitly mention mastoiditis as an indication.

• The drug is effective against staphylococcal infections, which may be a cause of mastoiditis.
• Vancomycin should be used to treat infections that are proven or strongly suspected to be caused by susceptible bacteria 2.

From the Research

Mastoiditis Treatment with Allergy to Penicillin

• Mastoiditis is an infection of the mastoid bone, which can be caused by various bacteria, including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 3.
• Patients with a reported allergy to penicillin may require alternative antibiotic treatments, as many antibiotics are derived from penicillin or have similar structures 4, 5.
• For patients with a low-risk allergy history, a direct amoxicillin challenge may be appropriate, while moderate-risk patients can be evaluated with penicillin skin testing 4.
• In cases of mastoiditis caused by MRSA, treatment with vancomycin or other antibiotics such as linezolid may be necessary 6, 7.
• Combination therapy with linezolid and other antibiotics may be effective in treating serious infections, including those caused by MRSA and vancomycin-resistant Enterococcus faecium (VRE) 7.

Alternative Antibiotic Options

• Clindamycin, lincomycin, and erythromycin are alternative antibiotics that can be used to treat less serious MSSA infections, such as skin and soft tissue infections, in patients with penicillin hypersensitivity 6.
• First-generation cephalosporins, such as cefazolin, cephalothin, and cephalexin, can be used to treat MSSA infections, but are contraindicated in patients with immediate penicillin hypersensitivity 6.
• Linezolid, a synthetic oxazolidinone antibiotic, has been shown to be effective against Gram-positive bacteria, including MRSA and VRE 7.

Considerations for Treatment

• The selection of antibiotic treatment should be based on the severity of the infection, the causative organism, and the patient's allergy history 6, 3, 4.
• Penicillin skin testing and graded challenge can be used to evaluate patients with a reported penicillin allergy, and desensitization may be necessary in some cases 4, 5.
• Combination therapy with multiple antibiotics may be necessary to treat complicated infections, such as those caused by MRSA and VRE 7.