Once-daily ofloxacin otic solution versus neomycin sulfate/polymyxin B sulfate/hydrocortisone otic suspension four times a day: a multicenter, randomized, evaluator-blinded trial to compare the efficacy, safety, and pain relief in pediatric patients with otitis externa

Comparative study of fibroblast growth factor 2 and ofloxacin ear drops for repairing large traumatic perforations: A randomized controlled study

OBJECTIVE

The objective of this study was to compare the healing outcome of fibroblast growth factor 2 (FGF2), ofloxacin ear drops (OFLX) and spontaneous healing for repairing large traumatic tympanic membrane (TM) perforations.

MATERIAL AND METHODS

A total of 75 traumatic large perforations with >1/4 of TM were randomly divided into FGF2 (n = 25), OFLX (n = 25), and spontaneous healing (n = 25) groups. The closure rates, closure times, and hearing gains were compared at 3 months.

RESULTS

At 2 weeks after treatment, the closure rate was 95.8 % in the FGF2 group, 96.0 % in the ofloxacin ear drops group, and 14.3 % in the spontaneous healing group (P < 0.01), respectively. At 3 months after treatment, the closure rate was 100 % in the FGF2 group, 100 % in the OFLX group, and 85.7 % in the spontaneous healing group, no among-group differences were significant (P > 0.05). The mean closure time was 9.69 ± 2.46 days in the FGF2 group, 9.45 ± 2.32 days in the OFLX group, and 30.94 ± 8.95 days in the spontaneous healing group (P < 0.01). The mean ABG was 10.37 ± 2.51 dB for the FGF2 group, 11.01 ± 1.31 dB for the OFLX group, and 10.86 ± 1.94 dB for the spontaneous healing group, no significant difference was found among three groups (P > 0.05).

CONCLUSIONS

This study suggested that both FGF2 and OFLX significantly shortened the mean closure time and improved the closure rate compared with spontaneous healing for repairing large traumatic perforations, while the healing outcome wasn't significantly different among FGF2 and OFLX groups.

Safety of Quinolones in Children: A Systematic Review and Meta-Analysis

BACKGROUND

The results of animal experiments show that quinolone antibacterial drugs may permanently damage the soft tissues of the weight-bearing joints of young animals. Out of safety concerns, using quinolones in children has always been controversial.

OBJECTIVE

The aim of this study was to assess the risk of using quinolones in children and provide evidence for clinicians to support decision making.

DATA SOURCES

The MEDLINE (Ovid), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), International Pharmaceutical Abstracts (Ovid), CINAHL, CNKI, VIP, and WanFang Data databases were searched from inception to 8 September 2021.

STUDY SELECTION

All types of studies that reported the safety data of quinolones in children, including clinical trials and observational studies.

DATA EXTRACTION

Data extraction and cross-checking were completed by two independent reviewers using a pilot-tested standardized data extraction form.

RESULTS

The overall incidence rate of adverse drug events (ADEs) in children using systemic quinolones was 5.39% and the most common ADEs were gastrointestinal reactions (incidence rate, 2.02%). Quinolone-induced musculoskeletal ADEs in children were uncommon (0.76%). Meta-analysis results showed that the risk of musculoskeletal ADEs in children using quinolones was higher than children in the control group (51 studies; rate ratio [RR] 2.03, 95% confidence interval [CI] 1.82-2.26; p < 0.001; I² = 18.6%; moderate-quality evidence). However, the subgroup analysis results showed that differences might only be observed in children who were followed up for 2 months to 1 year (2-6 months: RR 2.56, 95% CI 2.26-2.89; 7 months to 1 year: RR 1.35, 95% CI 0.98-1.86). Moreover, children (adolescents) aged between 13 and 18 years might be sensitive to the musculoskeletal toxicity of quinolones (RR 2.69, 95% CI 2.37-3.05; moderate-quality evidence) and the risk of levofloxacin-induced musculoskeletal ADEs might be higher (RR 1.33, 95% CI 1.00-1.77; low-quality evidence).

