"The problems of deafness are deeper and more complex, if not more
important than those of blindness. Deafness is a much worse misfortune,
for it means the loss of the most vital stimulus - the sound of voice - that
brings language, sets thoughts astir and keeps us in the intellectual
company of man" (Helen Keller 1880 -1968)
Two studies were carried out concerning ear infections at St. Luke's
Hospital in Malta, between July and November, 1991.peer-reviewe

Attard, Yvette

OAR@UM

THE RATIONAL THERAPY OF EAR INFECTIONS Yvette Attard Introductiun "The problems of deafness are deeper and more complex, if not more important than those of blindness. Deafness is a much worse misfortune, for it means the loss of the most vital stimulus - the sound of voice - that brings language, sets thoughts astir and keeps us in the intellectual company of man" (Helen Keller 1880 -1968) Two studies were carried out concerning ear infections at St. Luke's Hospital in Malta, between July and November, 1991. Aims Surveyl This survey dealt with ear infections in general. Its aims were to find the common infections, patients' age distribution, presenting signs and symptoms, diagnostic techniques used to identify the infections, pathogens and their sensitivity and resistance to antibiotics and drug treatment given. Survey 2 This survey concerned the potentially lethal ear infection Malignant Otitis Externa (MOE). The aims of this survey were to find the patients' age distribution, common presenting signs and symptoms, diagnostic techniques used to identify the infection, pathogens, any correlation between the severity of the disease and control of diabetes mellitus, treatment given and its total cost. The latter includes the cost of drugs used to treat M.O.E., any other drugs required to treat any other conditions suffered by the patient, for example anti-diabetics, antihypertensives, any operations performed and hospital stay. Methodology Surveyl Analysis of patient records over 3 months was performed at the Ear, Nose and Throat clinic of the outpatients' department of St. Luke's Hospital and data collected. 426 Survey 2 This was conducted on patients with M.O.E. who were admitted to the E.N.T. ward. For 5 months, patients' medical records were reviewed on admission and during their stay. A list of the Government's tender prices of the drugs used was obtained from the Government's Medical Stores. The daily cost of a hospital stay and operations' cost were obtained from the Department of Health. Results Survey 1 Types of ear infections This survey was conducted on 67 patients, 38 males and 29 females. The age range was 4 - 77 years, the mean age being 38 years. See Table 1. Table 1: Types of ear infections, their percentage incidence and their most common presenting sign or symptom Ear Infection Chronic suppurative otitis media (CSOM) Chronic diffuse otitis externa (COE) Otitis media with effusion (OME) Acute diffuse otitis externa (AOE) Otomycosis Acute suppurative otitis media (ASOM) Furunculosis Adhesive otitis media 427 Incidence 37.3 28.3 13.4 11.9 11.9 11.9 2.99 2.99 Most common presenting sign or symptom Perforated tympanic membrane Discharge Fluid in middle ear Otalgia Discharge Perforated tympanic membrane Otalgia, furuncle Fibrous exudate. hearing loss Diagnpsis was achieved by means of physical examination of the ear, tuning fork tests, pure tone audiometry, culture and sensitivity tests, histology, X-rays, computerised tomographic (er) scans and surgery. No culture and sensitivity tests were recorded for furunculosis, AOE, ASOM, OME and adhesive otitis media. OtomycosiS was mainly caused by fungi, which were not Candida albicans. The most common pathogen of both COE and CSOM was Pseudomonas aeruginosa. Among the most commonly used topical preparations were Dexamethasone, hydrocortisone, neomycin, sulphate and polymyxin B. Some of the most commonly administered systemic antibiotics were amoxycillin plus clavulanic acid, ampicillin and pseudoephedrine HCl. Survey 2 Malignant Otitis Externa This survey was conducted on 9 patients, 6 males and 3 females, 90% of yearly cases, mean age 68.64 (age .range 52 - 92 years). All patients were diabetics. The oresenting signs and symptoms were recorded. Diagttostic techniques used to identify malignant otitis externa were the same as those used to diagnose other ear infections. The types of organisms found in the affected ear were Pseudomonas aeruginosa, Staphylococcus albus, Proteus, Gram-negative bacilli, Candida albicans and yeasts. No correlation was found between blood glucose-level and the severity