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AOM – Role for Oral Cephalosporins

The AOM guidelines from the American Academy of Pediatrics include enteral second and third generation cephalosporins, including cefdinir and cefpodoxime, as alternative agents for initial treatment of acute otitis media in patients unable to receive amoxicillin.1 While spectrum of activity for oral second and third generation cephalosporins includes the most common bacteria causing acute otitis media (i.e. Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes), the pharmacokinetic and pharmacodynamic properties of the oral second and third generation cephalosporins result in them being inferior to high dose amoxicillin for Streptococcus pneumoniae coverage.3

The difference is related to the pharmacokinetic properties of oral cephalosporins with most having overall low bioavailability, high protein binding, and short half-lives resulting in them only achieving sufficient time above the minimum inhibitory concentration (MIC) for highly penicillin-susceptible Streptococcus pneumoniae.2 Due to the inferior Streptococcus pneumoniae coverage with oral cephalosporins compared to high dose amoxicillin, patients who do not respond to high dose amoxicillin/clavulanate should be treated with intramuscular ceftriaxone to optimize coverage for penicillin resistant Streptococcus pneumoniae.

References

1) Lieberthral et al. The diagnosis and management of acute otitis media. Pediatrics. 2013; 131(3):e946 – e999.

2) Murphy et al. Predicting oral beta-lactam susceptibilities against Streptococcus pneumoniae. BMC Infectious Diseases. 2021; 21:679.

3) Parker et al. Cephem antibiotics: wise use today preserves cure for tomorrow. Pediatrics in Review. 2013;34(11):510. 

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.