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Variations in Amoxicillin Pharmacokinetic/Pharmacodynamic Parameters May Explain Treatment Failures in Acute Otitis Media

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Abstract

Pharmacokinetic/pharmacodynamic (PK/PD) modeling and Monte Carlo simulations suggest that amoxicillin should rarely fail as therapy for Streptococcus pneumoniae and Haemophilus influenzae acute otitis media (AOM) infections except when the S. pneumoniae are highly penicillin resistant or the H. influenzae are β-lactamase producing. However, important and not infrequent exceptions to this expectation have been described. The objective of this review was to define the biologic variations in amoxicillin PK/PD parameters for the treatment of AOM in children and assess whether these variations could explain why the commonly employed amoxicillin PK/PD model is imperfect in predicting outcome for every patient in this clinical setting. To this end, a literature search of MEDLINE (1966–2006) and EMBASE (1974–2006) was conducted to identify studies that evaluated ampicillin or amoxicillin intestinal absorption, serum concentrations, and/or middle ear fluid (MEF) concentrations. Analysis of studies identified for review showed that the intestinal bioavailability of amoxicillin depends on passive diffusion and a saturable ‘pump’ mechanism that produces variable serum concentrations of the antibacterial agent. Indeed, substantial differences from patient to patient in serum (5- to 30-fold) and MEF (up to 20-fold) concentrations of amoxicillin occur following oral administration, and 15–35% of children have no detectable amoxicillin in MEF. These findings suggest that variability in PK/PD parameters may impact amoxicillin concentrations in serum and MEF, possibly explaining some AOM treatment failures.

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Acknowledgments

No sources of funding were used to assist in the preparation of this review. Dr Reed has received grants and honoraria from, and has served as a consultant to, public and private entities, including pharmaceutical manufacturers, which have financial interests in drug discovery and drug development for the treatment of otitis media. Dr Pichichero has no conflicts of interest that are directly relevant to the content of this review. Dr Pichichero had full access to all the data in the review and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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  1. Legacy Pediatric Group, Rochester General Research Institute, Rochester, New York, USA

    Michael E. Pichichero

  2. Division of Clinical Pharmacology and Toxicology, Children’s Hospital Medical Center of Akron, Akron, Ohio, USA

    Michael D. Reed

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  1. Michael E. Pichichero
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Correspondence to Michael E. Pichichero.

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Pichichero, M.E., Reed, M.D. Variations in Amoxicillin Pharmacokinetic/Pharmacodynamic Parameters May Explain Treatment Failures in Acute Otitis Media. Pediatr-Drugs 11, 243–249 (2009). https://doi.org/10.2165/00148581-200911040-00003

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