Which systemic antibiotics are used for treatment of malignant otitis externa (MEO)?

Updated: Apr 13, 2020
  • Author: Brian Nussenbaum, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Until the development of third-generation antipseudomonal cephalosporins, long-term intravenous antibiotics using an antipseudomonal penicillin and aminoglycoside were the mainstay of medical treatment.

Several authors have demonstrated the effectiveness of intravenous ceftazidime monotherapy in the treatment of malignant external otitis (MEO).

Fluoroquinolones that attain high soft tissue and bone levels with oral doses were then developed. Subsequently, several authors have demonstrated the efficacy of oral ciprofloxacin monotherapy.

Although no established treatment guidelines are available, case series and anecdotal experience suggest that initial outpatient therapy with oral ciprofloxacin is efficacious for patients without a fluoroquinolone allergy, cranial neuropathy, or intracranial complication and who do not require hospital admission for diabetes or pain management.

The widespread use of fluoroquinolones for upper respiratory infections and simpler ear infections is beginning to confound the typical clinical spectrum of malignant external otitis (MEO). Ciprofloxacin-resistant P aeruginosa has been increasingly isolated in patients with malignant external otitis (MEO), accounting for as many as 33% of isolates in patients who failed outpatient management in a study by Berenholz et al. [20] Most notably in this patient population, 63% of isolates from 1998-2001 were resistant to ciprofloxacin, whereas only 15% of isolates were found to be resistant in the 10 years before this 3-year period. No increased morbidity or mortality was found in patients with ciprofloxacin-resistant Pseudomonas. Patients with resistant P aeruginosa require parenteral antibiotics with antipseudomonal beta-lactam antibiotics with or without an aminoglycoside.

A retrospective study by Carlton et al indicated that as rising antimicrobial resistance complicates treatment for malignant external otitis (MEO), multidrug and long-term parenteral antibiotic therapy with extended inhospital treatment are needed in select cases. [21]

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