CONCLUSIONS

Although the existing evidence shows that quinolone-induced musculoskeletal ADEs seem to be only short-term and reversible, and no serious skeletal and muscular system damage cases have been reported in children, quinolones should be avoided unless necessary in children because the incidence rate of quinolone-related ADEs is not low and they are broad-spectrum antibiotics that will induce the emergence of resistant strains if used frequently.

[External otitis: clinical diagnostics and treatment tactics]

OBJECTIVE

To summarize modern data about the epidemiology, etiology, clinical course and diagnosis of otitis externa.

MATERIAL AND METHODS

Materials of scientific publications included in the Cochrane Library, information bases of the RSCI, MEDLINE, PubMed were used as a data source. The choice of material was carried out according to the keywords: otitis externa, etiology, diagnosis, treatment, local treatment.

RESULTS

The role of combined drugs in the main etiopathogenetic mechanisms of the external ear inflammatory process is shown.

CONCLUSION

Analysis of published data from clinical trials indicates the importance of a fixed antibacterial agents and anesthetic combination in increasing the effectiveness of topical therapy for otitis externa.

Repair of large traumatic tympanic membrane perforation using ofloxacin otic solution and gelatin sponge

Introduction

Traumatic large tympanic membrane perforations usually fail to heal and require longer healing times. Few studies have compared the healing and hearing outcomes between gelatin sponge patching and ofloxacin otic solution.

Objectives

To compare the healing outcomes of large traumatic tympanic membrane perforations treated with gelatin sponge, ofloxacin otic solution, and spontaneous healing.

Methods

Traumatic tympanic membrane perforations >50% of the entire eardrum were randomly divided into three groups: ofloxacin otic solution, gelatin sponge patch and spontaneous healing groups. The healing outcome and hearing gain were compared between the three groups at 6 months.

Results

A total of 136 patients with large traumatic tympanic membrane perforations were included in analyses. The closure rates were 97.6% (40/41), 87.2% (41/47), and 79.2% (38/48) in the ofloxacin otic solution, gelatin sponge patch, and spontaneous healing groups, respectively (p = 0.041). The mean times to closure were 13.12 ± 4.61, 16.47 ± 6.24, and 49.51 ± 18.22 days in these groups, respectively (p < 0.001).

Conclusions

Gelatin sponge patch and ofloxacin otic solution may serve as effective and inexpensive treatment strategies for traumatic large tympanic membrane perforations. However, ofloxacin otic solution must be self-applied daily to keep the perforation edge moist, while gelatin sponge patching requires periodic removal and re-patching.

Healing Human Moderate and Large Traumatic Tympanic Membrane Perforations Using Basic Fibroblast Growth Factor, 0.3% Ofloxacin Eardrops, and Gelfoam Patching

OBJECTIVE

The goal of this study was to evaluate the effects of basic fibroblast growth factor (bFGF), 0.3% ofloxacin eardrops (OFLX), and Gelfoam patching on the healing of human moderate and large traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

A prospective, quasi-randomized, controlled clinical study.

SETTING

A University-affiliated teaching hospital.

SUBJECTS AND METHODS

We performed a quasi-randomized prospective analysis between January 2010 and December 2014. All patients had traumatic TMPs covering areas >25% of the entire tympanic membrane. The closure rates, closure times, hearing gains, and rates of otorrhea in patients who underwent conservative observation, Gelfoam patching, topical bFGF application, and direct application of OFLX were compared.

RESULTS

We ultimately included 185 patients. Closure rates did not significantly differ among the four groups (p = 0.257). Post-hoc multiple comparisons also showed that the closure rates did not differ between any two groups (p > 0.083). The mean closure times were 25.6 ± 13.32, 12.3 ± 8.15, 14.3 ± 5.44, and 13.97 ± 8.82 days for the observation, bFGF, Gelfoam patch, and OFLX groups, respectively. The closure times of the four groups differed significantly (p < 0.001). Post-hoc multiple comparisons showed that the differences between the observation group and each of the other groups were significant (p < 0.001). No other between- or among-group differences were significant (p > 0.0083).

