Learning Outcomes
By the end of this section, you should be able to:
- 39.2.1 Identify the characteristics of anti-inflammatory and anti-infective drugs used to treat ear disorders.
- 39.2.2 Explain the indications, actions, adverse reactions, and interactions of anti-inflammatory and anti-infective drugs used to treat ear disorders.
- 39.2.3 Describe nursing implications of anti-inflammatory and anti-infective drugs used to treat ear disorders.
- 39.2.4 Explain the client education related to anti-inflammatory and anti-infective drugs used to treat ear disorders.
Otic Anti-inflammatories
Anti-inflammatory drugs block substances in the body that cause inflammation. Otic anti-inflammatories are used for the treatment of superficial bacterial infections of the external auditory canal (i.e., otitis externa) caused by susceptible organisms. Anti-inflammatory medications frequently are administered in combination with antibiotics. A treatment response should occur within 48–72 hours, otherwise the provider should reassess (Medina-Blasini & Sharman, 2023).
Adverse Effects and Contraindications
Adverse effects are rare; however, clients can experience allergic reactions characterized by rash, itching, and redness. Dizziness may occur. Prolonged usage can result in a superinfection that requires additional medications to resolve.
Table 39.1 is a drug prototype table for otic anti-inflammatories featuring neomycin and polymyxin B sulfates, and hydrocortisone otic solution (Cortisporin). It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Antibacterial and anti-inflammatory Mechanism of Action Suppresses the inflammatory response (hydrocortisone) Works against susceptible organisms (anti-infectives) |
Drug Dosage Adults: 4 drops of medication instilled in the ear 3–4 times daily, not to exceed 10 days. Children: 3 drops of medication instilled in the ear 3–4 times daily, not to exceed 10 days. Each mL contains: neomycin sulfate 3.5 mg, polymyxin B 10,000 units, and hydrocortisone 10 mg (1%). |
| Indications For the treatment of superficial bacterial infections of the external auditory canal (i.e., otitis externa) caused by susceptible organisms For the treatment of infections of mastoidectomy Therapeutic Effects Reduces ear pain Reduces bacterial infection Decreases inflammation |
Drug Interactions No significant interactions Food Interactions No significant interactions |
| Adverse Effects Local, adverse reactions (most common are burning, itching, irritation, and dryness) Stinging and burning (if medication reaches the middle ear) Hearing loss (with prolonged use—treatment should be limited to 10 days) |
Contraindications Perforated eardrum Fungal or viral lesions Hypersensitivity to any medication components |
Nursing Implications
The nurse should do the following for clients who are taking otic anti-inflammatories:
- Recognize and monitor for serious and other potential side effects. Rarely, anaphylaxis can occur with the first dose.
- Clients with latex allergies may need to use an alternative (latex-free) dropper for administration.
- Perform hand hygiene before administering otic anti-inflammatory medication.
- Educate the client on ear position and time to remain in a lying position after instillation.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an otic anti-inflammatory should:
- If this is the first time using these drugs, administer with another person present for assistance in case a serious allergic reaction occurs.
- Always wash their hands before handling a bottle of otic drops and be mindful of the bottle cap to ensure that it remains as germ-free as possible.
- Roll the bottle of otic drops between their hands for a few moments to warm the drops. Instillation of cold drops can cause dizziness.
- Administer the drops with the pinna in an upward position; it should remain up during otic drop instillation.
- Keep the ear facing up for about 5 minutes for the drop(s) to bathe the ear canal and minimize the amount of medication leakage (Mayo Clinic, 2023).
- Use a latex-free dropper if they have a latex allergy.
The client taking an otic anti-inflammatory should not:
- Heat the drops above body temperature because administering drops that are too warm can damage the ear canal.
- Drive or operate machinery until any occurrences of dizziness and vertigo have subsided.
- Use cotton swabs in their ears due to the risk of perforation and further irritation and injury (Cleveland Clinic, 2022a).
- Use the medication for longer than the prescribed duration.
Otic Topical Anti-infectives
Otic anti-infectives are indicated for clients who have otitis externa. Topical anti-infectives are prescribed to treat bacterial infections but are ineffective for viral infections. If the infection does not improve after 1 week of treatment, cultures and susceptibility tests should be repeated to verify the identity of the organism and to determine whether the therapy should be changed.
