Thanks so much for the excellent review of otitis externa by James Roberts, MD. (EMN 2019;41:17; http://bit.ly/2tsAPLw.) I always look forward to your articles in EMN.
Given that this condition is basically a cellulitis and we so easily prescribe a course of oral antibiotics for that, why not follow suit with this condition? My concern here is price. As you said, a bottle of Ciprodex can be $250-$300, while a course of Augmentin is about $15. You mentioned that oral antibiotics have “adverse effects, can generate resistant organisms, and seem to be associated with recurrence.”
Can you elaborate on the recurrence part? A $15 course of orals just seems like a far better option to me, and I am confused why we still recommend a $250 topical.
I know Cipro otic without steroid is far cheaper in the United Kingdom. Since I learned that, I have been prescribing Cipro ophthalmic 0.3% to be used in the ear for otitis externa. It is available for about one-tenth of the price. I just put on the “sig” to the pharmacist, “yes, I do want them to put it in the ear.” Thoughts?
Jeremy Gabrysch, MD
Dr. Roberts responds: Thanks for the letter. It seems that topicals deliver much higher concentrations of antibiotic to the superficial skin surface where the infection of otitis externa exists, plus topicals don't have systemic effects. Because oral meds don't seem to get concentrated on the skin surface, their presence does not totally eradicate the bugs, so resistance can develop, and the cure is not total, hence recurrence. Maybe I made that up, but at least that makes sense to me. None of the literature I read recommends oral antibiotics for simple otitis externa. Cure rates with topicals are very good plus the diarrhea of Augmentin can be avoided.
Thanks so much for the fantastic suggestion of using ciprofloxacin eye drops for the ear. I was not aware of that use, and although eye drops are not licensed for ear infections, recommendations for such use can be found in the literature. The cost difference between eye and ear ciprofloxacin preparations is gigantic. I agree that it's best to write “OK to use eye drops in the ear” for the pharmacist and to tell the patient, so they don't think you made a mistake. Also, don't forget that the internet has some amazing coupons for almost any medication (simply Google ciprofloxacin), and anyone can join GoodRx.