CONCLUSION

The findings of this study suggest that OFLX, bFGF, and Gelfoam patching accelerated the closure of human moderate and large traumatic TMPs. Hence, treatment of human traumatic TMPs should be revisited clinically. Topical application of OFLX may be recommended, because OFLX is more easily available and convenient than bFGF or Gelfoam patch for otology outpatients.

A comparative study to evaluate the efficacy of EGF, FGF-2, and 0.3% (w/v) ofloxacin drops on eardrum regeneration

BACKGROUND

Traumatic tympanic membrane perforations (TMPs) tend to spontaneous healing, however, large TMPs usually fail to healing. Clinical and experimental studies had demonstrated that growth factors accelerated the healing of large TMPs. The aim of this study was to compare the effects of growth factors and 0.3% (w/v) ofloxacin drops n the healing of human large TMPs.

METHODS

A total of 184 human large traumatic TMPs were randomly assigned to receive epidermal growth factor (EGF) treatment, fibroblast growth factor-2 (FGF-2) treatment, 0.3% (w/v) ofloxacin drops treatment, and conservative observation (only).

RESULTS

A total of 180 patients were analyzed in this study at the 6-month follow-up. The closure rates of the perforations in the EGF, FGF-2, 0.3% (w/v) ofloxacin drops, and conservative observation groups were 91.11%, 93.18%, 95.65%, and 82.22%, respectively, the closure rates did not significantly differ among the groups (P = .165). Similarly, pairwise comparisons did not reveal any significant between-group differences (P > .0083). However, the difference of the mean closure time was significant among the 4 groups (P < .001), pairwise comparisons showed that closure time was significantly longer in the observational group than in the other 3 groups (P < .001). Nevertheless, no significant difference in mean closure time was evident between any 2 treated groups (P > .0083). The mean hearing gain after 6 months was 11.49 ± 5.88 dB for the EGF group, 10.89 ± 5.16 dB for the FGF-2 group, 10.54 ± 5.56 dB for the ofloxacin group, and 9.29 ± 5.36 dB for the observation group. Differences in hearing improvement rates among the 4 groups were not statistically significant (P = .283).

CONCLUSION

Epidermal growth factor, FGF-2, and 0.3% (w/v) ofloxacin drops accelerated the closure of large TMPs compared with conservative treatment. Surprisingly, neither the closure rate nor closure time differed significantly among the 3 treated groups. Further experimental studies to demonstrate whether 0.3% (w/v) ofloxacin per se accelerates the healing of TMPs will be interesting in the future.

The Use of Systemic and Topical Fluoroquinolones

Appropriate prescribing practices for fluoroquinolones, as well as all antimicrobial agents, are essential as evolving resistance patterns are considered, additional treatment indications are identified, and the toxicity profile of fluoroquinolones in children has become better defined. Earlier recommendations for systemic therapy remain; expanded uses of fluoroquinolones for the treatment of certain infections are outlined in this report. Prescribing clinicians should be aware of specific adverse reactions associated with fluoroquinolones, and their use in children should continue to be limited to the treatment of infections for which no safe and effective alternative exists or in situations in which oral fluoroquinolone treatment represents a reasonable alternative to parenteral antimicrobial therapy.

A retrospective study of EGF and ofloxacin drops in the healing of human large traumatic eardrum perforation

OBJECTIVE

We evaluated the effects of epidermal growth factor (EGF) and ofloxacin otic drops on the healing of large human traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary university hospital.

METHODS

Retrospective case review of patients with traumatic TMP larger than 25% of the TM seen between February 2007 and December 2008. Patients were stratified into EGF drops, ofloxacin drops, and observation groups. The closure rate, closure time, and hearing level were compared among the three groups at 6months.

