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Use of Systemic Antimicrobials
in Canine Bacterial Otitis
John M. MacDonald, MEd, DVM, Diplomate ACVD
Auburn University, College of Veterinary Medicine, Small Animal Clinic, Auburn, Alabama, USA
Otitis is one of the more common
reasons clients seek veterinary atten-
tion for their dogs. The incidence of
otitis externa from all causes has been
estimated to be as high as 20% of the
general canine population and is also
reported to account for as many as
16% of canine hospital admissions.
The incidence is much lower in cats,
estimated at 2% to 6.6%.1 Regardless
of the exact number, it can certainly be
generalized that ear disease represents
a sizable problem in the dog. In addi-
tion to the relatively high incidence of
otitis, it is one of the more chronic and
frustrating diseases for veterinarians to
treat. Pathology is often multifactorial,
and unless all the factors are identified
and treated, successful management is
doubtful and the disease will progress.
Classification of Otitis
Otitis is classified by the anatomic
area affected: Otitis externa relates to
an inflammatory process affecting the
external auditory canal. Otitis media
and otitis interna refer to inflammation
of the middle ear and the inner ear
structures, respectively. Although otitis
interna is not as commonly encoun-
tered as otitis externa or otitis media, it
has been associated with nearly 50% of
the cases of vestibular syndrome.2
Therefore, examination for otitis is
important in the evaluation of cases
with peripheral vestibular disease.
Supplement to Compendium on Continuing Education for the Practicing Veterinarian, Vol. 21, No. 12(M), 1999
Otitis Externa
Otitis externa may be caused by a
wide range of categorized factors
(Table 1).
Otitis Media
Otitis media is an inflammation of
the middle ear and represents a more
difficult infection to treat. Inflamma-
tion of the middle ear can occur by
three possible routes. First and most
common is the extension of otitis exter-
na across the tympanic membrane. As
otitis externa becomes more chronic
and the accumulation of inflammatory
products, including enzymes, contacts
the tympanum, necrosis and ultimately
rupture occur, leading to extension of
the infection to the middle ear. A sec-
ond method of acquiring otitis media is
through the auditory tube, which con-
nects the nasopharynx to the middle
ear cavity. The progression of pharyn-
geal infection to the middle ear,
although common in humans, occurs
infrequently in the dog. Cats may have
a higher chance of this occurring as a
consequence of an upper respiratory
disease. The last possible source of
infection is by hematogenous spread,
but this is uncommon.
Antimicrobial Therapy
Routine management of otitis exter-
na relies mostly on topical therapy
using either antibiotic products or anti-
fungal products, or both, depending
on whether a bacterial or a yeast infec-
tion is present. While systemic anti-
biotics are used occasionally for
uncomplicated otitis externa, the main
indication is for otitis media or otitis
interna.1–6 Systemic antibiotics should
be chosen on the basis of culture and
susceptibility testing. Topical treatment
of the concurrent otitis externa should
be initiated and weekly otoscopic
examinations and cleansing should be
carried out. Neurologic examinations
should be performed and documented
during treatment and reevaluations.
Systemic antibiotic therapy has been
used in cases of suppurative otitis
externa, especially if opportunistic
gram-negative organisms, particularly
Pseudomonas spp., are part of the
pathology. Systemic antibiotics may be
helpful not only to resolve the active
infection but also to prevent progres-
sion to otitis media. Systemic anti-
microbial therapy should be used 1 to 2
weeks beyond clinical resolution.
Systemic antibiotics are indicated in
every case of otitis media and should
be based on bacterial cultures obtained
from the middle ear. In general, expect
the presence of Pseudomonas in many
cases of otitis media. Systemic anti-
biotics may be indicated in selected
cases of otitis externa. Antibiotic dos-
ing should be at the high end of the
range and based on actual animal
weight rather than approximation.
57
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Predisposing Factors
Canal conformation
Stenosis
Pendulous pinnae
Hair in the canal
Climatic variations
Excessive moisture
Maceration of the ear canal
Treatment effects
Systemic disease
Treatment should be continued with a
regular interval of administration for a
minimum of 4 weeks or to 2 weeks
beyond remission of clinical signs and
negative laboratory findings for active
infection. Therapy lasting 4 to 12
weeks or more may be necessary.
Administration of systemic antibiotics
does not exclude the necessity for reg-
ular intermittent evaluation, otic clean-
ing, and topical therapy in the external
ear canal.
The ideal systemic antibiotic possess-
es a number of properties, of which
bacterial susceptibility is the most obvi-
ous. Factors related to penetration of
the site of infection are important
aspects for optimal antimicrobial
effect.7 This becomes more important in
relationship to otitis media because of
the bony encasement created by the
bullae and the debris that accumulates
in that cavity, making antibiotic levels
difficult to achieve. In addition, some
antibiotics, such as aminoglycosides,
bind to necrotic debris, rendering them
ineffective.7 The fact that the infectious
process is located in a protected area
suggests that optimal success requires
an antibiotic that is effective at low
minimum inhibitory concentrations
(MICs) or that has a wide safety margin
to allow increased dosage to acquire
higher blood levels.
