Is cefexime (oral cephalosporin antibiotic) and ofloxacin (fluoroquinolone antibiotic) an effective treatment for a patient with acute otitis externa (swimmer's ear)?

Cefixime and Ofloxacin for Swimmer's Ear

Neither cefixime nor oral ofloxacin should be used for uncomplicated acute otitis externa (swimmer's ear)—topical ofloxacin 0.3% otic solution is the appropriate treatment, not oral antibiotics. 1

Why Oral Antibiotics Are Inappropriate

• Topical therapy is the definitive first-line treatment for uncomplicated acute otitis externa, achieving clinical cure rates of 65-90% within 7-10 days, while oral antibiotics should NOT be prescribed as initial therapy. 1

• Topical antibiotics deliver drug concentrations 100-1000 times higher than systemic therapy at the infection site and demonstrate superior outcomes compared to oral antibiotics, with clinical cure rates of 77-96% versus only 30-67% for oral therapy. 1

• Approximately 20-40% of patients inappropriately receive oral antibiotics for acute otitis externa, and most oral antibiotics prescribed are inactive against the primary pathogens Pseudomonas aeruginosa and Staphylococcus aureus, which cause 98% of cases. 1, 2

Why Cefixime Specifically Is Wrong

• Cefixime is a third-generation oral cephalosporin that is inactive against Pseudomonas aeruginosa, the most common pathogen in swimmer's ear (isolated in 62% of cases). 3, 4

• French guidelines explicitly state that cefixime is "not recommended" for infections where Pseudomonas coverage is needed. 3

The Correct Treatment: Topical Ofloxacin

Prescribe ofloxacin 0.3% otic solution: 10 drops once daily for 7 days (5 drops for children 6 months to <13 years). 1, 4

Why Topical Ofloxacin Is Optimal

• Provides excellent coverage against both P. aeruginosa (62% of cases) and S. aureus (13% of cases), with 96% bacterial eradication rates. 2, 4

• Non-ototoxic, making it safe even when tympanic membrane integrity is uncertain or compromised—unlike aminoglycoside-containing drops. 1, 5

• Achieves 91% clinical cure rate with once-daily dosing for 7 days, with 68% of patients cured within the first week. 4

• Superior adherence compared to multiple-daily-dosing regimens, with mean adherence of 98% in clinical trials. 4

Essential Treatment Steps

Before Administering Drops

• Clean the ear canal of debris, cerumen, and inflammatory material using gentle suction, dry mopping, or irrigation to ensure medication reaches infected tissues. 1

• Consider placing a compressed cellulose wick if severe edema prevents drop entry or if the tympanic membrane cannot be visualized. 1

Proper Drop Administration

• Warm the bottle in hands for 1-2 minutes to prevent dizziness. 1
• Have someone else administer drops if possible (only 40% of patients self-administer correctly). 1
• Lie with affected ear upward, fill canal completely with drops, maintain position for 3-5 minutes. 1
• Apply gentle to-and-fro movement of pinna or tragal pumping to eliminate trapped air. 1

Pain Management

• Prescribe acetaminophen 650-1000 mg every 6 hours or ibuprofen 400-600 mg every 6 hours for mild-to-moderate pain. 2
• Pain typically improves within 48-72 hours of starting topical therapy. 1, 2

When Oral Antibiotics ARE Indicated

Reserve systemic antibiotics (oral fluoroquinolones like ciprofloxacin, NOT cefixime) for these specific situations only: 1

• Extension of infection beyond the ear canal (periauricular cellulitis)
• Diabetes mellitus or immunocompromised status
• Topical therapy cannot reach the infected area
• Treatment failure after 48-72 hours of appropriate topical therapy

If oral antibiotics are needed, use ciprofloxacin 500 mg twice daily (provides Pseudomonas coverage), never cefixime. 1

Activity Restrictions

• Keep the ear dry during treatment—no swimming or water exposure until infection resolves. 2
• Cover ear canal with earplug or petroleum jelly-coated cotton before showering. 1
• Avoid inserting cotton swabs or any objects into the ear canal. 1

Reassessment Criteria

• Reassess if no improvement within 48-72 hours of starting treatment. 1, 2
• Continue drops until symptom resolution for maximum of 7 additional days (14 days total maximum). 1

Causes of Treatment Failure

• Inadequate drug delivery due to canal obstruction
• Poor adherence to therapy
• Fungal co-infection (especially in diabetics)
• Allergic contact dermatitis from topical agents
• Incorrect diagnosis 1

Critical Pitfalls to Avoid

• Never prescribe oral antibiotics for uncomplicated acute otitis externa—this represents inappropriate antibiotic stewardship. 1
• Never use cefixime for swimmer's ear—it lacks Pseudomonas coverage. 3
• Never use aminoglycoside-containing drops when tympanic membrane integrity is uncertain. 1
• Never fail to clean the ear canal before administering drops. 1
• Never undertreat pain—prescribe appropriate analgesics from the start. 1, 2