RESULTS

In total, 120 patients met the inclusion criteria. The total closure rate was 89.2% (107/120) and the total mean closure time was 22.6±7.4days. The closure rates of perforation in the EGF, ofloxacin otic drops, and observation groups were 93.5%, 92.0%, and 82.2%, respectively. The closure rates among the three groups were not statistically different (p=0.19). The mean perforation closure times were 12.6±6.9, 12.9±5.1, and 35.7±9.2days for the EGF, ofloxacin otic drops, and observation groups, respectively. The average closure time in the observation group was significantly longer (p=0.01) than that in the EGF and ofloxacin otic drops groups. However, the closure times in the EGF and ofloxacin otic drops groups were not significantly different (p=0.84).

CONCLUSIONS

The study surprisingly found that both topical application of EGF and ofloxacin otic drops result in more rapid closure compared with spontaneous healing for human large traumatic TMPs. The benefit would be great as a shorter recovery time may reduce health care costs. Therefore, ofloxacin otic drops should be considered in clinics.

The effect of ofloxacin otic drops on the regeneration of human traumatic tympanic membrane perforations

OBJECTIVE

To investigate the effects of direct application of ofloxacin otic drops on human traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

Prospective, sequential allocation, controlled clinical study.

SETTING

Tertiary university hospital.

PARTICIPANTS

In total, 149 patients with traumatic TMPs were recruited. They were allocated sequentially to two groups: a conservative observation group (n = 75) and a ofloxacin drops-treated group (n = 74).

MAIN OUTCOME MEASURES

The closure rate, closure time and rate of otorrhoea were compared between the groups at 6 months.

RESULTS

In total, 145 patients were analysed. The closure rates of medium perforations between the groups were not significantly different (P = 0.35); however, the ofloxacin drops-treated group had a significantly shorter closure time for medium perforations than the observation group (P < 0.01). Additionally, the ofloxacin drops-treated group showed improvement in the closure rate of large perforations (P = 0.02) and a significantly shorter mean closure time (P < 0.01) than the observation group. However, purulent otorrhoea was not significantly different between the groups (P = 0.37).

CONCLUSIONS

The present findings indicate that the moist eardrum environment resulting from topical application of ofloxacin drops shortened the closure time and improved the closure rate, but did not affect hearing improvement or increase the rate of middle ear infection of large traumatic TMPs. Thus, although traumatic TMPs tend to heal spontaneously, moist therapy can be considered for traumatic, large TMPs in the clinic.

The use of systemic and topical fluoroquinolones

Appropriate prescribing practices for fluoroquinolones are essential as evolving resistance patterns are considered, additional treatment indications are identified, and the toxicity profile of fluoroquinolones in children becomes better defined. Earlier recommendations for systemic therapy remain; expanded uses of fluoroquinolones for the treatment of certain infections are outlined in this report. Although fluoroquinolones are reasonably safe in children, clinicians should be aware of the specific adverse reactions. Use of fluoroquinolones in children should continue to be limited to treatment of infections for which no safe and effective alternative exists.

A meta-analysis of the efficacy of quinolone containing otics in comparison to antibiotic-steroid combination drugs in the local treatment of otitis externa

BACKGROUND

The term otitis externa denotes the inflammation of the external auditory canal and can be treated locally in the form of monotherapy or a combination drug.

OBJECTIVE

The aim of the present meta-analysis was to compare the efficacy of an antibiotic-steroid combination drug with that of monotherapy. According to current data, a comparable investigation based on network analysis does not exist.

METHODS

After systematically searching the PubMed, Medline, Medpilot, Web of Science and Embase electronic databases, 12 relevant randomized, controlled, clinical studies were identified involving 2682 evaluable patients with regard to the cure rate and seven publications with 1251 microbiologically assessable patients. The collected data were compared directly and indirectly by means of network analysis.

