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Aural Betters Oral Quinolone in Otorrhea. (Safer, Cost Effective).

DENVER -- Antimicrobial ear drops are far superior to systemic therapy for otorrhea, Dr. Peter S. Roland said at a satellite symposium held in conjunction with the annual meeting of the American Academy of Otolaryngology.

"Topical therapy is not only safer and cheaper than systemic therapy, but there's also a tremendous amount of evidence that it's more effective," said Dr. Roland, professor and chairman of otolaryngology at the University of Texas, Dallas, and chief of pediatric otology at Children's Medical Center.

Ear drops offer a tremendous advantage in terms of the concentration of drug delivered to the infection site. Infusion of three to five drops of an ototopical agent delivers 2,000-3,000 [micro]g/mL of antibiotic to the treatment field. This kind of knock-out therapy minimizes emergence of resistant strains.

"There simply aren't any microorganisms running around--or very few, anyway--that have [minimum inhibitory concentrations] of 2,000 [micro]g/mL," the otolaryngologist observed at the satellite symposium sponsored by Alcon.

In contrast, high-dose systemic amoxicillin typically results in middle-ear fluid concentrations of 8-10 [micro]g/mL, while ceftriaxone produces middle-ear fluid antibiotic concentrations of less than 30 [micro]g/mL.

The microbiology is basically the same regardless of whether a patient's otorrhea is due to acute or chronic otitis externa, myringitis, chronic suppurative otitis media, or tympanostomy tube otorrhea. Pseudomonas species are present in 40%-80% of cases, Staphylococcus aureus in 10%-25%, and other gram-negative organisms in 15%-20%. This means that the antibiotic selected must be effective against both gram-positive and -negative bugs.

Only two classes of topical antimicrobials fit this description: the aminoglycosides and fluoroquinolones. The aminoglycosides are surrounded by medicolegalk concerns due to their potential for ototoxicity.

"The advantage of the fluoroquinolones is that they have no real potential for ototoxicity. That means you can't cause ototoxicity; it also means, by the way, that you can't be accused of causing ototoxicity," Dr. Roland continued.

Two quinolones are approved for use in the ear: Floxin Otic (0.3% ofloxacin) and Cipro HC Otic (a suspension of cipro floxacin and hydrocortisone). Floxin is approved for treatment of otitis externa, chronic suppurative otitis media, and acute otitis media in children with tympanostomy tubes, while Cipro is approved for treatment of acute otitis externa.

The biggest disadvantage of topical therapy for otorrhea is that it requires direct contact with the treatment site. This means that in addition to an appropriate antibiotic, successful topical therapy involves two other essential elements: removal of debris from the external auditory canal and control of granulation tissue.

There is "overwhelming" consensus among experts but no hard data to show that corticosteroids are an important means of controlling granulation tissue. Steroids more potent than hydrocortisone are preferred because they're more effective, according to the otolaryngologist.

Cautery using silver nitrate is also effective in controlling granulation tissue, but it's difficult to control the depth of the resultant burn. There are documented cases of irreversible injury to the facial nerve.
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Author:Jancin, Bruce
Publication:Internal Medicine News
Geographic Code:1USA
Date:Nov 1, 2001
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