What antibiotic and dosing is recommended for a patient with otitis media (inflammation of the middle ear) or sinusitis (inflammation of the sinuses) who has allergies to Penicillin (PCN) and Doxycycline?

From the Guidelines

For patients with otitis media or sinusitis who have allergies to penicillin and doxycycline, I recommend azithromycin as the first-line alternative, as supported by 1. The typical adult dosing is 500 mg on day 1, followed by 250 mg daily for 4 additional days (5 days total). For children, the dose is 10 mg/kg on day 1 (maximum 500 mg), then 5 mg/kg (maximum 250 mg) for days 2-5. Alternatively, levofloxacin can be used at 750 mg once daily for 5 days for adults with sinusitis, or 500 mg daily for 10 days for otitis media. For children with true penicillin allergy, clarithromycin is another option at 15 mg/kg/day divided twice daily for 10 days (maximum 500 mg twice daily) 1. When prescribing these alternatives, it's essential to verify the nature of the allergic reactions to penicillin, as true anaphylactic reactions are less common than reported, as noted in 1. These medications are effective because they provide adequate coverage against common respiratory pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Azithromycin and clarithromycin work by inhibiting bacterial protein synthesis, while levofloxacin inhibits bacterial DNA gyrase, preventing DNA replication. It's also important to consider the patient's age, general health, and comorbid conditions when selecting an antibiotic, as recommended in 1 and 1. In cases of severe illness or lack of improvement with initial treatment, consultation with a specialist may be necessary, as suggested in 1.

From the FDA Drug Label

Acute bacterial sinusitis 500 mg QD × 3 days Acute Otitis Media 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. Acute Bacterial Sinusitis The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute bacterial sinusitis is 10 mg/kg once daily for 3 days.

For a patient with otitis/sinusitis and allergies to PCN and DOxycycline, the recommended antibiotic is azithromycin.

• For adults, the recommended dose for acute bacterial sinusitis is 500 mg QD × 3 days.
• For pediatric patients, the recommended dose for acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days, and for acute bacterial sinusitis is 10 mg/kg once daily for 3 days 2.

From the Research

Antibiotic Options for Otitis/Sinusitis with Allergies to PCN and Doxycycline

• For patients with allergies to penicillin (PCN) and doxycycline, alternative antibiotics can be considered for the treatment of otitis media or sinusitis 3, 4, 5.
• Erythromycin ethylsuccinate and sulfisoxazole or TMP-SMZ may be used in patients who are allergic to penicillin 3.
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed 4.
• For patients with a beta-lactam allergy, appropriate antibiotics include a respiratory fluoroquinolone; clindamycin plus a third-generation cephalosporin is an option for children with non-type I hypersensitivity to beta-lactam antibiotics 5.
• Azithromycin has been shown to be effective in the treatment of acute sinusitis, with a significantly faster resolution of signs and symptoms compared to amoxicillin/clavulanate 6.

Dosing Considerations

• The optimal duration of therapy is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days 4.
• A 3-day course of azithromycin has been shown to be as effective and well-tolerated as a 10-day course of amoxicillin/clavulanic acid in the treatment of acute sinusitis 6.
• High-dose amoxicillin or amoxicillin-clavulanate may be considered for patients with suspected penicillin-resistant pneumococcus 3, 4.

Resistance and Susceptibility

• Penicillin resistance is defined by using a breakpoint of 2 microg/mL or more, and intermediate resistance is concentration dependent 7.
• Except for very highly resistant strains, the treatment of penicillin-resistant S. pneumoniae causing bacteremia, sinusitis, otitis, bronchitis, or community-acquired pneumonia remains penicillin or any beta-lactam 7.
• Clinicians should be selective in antibiotic selection to minimize further decreases in penicillin susceptibility to S. pneumoniae, and optimal therapy for non-central nervous system pneumococcal infection is with a respiratory quinolone, clindamycin, doxycycline, or third-generation cephalosporins 7.