What is the treatment for an adult with an ear infection and purulent drainage?

Treatment of Adult Ear Infection with Purulent Drainage

For adult ear infections with purulent drainage (acute otitis externa), the first-line treatment is topical antibiotic therapy rather than systemic antibiotics. 1

Diagnosis and Assessment

• Acute otitis externa (AOE) is a cellulitis of the ear canal skin and subdermis with acute inflammation and variable edema
• Nearly all (98%) AOE in North America is bacterial, with the most common pathogens being:
  • Pseudomonas aeruginosa (20%-60%)
  • Staphylococcus aureus (10%-70%)
  • Often occurring as polymicrobial infections

Treatment Algorithm

Step 1: Assess for Modifying Factors

Before initiating treatment, assess for factors that modify management 1:

• Non-intact tympanic membrane
• Presence of tympanostomy tube
• Diabetes
• Immunocompromised state
• Prior radiotherapy

Step 2: Pain Management

• Assess pain severity and recommend appropriate analgesics 1
• Options include:
  • Acetaminophen or ibuprofen for systemic relief
  • Topical analgesics for faster relief (within 10-30 minutes)

Step 3: Topical Therapy

• Topical antibiotic therapy is the treatment of choice for uncomplicated AOE
• Clean the ear canal of debris before administering drops
• Common topical options:
  • Ofloxacin drops
  • Ciprofloxacin-dexamethasone drops
  • Other antibiotic drops with or without steroids

Step 4: Avoid Systemic Antibiotics

• Systemic antimicrobials should NOT be prescribed as initial therapy for diffuse, uncomplicated AOE 1
• Exceptions where systemic antibiotics may be warranted:
  • Extension of infection outside the ear canal
  • Specific host factors (severe diabetes, immunocompromised state)

Step 5: For Complicated Cases or Treatment Failures

• If no improvement after 48-72 hours, consider:
  • Alternative topical antibiotics
  • Systemic antibiotics if infection has spread beyond the ear canal
  • Ceftriaxone (IM) may be considered for severe cases or when oral therapy fails 2

Special Considerations

For Patients with Tympanostomy Tubes

• Topical antibiotic drops are preferred over oral antibiotics 3
• Avoid aminoglycoside-containing eardrops due to risk of ototoxicity
• Limit topical therapy to a single course of no more than 10 days

For Immunocompromised Patients

• Consider broader spectrum antibiotics and possibly systemic therapy
• More frequent follow-up may be needed
• Lower threshold for specialist referral

Common Pitfalls to Avoid

1. Prescribing systemic antibiotics unnecessarily - Topical therapy is more effective and reduces risk of systemic side effects and antibiotic resistance
2. Failing to clean the ear canal - Debris can prevent topical medications from reaching infected tissue
3. Not addressing pain adequately - Pain management is a critical component of treatment
4. Missing underlying conditions - Diabetes and immunocompromised states can complicate treatment and require modified approaches
5. Prolonged use of topical antibiotics - Limit therapy to 7-10 days to prevent fungal superinfection

By following this evidence-based approach, most adult ear infections with purulent drainage can be effectively treated while minimizing unnecessary antibiotic use and potential complications.