Topical quinolones in the treatment of chronic suppurative otitis media and recurrent otorrhea.

The purpose of this article is to briefly review the use of topical fluoroquinolones in chronic suppurative otitis media (CSOM) and recurrent otorrhea.

CSOM

In 1998, Asian et al in Turkey conducted a study of the clinical and bacteriologic efficacy of two dosages of topical ciprofloxacin/hydrocortisone in 62 ears (60 patients, aged 15 to 70 yr) with CSOM. (1) Thirty patients (32 ears) received 250 [micro]g/ml of ciprofloxacin in solution (4 drops q8h), and the other 30 patients (30 ears) received 125 [micro]g/ml at the same dosage and frequency. At the 14-day follow-up, the clinical cure rates in the two groups were 78.1 and 83.3%, respectively. At 21 days, the clinical and bacterial cure rates in both groups were 100%. The authors concluded that the 125-[micro]g/ml strength was for all practical purposes as effective as the 250-[micro]g/ml strength as long as the drug was taken for at least 14 days.

What was interesting about this trial was not so much the differences in cure rates, but the fact that at least 14 days of therapy were necessary. We practice medicine in an era in which the focus of new antimicrobial drug development has been on shorter treatment courses and fewer daily doses. Of course, because the overwhelming amount of new drug development in this area is devoted to systemic rather than topical agents, there is a good deal of merit in such an approach. Aside from compliance issues, there is a mounting body of evidence to support the concept that shorter treatment courses of antibiotics are associated with less resistance. However, concerns over resistance are not as pronounced with topical agents and, therefore, there should be less reluctance to prescribe longer treatment courses that result in better outcomes.

Recurrent otorrhea

In 1997, Wintermeyer et al studied 29 children who had confirmed Pseudomonas aeruginosa infection and otorrhea that were refractory to other antibiotics. (2) Each patient received 3 drops of topical ciprofloxacin three times a day for 14 days, along with aural toilet. After 14 days, 18 patients (62.1%) were cured and eight (27.6%) improved (one patient showed no improvement, possibly because the external ear canal was very small, and two others were cured after being switched to a different agent). Two of the eight patients who has shown improvement at day 14 were cured by day 21. There were no adverse effects of treatment. During a follow-up that ranged from 3 to 15 months, 12 patients had not experienced any recurrence.

What this study teaches us is that there is little basis for hopping from one drug to another. It is very likely that the two patients who were cured after an antibiotic switch might have had the same outcome had they stayed with their original agent for a longer period. When I have a treatment failure, I first assess the adequacy of drug delivery. Several aspects of drug delivery should be checked. First, aural toilet to remove otorrhea and ceruminous and squamous debris improves drug delivery by clearing a path to the middle ear. Second, it is useful to provide simple instructions to the caregiver who administers the drops to retract the pinna superiorly and posteriorly in order to straighten the external auditory canal.

Perhaps the most important aspect of reviewing proper drug administration is to remind the caregiver to pump the tragus several times to overcome the surface tension of the tympanostomy tube, which will enhance entry of the drops into the middle ear. Finally, the longer the dosed ear canal remains upright following the administration of drops, the better (although some product information labels might not agree). This prevents runoff and lengthens the time that the drug remains in the middle ear--ideally at concentrations well above the minimum inhibitory concentration (MIC) for the pathogen being treated. It is a pharmacodynamic principle that the longer agents are above the MIC, the better the eradication rates are.

References

(1.) Aslan A, Altuntas A, Titiz A, et al. A new dosage regimen for topical application of ciprofloxacin in the management of chronic suppurative otitis media. Otolaryngol Head Neck Surg 1998;118:883-5.

(2.) Wintermeyer SM, Hart MC, Nahata MC. Efficacy of ototopical ciprofloxacin in pediatric patients with otorrhea. Otolaryngol Head Neck Surg 1997;116:450-3.

Joseph E. Dohar, MD, MS, FAAP, FACS 

Dr. Dohar is a pediatric otolaryngologist at Children's Hospital in Pittsburgh. His primary interests are ear disease and airway wound healing in children.