Antibiotic therapy in necrotising external otitis: case series of 32 patients and review of the literature

Abstract

Necrotising external otitis (NEO) is a rare but severe bone infection, usually due to Pseudomonas aeruginosa, the management of which is not standardised. Systemic antibiotic therapy is usually prescribed for at least 6 weeks, but no review has been published on this topic. We report our experience and have reviewed the literature regarding antibiotic therapy in NEO. Here we describe a case-series of consecutive NEO cases seen over an 8-year period (2004-2011) in a French tertiary-care teaching hospital. Since 2009 we have shortened the duration of antibiotic therapy to 6 weeks. We also present a review of the literature regarding antibiotic therapy in NEO. We include 32 NEO cases, with positive microbiological cultures in 30 cases. Among the 30 patients with suspected or proven P. aeruginosa infections, 27 received an initial combination therapy of ceftazidime and ciprofloxacin. The duration of antibiotic therapy and length of hospital stay were significantly reduced after 2009 (9.4 ± 3.2 weeks versus 5.8 ± 0.7, P < .0.001; and 18.2 ± 8.7 days versus 11.6 ± 6.9, P = .0.03, respectively). Patient outcomes were favorable in all cases, with a 14-month median duration of follow-up. Our literature review (30 case series) shows that initial combination therapy is associated with better outcomes as compared with single therapy (97 % versus 83 %, P < .0.001). We suggest 3 weeks of initial combination therapy (ceftazidime + ciprofloxacin, high doses) followed by 3 weeks single therapy with ciprofloxacin in susceptible P. aeruginosa NEO. A close collaboration between ear, nose and throat and infectious diseases specialists is needed.

Management of Necrotizing Otitis Externa: Our Experience with Forty-Three Patients

“…A French study of 32 cases of necrotizing otitis externa found that mean length of stay (18.2±8.7 vs. 11.6±6.9 days, p=0.03) and duration of antibiotic therapy (9.4±3.2 vs. 5.8±0.7 weeks, p<0.001) were significantly lower after 2009 when a management protocol for necrotizing otitis externa was introduced. This supports our data and our conclusions [9] . Our mortality rate is significantly lower (2.4%) than that of other studies (14.8%), possibly due to the fact that these patients are managed jointly with infectious diseases [5] .…”

“…The most common presenting features found in our study of otalgia and otorrhea are in common with other larger case series and highlight the need for high clinical suspicion in immunocompromised or diabetic patients with these symptoms [9] . Facial nerve palsy was a less common presentation in the group post-intervention, although this was not statistically significant, and may have been due to the fact that post-intervention, there was greater awareness of necrotizing otitis externa, so these patients were managed earlier, before developing complications such as facial nerve palsy.…”

Malignant otitis externa: An assessment of emerging pathogens and the prognostic factors

“…However, conclusive prognostic factors are yet to be identified. The emergence of fluoroquinolonesresistant and multidrug resistant pseudomonas organisms have created difficulty in developing consensus on the optimal choice of antibiotics and duration of therapy (Pulcini et al, 2012;Berenholz et al, 2002). The study found diabetes as the underlying debilitating disease in 53% of the patients, whereas 29% were immune depressed due to HIV infection similar to other reports (Franco-Vidal et al, 2007;Martel et al, 2000).…”

“…The study found diabetes as the underlying debilitating disease in 53% of the patients, whereas 29% were immune depressed due to HIV infection similar to other reports (Franco-Vidal et al, 2007;Martel et al, 2000). However higher diabetic figures of 80 to 95% have been reported (Lee et al, 2011;Loh and Loh, 2013;Pulcini et al, 2012;Chen et al, 2011).…”

“…Malignant otitis external is a relatively uncommon but severe disease of the external auditory canal which has been associated with mortality of 40 to 60% (Lasisi and Nwaorgu, 2001;Lee et al, 2011;Stevens et al, 2015;Kwon et al, 2006). The development of anti-pseudomonal antibiotics such as fluoroquinolones and ceftazidime, has reduced mortality significantly with increasing number of reports indicating better mortality figures at <10% (Franco-Vidal et al, 2007;Pulcini et al, 2012). A number of studies have examined potential prognostic factors such as clinical presentation, imaging findings, microbiology and facial nerve involvement (Lee et al, 2011;Loh and Loh, 2013;Stevens et al, 2015;Kwon et al, 2006;Soudry et al, 2011;Soudry et al, 2007).…”