of the disease . . The types of antibiotics used were the aminoglycosides, cephalosporins, the penicillins, erythromycin, sulphadiazine, metronidazole and rifampicin, giving a total of eleven combinations. Table 2 shows the different combfnations given to each patient and the total cost of therapy of each patient. Three different therapies-monotherapy with ceftazidime (CEFT), the ciprofloxacin-rifampicin (CIPR-RIF) _combination and the ceftazidime-ciprofloxacin-rifampicin (CEFT-CIPR-RIF) combination were compared with the other drug combination used as treatment of M.E.O. Such tlllerapies were chosen since they include the newest drugs found to be 428 Table 2: The drug therapy and total cost for all the 9 patients with Maligp:mt OtiHs Externa Patient A' B C' D E F G 1-1* Drug Combination Ceftazidime erythromycin gentamicin metronidazole Ceftazidime su Iphad iazine Ceftazidime cephalothin gentamicin metronidazole sulphadiazine Ciprofloxacin rifampicin Ceftazidime ciprofloxacin rifampicin Carbenicillin gentamicin metronidazole Amikacin carbenicillin Azlocillin Ceftazidime Amikacin Ampicillin / cloxacillin Ccftazidimc Gentamicin Metronidazole Ccftazidime Gentamicin Ceftazidime ciprofloxach, rifampicin Azlocillin ccftazidime Length of hospital stay /days 52 21 72 23 15 57 97 49 81 34 72 43 'Patients A, C and 1-1 have more than one drug combination because they were admitted more than once to hospital. 429 Table 3 Patient Cost of Cost of Cost of Cost of Total cost drugs for othcr drugs/Lm operations hospital/Lm treatment of stay/Lm malignant otitis extcrna /Lm A' 282.39 55.04 1.20 3120 3577.43 423.36 27.25 1260 1710.61 1043.17 67.11 4320 5430.28 65.()9 7.76 1380 1452.85 12171.17 B 53.39 3.26 60 900 1016.65 C' 304.75 134.66 60 3420 3919.41 347.94 169.21 5820 6337.15 10256.56 D 7()9.97 31.10 2940 3681.07 E 974.33 77.78 4860 5912.11 F 495.77 14.83 60 2040 2610.60 G 605.48 74.76 4320 5000.24 H' 429.49 24.03 120 2580 3153.52 208.45 11.97 840 1060.42 4213.94 230.88 13.39 60 1560 1864.27 46726.61 ·Patic·nts A, C alid H have more than on total cost of thcrapy because thcy wcre admitted more than once to hospital. All prices in Maltese Lira. 430 ..... '.-J --' Patient Total cost/saving Total cost/saving Total cost/saving if if ceft. used/LM if cipr. rif. ceft. ci pr. rif. combination combination used/LM used/LM A 73:2:7.78 4792.95 5983.75 6186.98 12171.86 -1.13* B 1852.42 308.32 1506.09 1556.93 1016.65 / C 3748.54 6508.51 3044.64 7217.41 6187.06 4069.99 0 1813.98 762,94 1465.53 1110.64 3012.18 -431.58* E 1815.85 4095.55 1467.18 4444.22 3015.33 3229.15 F 1862.22 747.65 1515.12 1094.75 3052.27 -1102.40* G 1835.18 308.32 1484.28 1556.93 5018.98 / H 3728.50 G> 1525.88 2221.28 3033.84 6111.42 -863.16* I 1864.27 / 1516.94 347.33 3055.74 -1191.47* 25898.74 19050.12 21017.37 25731.47 42641.49 3709.40 *The minus sign indicates that losses would have been involved if one of the three particular regimens were used in that case. Table 4: Total cost of treatment and saving of all the 9 patients with malignant otitis externa if the three particular regimens were used effective.in the treatment of the infection. Table 4 shows the total cost of treatment and total savings for all the 9 patients, for each individual when treated with the three particular regimens. Thus the'total savings that would have been involved are: 1) Ceftazidime only: Lm19,050: 12, i.e. 40.8% of the actual total cost of treatment of all the 9 patients (Lm46,726.61) 2) Ciprofloxacin and rifampicin: Lm25,731.47, i.e. 55.1%. 3) Ceftazidime, ciprofloxacin and rifampicin: Lm3,709.40, i.e. 7.94% Alternatively, the savings associal",d with each patient would have been 4.5% if ceftazidime was used, 6.1 % if ciprofloxacin and rifampicin was used and 0.9% if ceftazidime-ciprofloxacin-rifampicin combination was used. Discussion and Conclusions Survey 1: Cases registered shoVvC:u that ear infections can occur in all age groups without preference. The mo~t common infections were found to be CSOM and COE. Had diffuse otitis externa not been divided into acute and chronic stages, the percentage incidence of this infection would be grater than that of CSOM. Some presenting signs and symptoms can be simila.r for the different ear infections. However, other signs and symptoms are specific to a particular infection. Thus diagnostic. techniques are very important for thorough examination of the ear, identification of the signs and symptoms and hence the particular infection and correct treatment. rhe most common pathogen of both· COE and CSOM was Pseudomonas a{!ruginosa. This was also reported in a