April 24, 2017

How Much Better are Antibiotic Ear Drops Compared to Oral Antibiotics?

Antibiotic ear drops deliver vastly higher amounts of antibiotics compared to oral and even IV antibiotics. There is no comparison. It is literally 300 times better than oral antibiotics. The catch is that the ear drops need to get down to where the infection is in order to work, whether into the ear canal (if dealing with otitis externa or swimmer's ear) or through a hole or tube in the eardrum (if dealing with otitis media).

(Watch video below to see how to properly administer ear drops for maximal effectiveness.)

For example, two of the most common ear drops prescribed are 0.3% ofloxacin (Floxin) drops and Ciprodex which both contain 3000 mcg/ml of antibiotics. Cortisporin drops contain 3500 mcg/ml of antibiotic.

Compare these middle ear concentrations with that found with oral antibiotics after ingestion.

• Amoxicillin with an oral dose of 90 mg/kg resulted in middle ear concentration of 6-10 mcg/ml
• Cefuroxime at 500mg resulted in 2-4 mcg/ml
• Clarithromycin at 500mg resulted in 2-5 mcg/ml

Even IV antibiotics deliver lower concentrations of antibiotics compared to the ear drops:

• Ceftriaxone (35 mcg/ml)

Indeed, a 2017 meta-analysis determined that antibiotic ear drops resolved ear infections more often and effectively than oral antibiotics.

However, oral antibiotics may still be helpful in those situations where the ear drops may have trouble penetrating to the source of the ear infection. Such situations include when the ear drainage is so copious that the ear drops are not getting down to the middle ear effectively, even with tragal pumping. As such, in these situations, a few days of oral antibiotics in combination with ear drops may work better than either oral or ear drops by itself. But before resorting to oral antibiotics, I typically recommend patients to try tissue spearing first to help remove ear drainage prior to ear drops.

Beyond concentration, there are other advantages of topical ear drops over oral antibiotics including avoidance of systemic side effects, especially nausea and diarrhea as well as much lower risk of multi-drug resistance infections.

In order to maximize antibiotic ear drop effectiveness,

• Remove as much of the ear drainage as possible prior to ear drop usage (typically, one can roll up a corner of a tissue and stick in the ear canal to soak up as much drainage as possible, also known as tissue spearing.)
• Perform tragal pumping after ear drop administration to try and "push" the ear drops as deeply into the ear canal as possible. Tragal pumping is performed by pressing the tragus against the opening of the ear canal repeatedly several times.
• Should the ear canal be swollen shut as found in swimmer's ear or otitis externa, place an ear wick (a small sponge) first so that any ear drops placed can be wicked down past the swollen ear canal skin. Occasionally, a single dose of steroids can be very helpful to reduce the ear canal swelling (and pain) quickly.

Prevention and Treatment of Tympanostomy Tube Otorrhea: A Meta-analysis. Pediatrics. Vol. 139, Issue 6, 1 Jun 2017

Ototopical Antibiotics. Medscape 11/29/16.

Clinical and pharmacokinetic basis for the antimicrobial treatment of acute otitis media. Otolaryngol Clin North Am. 1991 Aug;24(4):859-75.

The chinchilla microdialysis model for the study of antibiotic distribution to middle ear fluid. AAPS J. 2006 Feb 3;8(1):E41-7.

Microdialysis studies of the distribution of antibiotics into chinchilla middle ear fluid. Pharmacotherapy. 2005 Dec;25(12 Pt 2):140S-145S.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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