Managing Acute Otitis Externa: The Latest Guidelines

Gordon H. Sun, MD, MS


March 02, 2016

When to Use Oral Antibiotics

The AAO-HNSF clinical practice guideline on AOE unequivocally states that ototopical medications, and not systemic antibiotics, should be initial therapy for uncomplicated AOE.[3] Two randomized controlled trials demonstrated no additional clinical benefit with the addition of an oral antibiotic to an ototopical therapeutic regimen for AOE.[21,22] Oral antibiotics have numerous well-documented adverse effects, ranging from rashes and allergic reactions to development of bacterial resistance. The AAO-HNSF guidelines on AOE also mention that the efficacy of numerous non-antibiotic ototopical medications was another argument against the use of oral antibiotics for routine, uncomplicated AOE.[3] Of interest, in spite of the evidence against the use of oral antibiotics for uncomplicated AOE, the rate of oral antibiotic use in US ambulatory care centers actually increased from 21.7% to 30.5% after publication of the initial version of the AAO-HNSF guideline on AOE in 2006.[23]

There are several specific situations in which systemic antibiotic therapy can serve as an effective adjunct to ototopical therapy for AOE.[3,4,24] If prescribed, systemic antibiotics should adequately cover such common AOE pathogens as P aeruginosa and Staphylococcus aureus. These specific situations include the following:

  • Uncontrolled diabetes;

  • HIV infection, AIDS, or other conditions that can impair immune responses;

  • History of localized radiation therapy;

  • Infection extending outside the external auditory canal;

  • Active otologic complications such as osteitis, localized abscess, middle ear disease, or recurrent, persistent infections; and

  • Inability to effectively deliver topical antibiotics.

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