What antibiotic is recommended for a child with Acute Otitis Media (AOM) and a history of anaphylactic reaction to Penicillin (PCN)?

From the Guidelines

For a child with acute otitis media (AOM) and an anaphylactic reaction to penicillin, the recommended antibiotic is cefdinir, due to its low risk of cross-reactivity with penicillin and effectiveness against common AOM pathogens 1. The choice of antibiotic in this scenario is crucial to ensure effective treatment while minimizing the risk of an allergic reaction.

• Cefdinir is a suitable option, with a dosage of 14 mg/kg per day in 1 or 2 doses, as it has a distinct chemical structure that reduces the likelihood of cross-reactivity with penicillin 1.
• Alternatively, cefuroxime (30 mg/kg per day in 2 divided doses) or ceftriaxone (50 mg IM or IV per day for 1 or 3 days) can be considered, as they also have a low risk of cross-reactivity with penicillin and are effective against common AOM pathogens 1.
• It is essential to note that the risk of cross-reactivity between penicillins and cephalosporins is lower than historically reported, and the chemical structure of the cephalosporin determines the risk of cross-reactivity 1.
• The American Academy of Pediatrics recommends cefdinir, cefuroxime, cefpodoxime, and ceftriaxone as alternative treatments for patients with a history of penicillin allergy, selecting out those with severe reaction histories 1.
• In cases where the infection is severe or there's concern about resistance, clindamycin at 30-40 mg/kg/day divided into three doses for 10 days can be considered, although it is not the first-line treatment for AOM 1.
• It is crucial to complete the full course of antibiotics even if symptoms improve quickly and to reassess the child if there is no improvement within 48-72 hours, as this might indicate antibiotic resistance or another complication 1.
• Supportive care with appropriate pain management using acetaminophen or ibuprofen (if not contraindicated) should also be provided to ensure the best possible outcome for the child.

From the FDA Drug Label

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. For a child with Acute Otitis Media (AOM) and an anaphylactic reaction to Penicillin (PCM),

• Azithromycin is a suitable alternative antibiotic.
• The recommended dosage is 30 mg/kg as a single dose or 10 mg/kg once daily for 3 days. 2

From the Research

Antibiotic Options for AOM with Anaphylactic Reaction to PCM

• For a child with acute otitis media (AOM) and an anaphylactic reaction to penicillin (PCM), alternative antibiotics can be considered 3, 4.
• Cephalosporin antibiotics are endorsed by the American Academy of Pediatrics for patients with reported allergies to penicillin, including those with AOM 3.
• Trimethoprim/sulfamethoxazole (TMP/SMX) is also an option for treating AOM in patients with a reported penicillin allergy, as it has been found to be effective and safe 4.
• Amoxicillin is often recommended as the first-line treatment for AOM, but in cases of penicillin allergy, alternative antibiotics such as cefdinir may be prescribed 5.

Considerations for Antibiotic Treatment

• The need for antibiotics in AOM is still a topic of debate, and some guidelines recommend watchful waiting in certain cases 6, 5.
• The choice of antibiotic should be based on the severity of the infection, the patient's medical history, and the likelihood of antibiotic resistance 6, 5.
• A shortened course of antibiotics (less than 7 days) may be effective for uncomplicated AOM, but the optimal duration of treatment is still a topic of research 7.