RESULTS

The direct comparison showed a trend towards the superiority of the monotherapy containing quinolone. The network analysis verified this tendency and demonstrated that pure quinolone drugs can achieve a significantly higher cure rate (OR: 1.29; 95% CI: 1.06-1.57; p = 0.01) and a significantly superior eradication rate (OR: 1.44; 95% CI: 1.03-2.02; p = 0.03) compared to combination drugs not containing quinolone. We found substantial heterogeneity (with I(2) up to 88.7%) between studies, presumably due to treatments applied in varying frequency, thus bearing on compliance and outcome.

CONCLUSION

With a level Ia evidence, this investigation validates the clinical benefit of quinolones as compared to classic combination drugs in the local treatment of acute otitis externa.

Acute bacterial otitis externa: efficacy and safety of topical treatment with an antibiotic ear drop formulation in comparison to glycerol treatment

OBJECTIVES

To demonstrate the efficacy and safety of an antibiotic ear drop formulation combining polymyxin B sulfate, neomycin sulfate and gramicidin (PS) in patients with acute bacterial otitis externa (AOE). The combination was compared to glycerol ear drops, a non-pharmacologic treatment of AOE.

METHODS

An active controlled, double-blind, randomized, parallel group, multicenter clinical trial study design was performed in ear, nose and throat (ENT) practices with a planned interim analysis for sample size adaptation. In total, 244 patients aged 19-84 with no previous episode of otitis externa within the last year were randomized to receive either PS or glycerol ear drops thrice daily for 10 ± 2 days.

OUTCOME MEASURES

Absolute change in the clinical symptom score (CSS) (with subscores redness, swelling, pain, and secretion) from Day 1 to 4 was measured. As second endpoints, absolute change in CSS, individual subscores, pain perception measured on a visual analog scale (VAS) and intake of paracetamol 500 mg tablets were noted. Moreover, patient's assessment of efficacy at Day 10 and the frequency and type of adverse events were noted.

RESULTS

On Day 4, the CSS showed a clear advantage for the PS group over the glycerol group, being lower by 0.6 (p < 0.03); the clinical outcome was even more pronounced after 10 days (p = 0.006). The swelling subscore showed a statistically significant difference favoring the PS treatment group in Days 1-4 (p = 0.01) and Days 1-10 (p = 0.003). More PS- than glycerol-receiving patients rated the efficacy as good (glycerol: 32%; PS: 36%) or very good (glycerol: 38%; PS: 48%). Males, patients with AOE for >2 days and those with positive microbiologic findings profited most from PS therapy.

CONCLUSION

This study proves that PS is an effective and well-tolerated drug, showing results superior to glycerol, especially in patients with a longer pre-existing condition before therapy. The absence of a group treated with another established antibiotic is a limitation of this trial.

Comparison of steroid antibiotic pack and 10% ichthammol glycerine pack in relieving pain of acute otitis externa in children

OBJECTIVE

This study was carried out with the objective of comparing clinical efficacy of 10% ichthammol glycerine (IG) pack with steroid-antibiotic pack for relieving pain in cases of acute otitis externa.

MATERIALS AND METHODS

A prospective quasi-randomized clinical trial was completely carried out in 65 patients at Department of ENT and Head and Neck Surgery, TU Teaching Hospital, Kathmandu. Patients of less or equal to 12 years of age and both gender presenting in our outpatient department from October 2008 to December 2009 and diagnosed to have acute otitis externa was evaluated. Six patients were excluded from the study because of not meeting the inclusion criteria. Alternately IG and steroid antibiotic packing were done. For steroid antibiotic group, we use betnovate-N, a combination of betnovate sodium phosphate 0.1% and neomycin sulphate 0.5%. Before packing was carried out, pain was assessed using Wong Baker Scale. Statistical analysis was done using "Z" test of mean to compare average number of pain score and visits in two different groups.