previous study (Yagi, 1990). Various drugs 'were used in the treatment of ear infections. The antibiotics were prescribed topically, namely in the form of ear drops and creams, the former being much more common, and systemically, namely periorally, intramuscularly and intravenously, periorally being the most common. Topical steroids were also prescribed in combination with topical antibiotics. In fact, the most common topical preparations used wre hydrocortisone, neomycin sulphate, polymyxin B sulphate plus to;naftate drops and dexamethasone, framycetin sulphate and 432 gramicidin drops. The most common systemic antibiotics were amoxycillin plus clavulanic acid, ampicillin and erythromycin. Survey 2: Malignant otitis externa, also termed necrotising otitis externa, is.both an important and interesting clinical entity. It is a potentially lethal disease affecting patients who are usually elderly and diabetic in whom. Pseudomonas .aeruginosa causes an osteomyelitis of the skull base, using the external ear as a port of entry (Sade et aI, 1989). In fact all patients in the study were elderly diabetics and the most common pathogen was Ps. aeruginosa. The microangiopathy of diabetes, specifically microangiopathy of the skin of the external auditory meatus, results in local tissu~ perfusion and creates an environment well suited for invasion by Ps. aeruginosa (Doroghazi et al., 1981). Blood glucose level was not found to be an indication of the severity of the· disease. This was also reported in a previous study (Doroghazi et al" 1981). Prompt diagnosis and correct treatment are very important -to avoid extension of the inflammation and neurological complications. Thus diagnostic techniques are essential for correct diagnosis. Various combinations of antibiotics haye been used in Malta throughout the years, in accordance with the current therapy used in other countries for the disease in question. In the present study, it was found that monotherapy with ceftazidime, the ciprofloxacin-rifampicin. combination and the ceftazidime-ciprofloxacin-rifampicin .combination ate all cost-effective because the total cost of therapy is cheaper than that of the other therapies and the drugs are safer than the others. The most cost-effective therapy was found to be the ciprofloxacin-rifampicin combination, ciprofloxacin being given SOO-7SOmg and rifampicit;\- 600mg, both twice daily and periorally. Using the ciprofloxac\n-rifampicin combination, the disease can be trated without the patient being admitted to hospital or at least for a short period of time for observation. The results given previously are theoretical and could be subject to some change. Malignant otitis externa seems to be more common in Malta than in other countries. This is probably due to the fact that diabetes has a relativley high incidence in Malta (9.8%) compared to other countries (5.2%) 433 (Papoz, 1990) and that Malta has a hot and humid climate, both faCtors being prognostic for M.O.E. The pharmacist has a role in the treatment of ear infections both in the community and at hospital. He/she can give advice on the proper use of ear drops (e.g. 2 or 3 drops should be placed in the affected ear with the head tilted on the other side and kept thus for five minutes to ensure adequate contact of the active ingredients with the infected areas) as this is mandatory for effective treatment of the infection.. At hospital, the pharmacist can ensure that the patients are compliant, that is, they are taking the prescribed drugs appropriately. He/she can also monitor the drug blood levels of patients to whom ototoxic and/or nephrotoxic drugs such as the aminoglycosides are administered. Thus the pharmacist can be an important member of the health care team for the treatment of patients suffering from ear infections. References Doroghazi A. et al. Invasive external otitis. The American Journal of Medicine 1981; 71: 603-613 Keller Hellen. Ear diseases and hearing disorders. In: The New EncyClopaedia Britannica. Editor: Warren E.Preece 1983: 1133-1138. Papoz 1. Evolution de l'epidemiologie du diabete dans les pays d'Europe et du pourtour mediterrneen. Medicographia 1990: 4-6 Sade J. et al. Ciprofloxacin treatment of malignant external otitis. The Americ,,"n Journal of Medicine 1989; 87 (Supp15A) 5A-138S-140S Yagi H.!. Chronic Suppurative otitis- media in Sudanese patients; East-Afr-Med-J.1990; 67: 4-8 434 

The rational therapy of ear infections

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The rational therapy of ear infections

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