Is ofloxacin (a fluoroquinolone antibiotic) effective in treating otitis media when used in combination with Augmentin (amoxicillin/clavulanate) oral antibiotics?

Ofloxacin and Augmentin Combination for Otitis Media

Topical ofloxacin is effective for treating otitis media with tympanic membrane perforation or tympanostomy tubes, but combining it with oral Augmentin is not recommended as standard practice for uncomplicated acute otitis media. 1

Appropriate Use of Ofloxacin in Otitis Media

• Topical ofloxacin (0.3% otic solution) is approved for use in patients with non-intact tympanic membranes, making it valuable for treating otitis media in patients with tympanostomy tubes or perforations 2
• Ofloxacin otic solution produces very high concentrations in the ear, providing broad-spectrum coverage against common ear pathogens 2
• For acute tympanostomy tube otorrhea (TTO), topical antibiotic therapy with agents like ofloxacin is superior to systemic antibiotics alone, with clinical cure rates of 77-96% versus 30-67% with systemic antibiotics 1
• Topical ofloxacin has been shown to be effective in treating chronic suppurative otitis media with a 76% success rate compared to only 26% with oral Augmentin alone 3

First-Line Treatment for Acute Otitis Media

• For uncomplicated acute otitis media without perforation, high-dose amoxicillin (80-90 mg/kg/day) remains the first-line treatment due to its effectiveness, safety, low cost, and narrow spectrum 1
• In children who have taken amoxicillin in the previous 30 days, those with concurrent conjunctivitis, or when coverage for M. catarrhalis is desired, high-dose amoxicillin-clavulanate should be used as initial therapy 1
• Amoxicillin-clavulanate should be dosed at 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate (14:1 ratio) in 2 divided doses to minimize diarrhea 1
• Fluoroquinolones (including ofloxacin) are not recommended as first-line therapy for uncomplicated acute otitis media 1, 4

When to Consider Ofloxacin with Augmentin

• The combination of topical ofloxacin with oral antibiotics may be considered in specific scenarios:
  • Severe cases of acute otitis media with tympanic membrane perforation 1
  • Treatment failures after initial appropriate antibiotic therapy 1
  • Chronic suppurative otitis media with persistent drainage 5
• When systemic symptoms are present alongside otitis media with perforation or tympanostomy tubes, combination therapy may be warranted 1

Treatment Algorithm

1. For uncomplicated acute otitis media without perforation:

   • First-line: High-dose amoxicillin (80-90 mg/kg/day) 1
   • If recent amoxicillin use (within 30 days): High-dose amoxicillin-clavulanate 1

2. For otitis media with tympanostomy tubes or perforation:

   • First-line: Topical ofloxacin alone 1, 2
   • Add systemic antibiotics (like Augmentin) only if:
     • Cellulitis of the pinna or adjacent skin is present
     • Concurrent bacterial infection exists elsewhere
     • Signs of severe infection are present
     • Topical therapy fails 1

3. For treatment failures after 72 hours:

   • If initial treatment was amoxicillin: Switch to amoxicillin-clavulanate 1
   • If initial treatment was amoxicillin-clavulanate: Consider ceftriaxone or clindamycin 1
   • For persistent drainage with tympanostomy tubes: Consider topical ofloxacin 1, 2

Clinical Considerations and Pitfalls

• Fluoroquinolones like ofloxacin should be used judiciously to prevent development of antimicrobial resistance 1, 4
• Topical ofloxacin is not ototoxic, unlike some other otic preparations containing aminoglycosides, making it safer for use with non-intact tympanic membranes 2
• Systemic fluoroquinolones have limited activity against some strains of Streptococcus pneumoniae, a common pathogen in acute otitis media 4
• The ear canal should be cleaned of debris before administering topical drops to ensure the medication reaches the middle ear space 1
• Common adverse events with topical ofloxacin include bitter taste (5%, primarily in patients with non-intact tympanic membranes) and pruritus (2%) 2
• Failing to distinguish between otitis externa (where topical therapy is appropriate) and uncomplicated acute otitis media (where systemic therapy is typically indicated) can lead to inappropriate antibiotic selection 4