Table 39.2 lists common otic topical anti-infectives and typical routes and dosing for adult and pediatric clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Ciprofloxacin 0.3% and dexamethasone 0.1% (Ciprodex) |
For the treatment of acute otitis media in adults and acute otitis media in children with tympanostomy tubes: 4 drops instilled into the affected ear twice daily for 7 days. |
| Ciprofloxacin 0.2% and hydrocortisone 1% (Cipro HC) |
For the treatment of acute otitis externa due to susceptible organisms: For clients ≥1 year: 3 drops instilled into the affected ear(s) twice daily for 7 days. Maximum dose: 6 drops daily to affected ear(s). |
| Ofloxacin (Floxin) |
For the treatment of otitis media and acute otitis media in children with tympanostomy tubes: For clients 1–12 years: 5 drops (0.75 mg) in the affected ear(s) twice daily for 10 days. For the treatment of long-term suppurative otitis media with perforated tympanic membranes: For clients 12 and older: 10 drops (1.5 mg) in the affected ear(s) twice daily for 14 days. For the treatment of otitis externa due to Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus: For clients 6 months to 12 years: 5 drops (0.25 mL, 0.75 mg ofloxacin) in the affected ear(s) once daily for 7 days. For clients 13 years and older: 10 drops (0.5 mL, 1.5 mg ofloxacin) in the affected ear(s) once daily for 7 days. |
Adverse Effects and Contraindications
Adverse effects of otic anti-infectives may include ear itching, fungal ear superinfection, earache, tinnitus, and transient hearing loss. Contraindications to taking otic anti-infectives include a history of hypersensitivity to any ingredient in the medication.
Table 39.3 is a drug prototype table for otic topical anti-infectives featuring ciprofloxacin 0.2%/hydrocortisone 1%. It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Otic topical anti-infective Mechanism of Action Kills bacteria Reduces inflammatory response that accompanies infection |
Drug Dosage For clients ≥1 year: 3 drops instilled into the affected ear(s) twice daily for 7 days. Maximum dose: 6 drops daily to affected ear(s). |
| Indications For the treatment of superficial bacterial infections of the external auditory canal (i.e., otitis externa) caused by susceptible organisms, including pseudomonas and staphylococcus For the treatment of infections of mastoidectomy Therapeutic Effects Eases discomfort Reduces inflammation Treats infection |
Drug Interactions No significant interactions Food Interactions No significant interactions |
| Adverse Effects Ear itching Fungal ear superinfection Earache Tinnitus Transient hearing loss Dizziness |
Contraindications A history of hypersensitivity to ciprofloxacin |
Nursing Implications
The nurse should do the following for clients who are taking otic anti-infectives:
- Recognize and monitor for serious and potential side effects, primarily a rash or any evidence of hypersensitivity to quinolones. Anaphylaxis can occur. Clients with latex allergies need to use a latex-free dropper to administer.
- Perform hand hygiene before administering.
- Educate the client on ear position and time to remain in a lying position after instillation.
- Monitor complete blood count, if ordered, for decreased eosinophils.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an otic topical anti-infective should:
- Report ear pain or worsening of itching to the health care provider; they may need an ear swab to test for superinfection if used for an extended period.
- Always wash their hands before handling a bottle of otic drops and be mindful of the bottle cap to ensure that it remains as germ-free as possible.
- Roll the bottle of otic drops between hands for a few moments to warm the drops. Instillation of cold drops can cause dizziness.
- Administer the drops with the pinna in an upward position; it should remain up during otic drop instillation.
- Keep the ear facing up for about 5 minutes for the drop(s) to bathe the ear canal and minimize the amount of medication leakage (Mayo Clinic, 2023).
The client taking an otic topical anti-infective should not:
- Warm the drops to greater than their body temperature because this can damage the ear.
- Drive or operate machinery until any occurrences of dizziness have subsided.
- Use cotton swabs in their ears due to the risk of perforation and further irritation and injury (Cleveland Clinic, 2022a).
Clinical Tip
Topical Otic Medication Administration
This video from Tacoma Community College demonstrates the proper procedure for administering otic medication to an adult client.
For pediatric clients, review these instructions from the American Academy of Pediatrics.
Systemic Anti-infectives for Infections of the Ear
Systemic otic anti-infectives are indicated for clients who have otitis media. Acute otitis media in adults can cause significant complications; therefore, most adults are treated with antibiotic therapy (Limb et al., 2023). Antibiotic therapy is used more judiciously in children to avoid antibiotic resistance and side effects. High-dose amoxicillin is the first-line choice for both children and adults (Danishyar & Ashurst, 2023). If high-dose amoxicillin is not effective, high-dose amoxicillin-clavulanate is the second-line treatment. For clients with penicillin allergies or non-responders, azithromycin or cefdinir are two alternatives that can be considered.
