What are the recommended antibiotic drops for Acute Otitis Media (AOM) with perforation?

Antibiotic Drops for Acute Otitis Media with Perforation

For acute otitis media (AOM) with tympanic membrane perforation, ofloxacin 0.3% otic solution is the recommended antibiotic drop treatment, administered as 5-10 drops twice daily for 10-14 days depending on patient age. 1

Recommended Antibiotic Drops

• Ofloxacin 0.3% otic solution is FDA-approved for use in patients with non-intact tympanic membranes, making it the first-line choice for AOM with perforation 1, 2
• Dosing recommendations for ofloxacin otic solution:
  • For children 1-12 years old: Five drops (0.25 mL) instilled into the affected ear twice daily for ten days 1
  • For patients 12 years and older: Ten drops (0.5 mL) instilled into the affected ear twice daily for fourteen days 1

Administration Technique

• Warm the solution by holding the bottle in hand for 1-2 minutes to avoid dizziness from instilling cold solution 1
• Position patient with affected ear upward before instilling drops 1
• After instillation, pump the tragus 4 times by pushing inward to facilitate penetration of drops into the middle ear 1
• Maintain this position for five minutes 1
• Repeat for opposite ear if necessary 1

Advantages of Topical Treatment for Perforated AOM

• Topical administration produces very high concentrations of antibiotic directly in the ear, broadening the spectrum of activity against common ear pathogens 2
• Ofloxacin otic solution avoids systemic side effects associated with oral antibiotics 2
• Clinical cure rates of 75-91% have been demonstrated for ofloxacin otic solution in treating otitis media with perforated tympanic membranes 2
• Unlike some other ototopical preparations, ofloxacin has not shown ototoxicity in clinical studies 2

Important Considerations

• When the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube, a non-ototoxic topical preparation should be prescribed 3
• Avoid aminoglycoside-containing drops (such as neomycin) in patients with perforations due to potential ototoxicity 3
• For severe external auditory canal edema where drop penetration may be difficult, consider placing a wick to facilitate drug delivery 3
• If the ear canal is too swollen to visualize the tympanic membrane or allow drops to enter, consider systemic antibiotics until the swelling subsides enough for topical therapy 3

Alternative Approaches

• If topical therapy fails or is not feasible, oral antibiotics may be considered:
  • Amoxicillin (80-90 mg/kg/day divided in 2 doses) is the first-line oral antibiotic for AOM 4, 5
  • For patients who have taken amoxicillin in the previous 30 days or require coverage for beta-lactamase producing organisms, amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) is recommended 5
  • For penicillin-allergic patients, cefdinir, cefpodoxime, or cefuroxime can be used 4, 5

Follow-up Recommendations

• If symptoms worsen or fail to improve within 48-72 hours of initial treatment, reassess the patient to confirm diagnosis 4, 5
• Signs of treatment failure include worsening condition, persistence of symptoms beyond 48 hours after starting treatment, and recurrence within 4 days of completing treatment 4, 6
• For treatment failures, consider culture and susceptibility testing if possible 5

Remember that proper diagnosis and treatment of AOM with perforation is essential to prevent progression to chronic suppurative otitis media and potential long-term complications affecting hearing and quality of life.