What to do if an ear treated with cipro (ciprofloxacin) for otitis externa still looks wet?

Management of Persistent Wetness in Ear Treated with Ciprofloxacin for Otitis Externa

The wet appearance likely represents persistent drainage that requires mechanical cleaning of the ear canal to improve drug delivery, and you should ensure proper administration technique with tragal pumping is being used. 1

Immediate Assessment Steps

First, determine if the "wet" appearance is from:

• Persistent otorrhea (drainage from infection)
• Accumulated debris or cerumen blocking medication penetration
• Medication pooling without proper absorption
• Treatment failure requiring escalation 1

The ear canal should be examined to identify obstructing debris, as topical therapy cannot be effective if the drug cannot reach the infected tissues. 1

Essential Cleaning and Drug Delivery Optimization

Perform aural toilet to remove obstructing material: 1

• Gently clean the ear canal opening by blotting with cotton-tipped swabs
• Remove visible secretions using an infant nasal aspirator for gentle suction
• Clean any dry crust or adherent discharge with a cotton-tipped swab dipped in hydrogen peroxide or warm water 1, 2
• For persistent debris, suction through an open otoscope head or use binocular microscope visualization (may require referral) 1

Verify proper administration technique: 1, 2

• Patient must lie with affected ear upward
• Fill the ear canal completely with drops
• Pump the tragus 4 times after instilling drops to facilitate penetration 2
• Maintain position for 3-5 minutes (use a timer for compliance) 1
• Have someone else administer drops when possible, as only 40% of patients self-administer correctly 1

Consider Wick Placement

Place an ear wick if: 1

• Significant canal edema prevents drop entry
• Most of the tympanic membrane cannot be visualized
• Debris removal alone doesn't improve drug delivery

Use compressed cellulose wick (expands with moisture) rather than cotton balls which can fragment. 1 The wick may fall out spontaneously within 24 hours to a few days as edema subsides, which indicates improvement. 1, 3

Timeline for Expected Improvement

Patients should experience improvement within 48-72 hours of starting appropriate therapy. 2, 3, 4 If drainage persists beyond 7 days despite proper technique and cleaning, this indicates treatment failure. 2, 4

When to Escalate Treatment

Add or switch to systemic antibiotics if: 1

• Cellulitis of the pinna or adjacent skin is present
• Signs of severe infection exist (high fever, severe otalgia, toxic appearance)
• Otitis externa persists or worsens despite topical therapy with proper administration
• Severe canal edema prevents adequate aural toilet or wick placement 1

Consider culture if: 1

• Persistent drainage despite topical therapy
• Need to detect resistant organisms (MRSA, fungi)
• However, most culture results identify organisms susceptible to topical quinolones 1

Critical Pitfalls to Avoid

• Failing to clean the canal before drops: Debris blocks medication from reaching infection site 1, 2
• Not using tragal pumping technique: Essential for drug penetration 2
• Stopping treatment when symptoms improve: Must complete full 7-day course to prevent relapse 3
• Assuming treatment failure too early: Allow 48-72 hours for response 2, 3
• Not keeping ear dry: Water entry during active infection impairs healing 1

Special Considerations

For diabetic or immunocompromised patients: 1

• Avoid aggressive irrigation with tap water (risk factor for malignant otitis externa)
• Use atraumatic cleaning with aural suctioning under microscopic guidance
• Have lower threshold for systemic antibiotics

Prolonged quinolone use (>10 days) may induce fungal external otitis, so limit topical therapy to a single course of no more than 10 days. 1