Table 39.4 lists common otic systemic anti-infectives and typical routes and dosing for adult and pediatric clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Amoxicillin (Amoxil, Trimox) |
Severe infections: Adults: 875 mg orally every 12 hours or 500 mg orally every 8 hours. Children <3 months: Amoxicillin 30 mg/kg daily for a 10-day course, given in 2 divided doses. Children ≥3 months: Amoxicillin 45 mg/kg daily for a 7-day course, given in 2 divided doses. |
| Amoxicillin-clavulanate (Augmentin) |
Severe infections: Adults: One 875 mg amoxicillin/125 mg potassium clavulanate tablet orally every 12 hours or one 500 mg amoxicillin/125 mg potassium clavulanate tablet orally every 8 hours. Children >40 kg: Use adult dosing. Children ≥3 months and weighing <40 kg: 45 mg/kg daily orally every 12 hours or 40 mg/kg daily every 8 hours (using 200 mg amoxicillin/28.5 mg potassium clavulanate mg per 5 mL or 400 mg amoxicillin/57 mg potassium clavulanate per 5 mL oral suspension). Children <3 months: 30 mg/kg daily orally every 12 hours (using 125 mg amoxicillin/31.25 mg potassium clavulanate mg per 5 mL oral suspension). |
| Azithromycin (Zithromax) |
For children with acute otitis media (using oral suspension 500 mg in 5 mL): Children ≥6 months: 30 mg/kg orally as a single dose, or 10 mg/kg once daily for 3 days, or 10 mg/kg as a single dose on day 1 followed by 5 mg/kg daily on days 2 through 5. |
| Cefdinir (Omnicef) |
For children with acute otitis media (using either 125 mg per 5 mL or 250 mg per 5 mL oral suspension): Children 6 months through 12 years: 7 mg/kg orally every 12 hours for 5–10 days or 14 mg/kg orally every 24 hours for 10 days. |
Adverse Effects and Contraindications
Systemic antibiotics can lead to diarrhea and possibly pseudomembranous colitis and Clostridium difficile infection. Symptoms of C. difficile can range from mild to life-threatening and may require hospitalization and extended therapy. Antibiotic-related diarrhea can occur up to 2 months after ceasing antibiotic therapy. Antibiotics can cause allergic reactions, especially in clients with other sensitivities.
Table 39.5 is a drug prototype table for otic systemic anti-infectives featuring amoxicillin. It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Systemic anti-infective; analog of ampicillin Mechanism of Action Bactericidal antibiotic effective for many gram-positive and gram-negative bacteria |
Drug Dosage Severe infections: Adults: 875 mg orally every 12 hours or 500 mg orally every 8 hours. Children <3 months: Amoxicillin 30 mg/kg/day for a 10-day course, given in 2 divided doses. Children ≥3 months: Amoxicillin 45 mg/kg/day for a 7-day course, given in 2 divided doses. |
| Indications For the treatment of acute otitis media and sinusitis Therapeutic Effects Treats infection |
Drug Interactions Probenecid Oral estrogen/progesterone contraceptives Food Interactions No significant interactions |
| Adverse Effects Sensitivity reactions, particularly in clients allergic to penicillin Diarrhea including from Clostridium difficile Abnormal liver function tests |
Contraindications Known hypersensitivity to penicillin |
Nursing Implications
The nurse should do the following for clients who are taking systemic anti-infectives for otic conditions:
- Recognize and monitor for serious and potential side effects including signs of allergic reactions and new onset of diarrhea.
- Follow dosing instructions carefully, particularly with amoxicillin-clavulanate (Augmentin). Different forms of Augmentin contain different amounts of amoxicillin but the same amounts of clavulanic acid, so the strengths are not interchangeable. For example, two 250 mg Augmentin tablets are not the equivalent of a 500 mg tablet. If a client is prescribed 500 mg, the client must take the 500 mg tablet, not two 250 mg tablets.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an otic systemic anti-infective should:
- Report episodes of diarrhea to their health care provider.
- Take all their antibiotic(s) as prescribed.
- Keep follow-up appointments.
The client an otic systemic anti-infective should not:
- Share antibiotics with others.