What alternative antibiotic can be used to treat a new middle ear infection in a patient who is intolerant to Augmentin (amoxicillin/clavulanate), Cefdinir (cefdinir), or Doxy (doxycycline)?

From the Guidelines

For a new middle ear infection when augmentin, cefdinir, and doxycycline cannot be used, I strongly recommend azithromycin as the first alternative, given its efficacy and safety profile as outlined in the pediatric community-acquired pneumonia guidelines 1. When considering alternatives for a new middle ear infection, it's crucial to prioritize options that are effective against common pathogens and have a favorable safety profile.

• Azithromycin is a suitable choice, with a dosing regimen of 10mg/kg on day 1 (maximum 500mg), followed by 5mg/kg (maximum 250mg) for 4 more days for children, as per the guidelines for pediatric community-acquired pneumonia 1.
• Another option, although less preferred due to potential resistance issues, is clarithromycin, which can be dosed at 15mg/kg/day in 2 doses for 7-14 days, as suggested for presumed atypical pneumonia in outpatient settings for children under 5 years old 1.
• Levofloxacin, a fluoroquinolone, is also an alternative, but its use in pediatric patients is more restricted due to concerns about musculoskeletal adverse events; the dose for children who have reached growth maturity or cannot tolerate macrolides could be considered, but this should be approached with caution and typically under close supervision 1. These recommendations are based on the most recent and highest quality evidence available, prioritizing morbidity, mortality, and quality of life outcomes. It's essential to monitor the patient's response to the chosen antibiotic and adjust the treatment plan as necessary, considering the potential for bacterial resistance and the need for effective symptom management.

From the FDA Drug Label

The following in vitro data are available, but their clinical significance is unknown: Levofloxacin exhibits in vitro minimum inhibitory concentrations (MIC values) of 2 mcg/mL or less against most (≥ 90%) isolates of the following microorganisms; however, the safety and effectiveness of levofloxacin in treating clinical infections due to these bacteria have not been established in adequate and well-controlled clinical trials Gram-Positive Bacteria Streptococcus pneumoniae (including multi-drug resistant isolates [MDRSP] )

Alternative antibiotics for middle ear infection:

• Levofloxacin 2 may be effective against Streptococcus pneumoniae, including multi-drug resistant isolates.
• Clindamycin 3 is indicated for the treatment of serious infections caused by susceptible strains of streptococci, pneumococci, and staphylococci. Key points:
• The effectiveness of these antibiotics in treating middle ear infections has not been established in adequate and well-controlled clinical trials.
• Bacteriologic studies should be performed to determine the causative organisms and their susceptibility to the chosen antibiotic.

From the Research

Alternative Antibiotics for Middle Ear Infection

Given the inability to use Augmentin, Cefdinir, or Doxy, alternative antibiotics must be considered for the treatment of a new middle ear infection.

• The first-line treatment for acute otitis media (AOM) is typically Amoxicillin, as recommended by 4 and 5.
• For patients who cannot take Amoxicillin or have failed Amoxicillin treatment, second-line options are considered.
• Ceftriaxone is suggested as a second-line agent by 4 and 5, particularly for cases where there is a high suspicion of drug-resistant Streptococcus pneumoniae.
• Azithromycin has been studied as an alternative, but its efficacy compared to Amoxicillin-clavulanate is variable, as shown in 6.
• Other options like cefuroxime axetil, cefprozil, and cefpodoxime proxetil are mentioned in 5 as potential second-line treatments, but their use should be guided by susceptibility patterns and clinical judgment.

Considerations for Antibiotic Selection

When selecting an antibiotic, it's crucial to consider factors such as:

• In vitro activity against common middle ear pathogens, including drug-resistant strains 4, 5.
• Pharmacokinetics and the ability of the drug to reach effective concentrations in the middle ear 4.
• Potential adverse events and the palatability of the antibiotic suspension, especially in pediatric patients 5.
• Cost and accessibility of the medication.

Diagnostic Approaches

For recurrent or severe cases, tympanocentesis may be useful for identifying the causative pathogen and guiding antibiotic therapy, as suggested by 4 and 5. This approach can help in selecting the most appropriate antibiotic based on culture and susceptibility results.