What is the best treatment for acute otitis media in a person with a penicillin (antibiotic) allergy?

From the Guidelines

For a person with penicillin allergy who has otitis media, the best treatment is typically Cefdinir (14 mg/kg per day in 1 or 2 doses) due to its low risk of cross-reactivity with penicillin allergy and effectiveness against common AOM bacterial pathogens. When considering treatment options for otitis media in patients with a penicillin allergy, it's crucial to weigh the risks and benefits of different antibiotics. According to the study published in Pediatrics 1, cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin allergy due to their distinct chemical structures. Some key points to consider when treating otitis media in patients with penicillin allergy include:

• The risk of cross-reactivity between penicillins and cephalosporins is lower than historically reported, with a reaction rate of 0.1% as stated by the Joint Task Force on Practice Parameters 1.
• Cefdinir, in particular, has been shown to be effective in treating recurrent AOM attributable to H influenzae, with eradication of the organism in 72% of patients 1.
• Other alternative treatments for penicillin-allergic patients include cefuroxime (30 mg/kg per day in 2 divided doses) and ceftriaxone (50 mg IM or IV per day for 1 or 3 d) 1. It's essential to note that the choice of antibiotic should be based on the severity of the infection, the patient's medical history, and the likelihood of resistant bacteria. Additionally, pain management with acetaminophen or ibuprofen and applying a warm compress to the affected ear may provide relief. Completing the full course of antibiotics is crucial to ensure complete eradication of the infection and prevent recurrence or resistance.

From the FDA Drug Label

In a double-blind, controlled, randomized clinical study of acute otitis media in pediatric patients from 6 months to 12 years of age, azithromycin (10 mg/kg per day for 3 days) was compared to amoxicillin/clavulanate potassium (7:1) in divided doses q12h for 10 days For the 366 patients who were evaluated for clinical efficacy at the Day 12 visit, the clinical success rate (i.e., cure plus improvement) was 83% for azithromycin and 88% for the control agent. The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5.

Best otitis media treatment for person with penicillin allergy:

• Azithromycin is a suitable alternative for the treatment of acute otitis media in patients with a penicillin allergy.
• The recommended dose of azithromycin for pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days.
• Clinical success rates for azithromycin in the treatment of acute otitis media have been reported to be around 83% at Day 12 and 74% at Day 24 to 28 visits 2.

From the Research

Otitis Media Treatment for Penicillin Allergy

• For individuals with a penicillin allergy, alternative antibiotics are necessary to treat otitis media.
• According to 3, clarithromycin is a viable option, with a clinical success rate of 93% in treating acute otitis media in children.
• The study 4 also supports the use of clarithromycin, showing its efficacy in treating otitis media caused by penicillin-susceptible, -intermediate, and -resistant Streptococcus pneumoniae.

Evaluation of Penicillin Allergy

• Before deciding on an alternative treatment, it is essential to evaluate the penicillin allergy, as many reported allergies may not be clinically significant 5.
• The evaluation can include penicillin skin testing, which has a high negative predictive value, and amoxicillin challenge for patients with low-risk allergy histories.
• Patients with a high-risk history, such as anaphylaxis or positive penicillin skin testing, should be approached with caution.

Alternative Treatments

• Other alternative treatments for otitis media include azithromycin, which is a macrolide antibiotic like clarithromycin 6.
• Additionally, vaccines and nasal sprays containing α-haemolytic streptococci with antimicrobial activity against otitis media pathogens are being developed as alternative treatments 7.
• Bacteriocins and bacteriocin-like inhibitory substances (BLIS) produced by lactic acid bacteria may also be explored as natural and safe treatments for otitis media.