RESULTS

There were 33 patients in IG pack group and 32 patients in steroid antibiotic group. In less than 4 years, there were 30 children and in more than 4 years children, there were 35 children. There was male predominance in both the treatment groups and disease was most common in age group less than 4 years. There was statistical significant decrease in number of visits in steroid group in both children less than and more than 4 years. There was also significantly less pain in children with steroid antibiotic group.

CONCLUSION

Use of steroid antibiotic pack in children presenting with acute otitis externa causes earlier relief of pain as well as significantly lesser number of visits. Thus, steroid antibiotic pack is better than 10% ichthammol glycerine packs in relieving pain in acute otitis externa in children.

New information about the polymyxin/colistin class of antibiotics

Infections by multidrug resistant Gram-negative bacilli (MDR-GNB) have become a major threat for patients hospitalized in intensive care units, representing a prevalent cause of morbimortality in the critically ill, since these microorganisms have developed resistance to most available antimicrobial agents. In this respect, very few therapeutic innovations have been developed in recent years, and it is not foreseen that any new drugs will be commercialized in the near future. Tigecycline represents an effective alternative in this setting, but lacks activity against Pseudomonas aeruginosa, and its use has not been validated for all organ-specific infections. Frequently, only old antibiotics like colistin remain a valid option. New pharmaceutical formulations and dosage regimens of polymyxins have considerably reduced the toxicity previously attributed to these antimicrobials, and have made it possible to reintroduce them into clinical practice. Nonetheless, the effectiveness of polymyxins is still suboptimal, and the expansion of heteroresistance and pan-drug-resistant strains of gram-negative bacilli is of concern. Improvements in dosing, alternative methods of administration and different synergic antimicrobial combinations have been proposed in recent literature, among other measures, to enhance the effectiveness of polymyxins. The latest data regarding polymyxins and their clinical use are discussed in this review.

Interventions for acute otitis externa

BACKGROUND

Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops.

OBJECTIVES

To assess the effectiveness of interventions for acute otitis externa.

SEARCH STRATEGY

Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009.

SELECTION CRITERIA

Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible.We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis.

DATA COLLECTION AND ANALYSIS

Two authors assessed eligibility and quality.

MAIN RESULTS

Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta-analyses were possible. The overall quality of studies was low.Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial).In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively).One trial of low quality comparing quinolone with non-quinolone antibiotics did not find any difference in clinical cure rate.No trials evaluated the effectiveness of ear cleaning.Only two trials evaluated steroid-only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks).

AUTHORS' CONCLUSIONS

There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available:Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow-up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid.The evidence for steroid-only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed.Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision.Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated.

Comparison of efficacy and safety of ciprofloxacin otic solution 0.2% versus polymyxin B-neomycin-hydrocortisone in the treatment of acute diffuse otitis externa*

OBJECTIVE

To compare the efficacy and safety of ciprofloxacin otic solution 0.2% to polymyxin B-neomycin-hydrocortisone (PNH) otic solution in the treatment of acute diffuse otitis externa in children, adolescents, and adults.

METHODS

This was a randomized, parallel-group, evaluator-blind, active-controlled, multicenter, noninferiority study. The primary efficacy endpoint was clinical cure of otitis symptoms at the test-of-cure (TOC) visit. Clinical cure at the end-of-treatment (EOT) visit and percentages of patients with clinical improvement and resolution and/or improvement of otalgia at EOT and TOC visits were secondary efficacy endpoints.

