Finally, the once- or twice-daily dosage regimen of the topical fluoroquinolones markedly improves therapeutic adherence when compared with the 4-timesdaily regimen of neomycin/polymyxin B/hydrocortisone.21,22,46
Preparations containing corticosteroids
The benefit of corticosteroids for otitis externa is not well established, though they are added to many topical antibiotic preparations. In one study, the addition of hydrocortisone to neomycin and polymyx in B reduced pain by approximately 1 day for patients with otitis externa.22 A combination of ciprofloxacin 0.3% and dexamethasone 0.1% administered twice daily is indicated for acute otitis externa,53 as was supported by an efficacy rate of 90.9% in a recent randomized, observer-masked, parallel-group, multicenter study in 468 children and adults.54 Although hypersensitivity to topical corticosteroids is well documented in published clinical studies, it seems to be rare in clinical practice.55-57
Severe pain. Inserting an ear wick and prescribing a topical fluoroquinolone plus an oral narcotic, such as acetaminophen with codeine, may be the optimal approach to resolving the infection and managing pain. Compared with neomycin combinations, ofloxacin and ciprofloxacin are somewhat more active in vitro against likely pathogens.
Otitis externa with concomitant acute otitis media. Antibiotics such as amoxicillin/clavulanate or cefdinir for acute otitis media should be used in addition to topical antibiotics.
Otitis externa with mild localized cellulitis. A standard oral antibiotic that covers staphylococci is recommended. Oral fluoroquinolones, for patients over 17 years of age, or intravenous ceftazidime may also be considered for more severe cases associated with aural cellulitis.
For younger children, I have prescribed oral ciprofloxacin (off-label), which has been recently approved for children older than 12 months with complicated urinary tract infection. Outpatient parenteral ceftriaxone may alternatively be used for some cases of cellulitis if the patient is only moderately ill. If rates of communityacquired methicillin-resistant S aureus exceed 15% to 20% in the community, clinicians should consider empiric therapy initially with trimethoprim-sulfamethoxazole or clindamycin.
Fungal infection. If a patient develops (1) otitis externa refractory to 2 consecutive courses of topical antibiotics, or (2) exhibits a discharge that looks like a white, fluffy exudate, suspect a fungal infection and obtain a culture of the exudate. Empiric therapy with either oral fluconazole (Diflucan) or topical ciclopirox (Loprox) solution should be considered.
Stan L. Block, MD 201 South Fifth Street, Suite 102, Bardstown, KY 40004. E-mail: [email protected]