This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Web of Science (8) Citing Articles via Google Scholar Google Scholar Articles by Schrader, N. Articles by Isaacson, G. Search for Related Content PubMed PubMed Citation Articles by Schrader, N. Articles by Isaacson, G. Related Collections Miscellaneous Related AAP Red Book topics: Fungal Diseases Social Bookmarking                         What's this?

PEDIATRICS Vol. 111 No. 5 May 2003, pp. 1123

Fungal Otitis Externa—Its Association With Fluoroquinolone Eardrops

To the Editor.—

The value of ototopical antimicrobials in the treatment of otorrhea has been debated for years.¹ Several recent articles have suggested that fluoroquinolone eardrops have the correct antimicrobial profile to treat posttympanostomy tube otorrhea and otitis externa in children.² Studies showing a lack of ototoxicity and efficacy similar to oral amoxicillin-clavulanate led the Food and Drug Administration to approve ofloxacin for treatment of otitis externa and tube otorrhea in children. Several authors have advocated the use of fluoroquinolone drops as first-line therapy for these indications,^3,4 and the pharmaceutical companies have responded with vigorous advertising campaigns for ofloxacin⁵ and ciprofloxacin drops. Little has been written about the potential complications from the widespread use of these very broad-spectrum agents.

During the summer of 2002, we noted a marked increase in the occurrence of fungal otitis externa in young children. Typically we treat 3 to 5 children for this infection each year. During that summer, some days several children would present with typical symptoms of clogged, itchy, or painful ears and thick fungal debris in the external auditory canals (Fig 1). We reviewed the records of 18 consecutive children with this presentation. Eleven of these had culture-proven fungal otitis externa (10 Candida albicans, 1 Aspergillus sp), 4 grew bacterial contaminants but no fungus, and 3 were not cultured or the culture was lost. Among lost children with fungal otitis externa, all had been treated with ofloxacin or ciprofloxacin. Most of the fungal infections were successfully treated with thorough cleaning under the operating microscope and application of topical clotrimazole solution. Several needed multiple treatments for control. Two required systemic antifungal therapy (fluconazole orally for 7 days). One has active fungal disease that has defied both topical and systemic therapies.

View larger version (105K): [in this window] [in a new window]   Fig 1. Extruded tympanostomy tube covered with debris from Candida albicans.

 
Secondary fungal overgrowth is a well-recognized complication of broad-spectrum antibacterial agents. It is usually controlled by debridement, recovery of skin integrity, topical or systemic antifungal agents, and, most importantly, the discontinuation of antibacterial agents.⁶ Fungal otitis externa is mentioned in the Floxin package insert as a possible complication. We have found a marked increase in the occurrence of this problem that seems correlated with growing enthusiasm for the use of topical quinolones. In several cases, primary physicians treated apparent fungal otitis by the application of more quinolone drops and/or oral antibiotics, increasing the intensity of symptoms. While usually a local problem, fungal skin infections can be difficult to clear once established. Pediatricians should be aware of this complication, understand the value of culturing the external auditory canal for diagnosis, and consider referral of children with refractory infections to an otolaryngologist for thorough debridement under an operating microscope.

Nicole Schrader, MD
Glenn Isaacson, MD
Department of Otolaryngology-Head and Neck Surgery
Temple University School of Medicine
Philadelphia, PA 19140

REFERENCES

1. Myer CM III. Treatment of otorrhea. Pediatr Infect Dis J.2001; 20 :466 –467[Medline]

2. Dohar JE, Garner ET, Nielsen RW, Biel MA, Seidlin M. Topical ofloxacin treatment of otorrhea in children with tympanostomy tubes. Arch Otolaryngol Head Neck Surg.1999; 125 :537 –545[Abstract/Free Full Text]

3. Ramsey AM. Related diagnosis and treatment of the child with a draining ear. J Pediatr Health Care.2002; 16 :161 –169[Medline]

4. Klein JO, McCracken GH Jr. The use of topical ofloxacin for otic diseases in infants and children. Summary and conclusions. Pediatr Infect Dis J.2001; 20 :123 –125[Medline]

5. http://www.floxinotic.com/

6. Cohen SR, Thompson JW. Otitic candidiasis in children: an evaluation of the problem and effectiveness of ketoconazole in 10 patients. Ann Otol Rhinol Laryngol.1990; 99(6, pt 1) :427 –431[Medline]

---

PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Web of Science (8) Citing Articles via Google Scholar Google Scholar Articles by Schrader, N. Articles by Isaacson, G. Search for Related Content PubMed PubMed Citation Articles by Schrader, N. Articles by Isaacson, G. Related Collections Miscellaneous Related AAP Red Book topics: Fungal Diseases Social Bookmarking                         What's this?