RESULTS

A total of 630 patients were randomized to ciprofloxacin twice daily (n = 318) or PNH 3 times daily (n = 312) for 7 days. Ciprofloxacin was shown to be noninferior to PNH. The percentage of patients with clinical cure at the TOC visit was 86.6% with ciprofloxacin and 81.1% with PNH; the treatment difference was 5.6% in favor of ciprofloxacin (95% CI: -0.9 to 12.1). At the EOT visit, clinical cure was achieved in 70.0% and 60.5% of patients, respectively, with a treatment difference in favor of ciprofloxacin (9.5%, 95 CI: 1.2 to 17.9). In all secondary efficacy variables, ciprofloxacin and PNH showed similar results, including pain duration and resolution. The clinical cure rate for patients with baseline cultures showing P. aeruginosa was 87.5% in the ciprofloxacin group and 78.6% in the PNH group, a treatment difference of 8.9% in favor of ciprofloxacin (95% CI: 0.6 to 17.3); for patients with baseline cultures showing S. aureus, the clinical cure rate was 72.7% for the ciprofloxacin group and 75.9% for the PNH group (treatment difference of 3.1% in favor of PNH, 95% CI: -21.1% to 27.4%). Most adverse events were mild and unrelated to study medication in both treatment groups. A limitation of this study is the assessment of signs and symptoms at baseline and after treatment, which does not provide data to evaluate the interim response.

CONCLUSIONS

Ciprofloxacin otic solution 0.2% was found to be noninferior to PNH. This efficacy, good tolerability, and ease of administration make ciprofloxacin otic solution 0.2% without a topical steroid an attractive option for the treatment of acute otitis externa.

Polymyxins: A Review of the Current Status Including Recent Developments

Introduction: Polymyxins have become the drug of choice for treatment of multidrug-resistant gram-negative bacilli infections in Singapore, simply because these pathogens are only susceptible to either aminoglycosides and polymyxins, or polymyxins only. Furthermore, there is no new antibiotic in the pipeline that targets these difficult-to-treat infections. Materials and Methods: All published literatures (up to end of February 2008) regarding polymyxins are included for review. Results: This review serves to give a summary of polymyxins from the current available literature, highlighting relevant clinical studies and information that help to guide informed prescription of polymyxins, should the need arise. Conclusions: However, there are substantial information gaps that needed to be filled urgently, to preserve the clinical utility of this very last line of antibiotic. Key words: Acinetobacter baumannii, Colistin, Multidrug resistance, Polymyxin B, Pseudomonas aeruginosa

Dexamethasone phosphate in antibiotic ear drops for the treatment of acute bacterial otitis externa

OBJECTIVES

To compare the efficacy and safety of polymyxin sulfate 7500 IU/neomycin sulfate 3500 IU/dexamethasone phosphate 0.1% (PN+Dx) otic solution with polymyxin sulfate 7500 IU/neomycin sulfate 3500 IU (PN-Dx) in patients with acute bacterial otitis externa (AOE), in order to determine the possible benefit of the addition of dexamethasone.

RESEARCH DESIGN AND METHODS

Active controlled, double-blind, randomized, parallel group, multi-center clinical trial in ear, nose, and throat (ENT) specialist practices with a planned interim analysis for sample size adaptation. In total, 338 patients aged 18-76 who had a previous episode of otitis externa within the last year were randomized to receive 10 +/- 2 days of treatment with two drops, three times daily, of either PN+Dx or PN-Dx.

MAIN OUTCOME MEASURES

Change in the clinical symptom score (consisting of the subscores redness, swelling, pain, and secretion) and of the visual analogue scale (VAS) rating for pain from Visit 1 (Day 1) to Visit 2 (Day 4 +/- 1), patient's assessment of efficacy at Visit 3 (Day 10 +/- 2), and the frequency and type of adverse events.

RESULTS

There was a significantly greater reduction of swelling from Visit 1 to Visit 2 with PN+Dx, and more patients rated the efficacy of PN+Dx as 'very good' or 'good' at Visit 3 (p = 0.03). There was also a significantly greater decrease in the clinical symptom score from Visit 1 to Visit 2 in the PN+Dx group in patients who had at least a moderately severe symptom score with more than seven points at Visit 1 (p = 0.01) and in patients suffering from their current episode of otitis externa for more than 2 days (p = 0.02). In total, 14 adverse events were reported during the study period with no related adverse drug reactions for PN+Dx.

