From the Guidelines
For patients with otitis media who have a penicillin allergy, the recommended first-line treatment is cefdinir (14 mg/kg per day in 1 or 2 doses) or cefuroxime (30 mg/kg per day in 2 divided doses), as these cephalosporins have limited cross-reactivity with penicillins 1.
Key Considerations
- The choice of antibiotic should be based on the severity of the infection and the patient's history of penicillin allergy.
- Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin allergy due to their distinct chemical structures 1.
- For patients with severe infections or treatment failures, alternative treatments such as clindamycin (30-40 mg/kg per day in 3 divided doses) with or without a third-generation cephalosporin may be considered 1.
Treatment Options
- Cefdinir: 14 mg/kg per day in 1 or 2 doses
- Cefuroxime: 30 mg/kg per day in 2 divided doses
- Clindamycin: 30-40 mg/kg per day in 3 divided doses, with or without a third-generation cephalosporin
Important Notes
- Patients should complete the full course of antibiotics even if symptoms improve quickly to prevent recurrence or resistance development.
- If symptoms worsen or don't improve within 48-72 hours, reevaluation is necessary.
- Supportive care with acetaminophen or ibuprofen for pain and fever is also important. The most recent and highest quality study 1 provides the best evidence for the treatment of otitis media in patients with penicillin allergy.
From the FDA Drug Label
Pediatric Patients -- The usual recommended daily dosage for pediatric patients is 20 mg/kg/day in divided doses every 8 hours In more serious infections, otitis media, and infections caused by less susceptible organisms, 40 mg/kg/day are recommended, with a maximum dosage of 1 g/day. 40 mg/kg/day (Otitis Media) Cefaclor may be administered in the presence of impaired renal function. Under such a condition, the dosage usually is unchanged
For a patient with penicillin allergy and otitis media, Cefaclor can be considered as a treatment option. The recommended dosage for otitis media is 40 mg/kg/day. However, it is crucial to note that Cefaclor is a cephalosporin antibiotic, and cross-reactivity with penicillin may occur in some patients. Therefore, caution should be exercised when administering Cefaclor to patients with a penicillin allergy 2.
- Key considerations:
- Dosage: 40 mg/kg/day for otitis media
- Caution: potential cross-reactivity with penicillin in patients with penicillin allergy
- Renal function: dosage usually unchanged in impaired renal function
From the Research
Otitis Media with Penicillin Allergy
- Otitis media is a common diagnosis in childhood, with 50% to 85% of children experiencing at least one episode by the age of three 3.
- Symptoms of otitis media include ear pain, fever, irritability, otorrhea, anorexia, and sometimes vomiting or lethargy 3.
- Treatment for otitis media typically includes pain management and observation or antibiotics, depending on the patient's age, severity of symptoms, and whether the infection is unilateral or bilateral 3.
Antibiotic Treatment for Penicillin Allergy
- For patients with a penicillin allergy, cefdinir or azithromycin are recommended as first-line antibiotics 3.
- Trimethoprim/sulfamethoxazole (TMP/SMX) is also an option for treating acute otitis media in patients with a reported penicillin allergy 4.
- Clarithromycin has been shown to be effective in treating acute otitis media, with comparable efficacy to amoxicillin/clavulanate 5, 6.
- Clarithromycin has also been shown to be effective against penicillin-susceptible, -intermediate, and -resistant Streptococcus pneumoniae in the treatment of acute otitis media 7.
Considerations for Treatment
- The need for antibiotics in acute otitis media remains controversial, and reported penicillin allergies may be an unreliable indicator of a potentially serious reaction 4.
- Gastrointestinal adverse events are common with antibiotic treatment, with diarrhea being the most frequent event 5.
- Tympanostomy tubes may be considered for children with recurrent episodes of otitis media 3.