Transcript topical antibiotics

Workup
Laboratory Studies
Prior to instituting systemic therapy, a culture
should be obtained for sensitivity.
Imaging Studies
• CT scanning
– Unresponsive to medical treatment, to look for
occult cholesteatoma or foreign body
– suspects a neoplasm
– intratemporal or intracranial complications.
Imaging Studies
• MRI
– intratemporal or intracranial complications are
suspected
– to reveal dural inflammation, sigmoid sinus
thrombosis, labyrinthitis, and extradural and
intracranial abscesses.
Updates on Management of CSOM
Aural toilet
• part of standard medical treatment
• reduce quantity of infected material from
middle ear
• could facilitate middle ear penetration of
topical antimicrobials
Aural toilet
• From the Cochrane review, aural toilet alone
was not significantly better in resolving
otorrhoea and in healing perforations than no
treatment.
Aural toilet
• This was based on two field trials among
children in the Solomon Islands (50) and
Kenya (155).
• Antimicrobial Treatment, aural toilet must be
combined with antibiotics or antiseptics to be
effective.
Oral antibiotics
Oral antibiotics are better than aural toilet
alone
• A trial comparing various oral antibiotics with
aural toilet alone reported a higher otorrhoea
resolution rate in the antibiotic treated group.
Oral antibiotics
• Another trial comparing oral clindamycin with
aural toilet alone found otorrhoea resolution
rates of 93% and 29%, respectively
Topical antibiotics
Topical antibiotics are better than aural toilet
alone
• The addition of topical antibiotics to aural
toilet was associated with a 57% rate of
otorrhoea resolution, compared to 27% with
aural toilet alone
Topical antibiotics
• topical antibiotics: framycetin, gramicidin,
ciprofloxacin, tobramycin, gentamicin and
chloramphenicol.
• Podoshin et al. also showed that topical
ciprofloxacin or tobramycin was more
effective than placebo (clinical response rates
were 78.9%, 72.2% and 41.2%, respectively)
Topical antibiotics are better than systemic
antibiotics
• The Cochrane review found that topical
antibiotics were more effective than systemic
antibiotics in resolving otorrhoea and
eradicating middle ear bacteria.
• topical antibiotics: gentamicin,
chloramphenicol, ofloxacin, and ciprofloxacin
• topical antiseptics: hydrogen peroxide and
boric acid with iodine powder as
• systemic antibiotics: cephalexin, flucloxacillin,
cloxacillin, amoxycillin, coamoxiclav,
erythromycin, metronidazole, piperacillin,
ciprofloxacin, azactam, trimethoprim-sulfa,
ofloxacin, and intramuscular gentamicin
Combined topical and systemic antibiotics are
no better than topical antibiotics alone
• The Cochrane review showed that combined
oral-topical antibiotics were no more
effective than topical antibiotics alone; the
rates of resolution of otorrhoea were 50% and
53%, respectively.
Thus, although combination antibiotics are
effective in resolving otorrhoea, adding oral
antibiotics to topical antibiotics and aural
toilet increases the cost without increasing
the success rate.
This confirms the difficulty of systemic drug
penetration through the devascularized,
fibrotic mucosa of the middle ear and
mastoid.
It also emphasizes the critical role of local
treatment.
Parenteral antibiotics
• Parenteral antibiotics are better than aural
toilet alone
• One trial found that intravenous mezlocillin
and ceftazidime were more effective than
aural toilet alone in resolving otorrhoea and
eradicating middle ear bacteria
• (100% and 8%, respectively).
Surgery
• Mastoidectomy and/or tympanoplasty are frequently necessary to permanently cure CSOM.
• Mastoidectomy
- removing the mastoid air cells, granulations and
debris using bone drills and microsurgical
instruments.
• Tympanoplasty
- closure of the tympanic perforation by a soft
tissue graft with or without reconstruction of the
ossicular chain.
References:
• Chronic suppurative otitis media, Burden of
Illness and Management Options, Child and
Adolescent Health and Development,
Prevention of Blindness and Deafness, World
Health Organization, Geneva, Switzerland,
2004