CONCLUSIONS

The addition of dexamethasone phosphate to polymyxin B/neomycin significantly reduces swelling in patients with AOE and leads to significantly higher patient's ratings of treatment efficacy. It especially leads to an overall reduction of symptoms in cases of moderately or more severe otitis externa and cases lasting for more than 2 days.

A double-blind randomised clinical trial of the treatment of otitis externa using topical steroid alone versus topical steroid-antibiotic therapy

The objective of the study was to determine if the addition of topical antibiotic increases the efficacy of topical steroid in controlling otitis externa. A double-blind randomised controlled trial was performed from February 2003 to April 2005 in an otolaryngology emergency clinic (acute urban teaching hospital) in the United Kingdom. Patients were followed up for 2 weeks. Forty-five adults with otitis externa based on the presence of oedema, discharge or debris in the outer ear canal were recruited. The patients were randomised to one of the two treatment groups, namely using betamethasone sodium phosphate 0.1% (Vista-Methasone) or betamethasone sodium phosphate 0.1% with neomycin sulphate 0.5% (Vista-Methasone N), and were instructed to use the trial medication at three drops three times a day for 2 weeks. Subjects' visual analogue symptom scores (blockage, pain, discharge, and itching) for otitis externa pre-treatment (day 0) and post-treatment (day 15), percentage changes in visual analogue symptom scores as a result of treatment, proportion of patients whose symptom scores failed to improve or deteriorated on treatment were analysed. The two experimental arms demonstrated statistically similar presenting symptom scores at recruitment (mean symptom scores of 19.2 for betamethasone group and 28.7 for betamethasone-neomycin group). The mean symptom score change in response to treatment was 82.8 and 47.8% in the betamethasone-neomycin and betamethasone-alone groups, respectively. There was no statistically significant difference between the groups in median percentage symptom score change in response to treatment. All patients in the betamethasone-neomycin group showed symptom improvement but in the betamethasone alone group, five patients got worse (Fishers exact, P = 0.05). Topical antibiotic-steroid combination therapy is superior to steroid-alone treatment for symptomatic control of otitis externa.

Polymyxin B: similarities to and differences from colistin (polymyxin E)

Hospital-acquired infections due to multidrug-resistant gram-negative bacteria constitute major health problems, since the medical community is continuously running out of available effective antibiotics and no new agents are in the pipeline. Polymyxins, a group of antibacterials that were discovered during the late 1940s, represent some of the last treatment options for these infections. Only two polymyxins are available commercially, polymyxin E (colistin) and polymyxin B. Although several reviews have been published recently regarding colistin, no review has focused on the similarities and differences between polymyxin B and colistin. These two medications have many similarities with respect to mechanism of action, antimicrobial spectrum, clinical uses and toxicity. However, they also differ in several aspects, including chemical structure, formulation, potency, dosage and pharmacokinetic properties.

A comparison of ciprofloxacin/dexamethasone with neomycin/polymyxin/hydrocortisone for otitis externa pain

Ciprofloxacin 0.3%/dexamethasone 0.1% (CIP/DEX) and neomycin 0.35%(polymyxin B 10,000 IU/mL/hydrocortisone 1.0% (NPH) were compared for relief of pain in patients with acute otitis externa. Patients received 7 d of treatment with CIP/DEX twice daily or NPH 3 times daily. Ear pain was assessed by patients/caregivers twice daily and by the study investigator on days 3, 8, and 18 (4-point scale). Higher percentages of CIP/DEX-treated patients had relief of severe pain over time (P=.0013) and relief of significant pain (moderate or severe pain) over time (P=.0456), compared with NPH-treated patients. The percentage of CIP/DEXtreated patients with severe pain decreased rapidly within the first 12 h; this contrasted with an increase in pain among NPH-treated patients. CIP/DEX-treated patients had significantly less inflammation (P=.0043) and edema (P=.0148) than NPH-treated patients. Overall, these results support greater pain relief attained over the first 3 d in patients with acute otitis externa treated with CIP/DEX compared with NPH and a rapid reduction in severe pain after initiation of treatment.