Antibiotics historically used for
treatment of otitis include potentiated
sulfa, clindamycin, cephalexin, and
enrofloxacin.1,3–5 Although aminoglyco-
sides may possess some desirable
attributes relevant to the susceptibility
patterns, their limitations for long-term
use because of toxicity and restriction
to parenteral administration make
them of little value for systemic treat-
58 Third International Veterinary Symposium on Fluoroquinolones Proceedings
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TABLE 1
Otitis Externa Factors
Primary Causes
Parasites
Foreign bodies
Hypersensitivities
Metabolic disorders
Autoimmune disease
Cornification disorders
Glandular disorders
ment. Fluoroquinolones are particularly
advantageous because of their spec-
trum of antibacterial effect, oral admin-
istration, safety for long-term therapy,
and lack of ototoxicity. Fluoroquino-
lones have been used more commonly
in the treatment of Pseudomonas otitis
externa and may be essential for chron-
ic cases and others with severe bacteri-
al infection. The properties of fluoro-
quinolones are well described.8–12 Both
enrofloxacin and orbifloxacin have flex-
ible dosing labels, allowing for some
variation. With Pseudomonas spp. rep-
resenting a major concern in the treat-
ment of otitis media with systemic
antibiotics, fluoroquinolones become
an ideal antibiotic choice. Dosage of
enrofloxacin for this type of infection
should go up to 10 to 15 mg/kg once
daily. Orbifloxacin has been reported to
have efficacy against Pseudomonas
spp. at a dosage of 7.5 mg/kg once
daily, which is the largest label dose
allowed.7,8 The author has limited expe-
rience with orbifloxacin or difloxacin in
the treatment of otitis. To the author’s
knowledge, there are no data available
comparing susceptibility and efficacy of
Enrofloxacin
has provided
optimal results
against
Pseudomonas
when used at
10 to 15 mg/kg
once daily.
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Perpetuating Factors
Opportunistic infectious agents
Pseudomonas spp.
Proteus spp.
Escherichia coli
Klebsiella spp.
the various fluoroquinolones in the
treatment of otitis. The author’s experi-
ence is limited to enrofloxacin, which
has provided optimal results when used
at 10 to 15 mg/kg once daily. Other
fluoroquinolones may be effective
regarding relative bioavailability and
dosage variation (e.g., ciprofloxacin,
norfloxacin, orbifloxacin, difloxacin,
and marbofloxacin). In summary,
fluoroquinolones have desirable char-
acteristics in the treatment of bacterial
otitis. They have few adverse side
effects, high bioavailability, long serum
half-life, spectrum of activity against
gram-negative bacteria (especially
important with Pseudomonas spp.),
provide excellent tissue penetration,
and are bactericidal.11
Repeated culture and susceptibility
testing is necessary in addition to
microscopic examination of exudate or
use of Gram’s stain. Client education is
even more critical in cases of otitis
media compared to otitis externa
because of the potential for complica-
tions. Total client compliance is essen-
tial, with follow-up of all examinations
to maximize success. Prognosis is diffi-
cult, if not impossible, but is guarded at
best. In cases of Malassezia pachyder-
matis infection, systemic antifungals,
such as ketoconazole (5–10 mg/kg
twice daily or 10–15 mg/kg once daily),
itraconazole (5–10 mg/kg once daily),
or terbinafine (5–10 mg/kg once or
twice daily), should be used.
Summary
Otitis media may be present in as
many as 80% of the cases of chronic
otitis externa. The tympanic membrane
may be intact in a large portion of the
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cases, with otitis media making the
diagnosis of otitis media difficult. Per-
foration of the tympanic membrane
indicates otitis media, but evaluation of
the tympanum may be achieved in only
28% of cases. There may be a signifi-
cant difference between bacterial iso-
lates of the external ear and the middle
ear in cases of otitis media. Pseudo-
monas is more commonly associated
with otitis media than with otitis exter-
na, showing a higher susceptibility to
fluoroquinolones. Systemic antibiotics
should be included in the treatment
regimen for otitis media, and fluoro-
quinolones are the best choice for
treatment. Systemic antibiotic therapy
should be administered for 4 to 12
weeks or 2 weeks beyond clinical reso-
lution. Intermittent examinations and
cleansing of the ear canal should be
included.
References
1. McKeever PJ, Globus H: Canine otitis
externa, in Bonagura J (ed): Kirk’s Cur-
rent Veterinary Therapy XlI. Philadel-
phia, WB Saunders, 1995, pp 647–
655.
2. Shell LG: Otitis media and otitis interna.
Vet Clin North Am Small Anim Pract
Supplement to Compendium on Continuing Education for the Practicing Veterinarian, Vol. 21, No. 12(M), 1999
Hit List Find Within This Publication
Systemic
antibiotic
therapy should
be administered
for 4 to 12
weeks or 2
weeks beyond
clinical
resolution.
18(4):885–899, 1998.
3. Griffin CE: Otitis externa and otitis
media, in Griffin CE, Kwochka K, Mac-
Donald JM (eds): Current Veterinary
Dermatology: The Art & Science of
Therapy. St Louis, Mosby-Year Book,
1993, pp 245–262.
4. Merchant SR: Medically managing
chronic otitis externa and media. Vet
Med, pp 518–534, June 1997.
5. Scott DW, Miller WH Jr, Griffin CE: Dis-
eases of eyelids, claws, anal sacs, and
ear canals. Muller & Kirk’s Small Animal
Dermatology, ed 5. Philadelphia, WB
Saunders, 1995, pp 971–989.
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6. Ahuja GS, Thompson J: What role for
antibiotics in otitis media and sinusitis?
Postgrad Med 104(3):93–99, 1998.
7. Papich MG: Optimum strategy for
antibacterial therapy. Bayer Selected
Proceedings: The 1998 North American
Veterinary Conference, 1998, pp 21–
24.
8. Aucoin DP: Avoiding antimicrobial fail-
ure. Bayer Selected Proceedings: The
1998 North American Veterinary Con-
ference, 1998, pp 25–27.
9. Brown SA: Fluoroquinolones in animal
health. J Vet Pharmacol Ther 19:1–14,
1996.
10. Hawkins EC, Boothe DM, Guinn A, et
al: Concentration of enrofloxacin and
its active metabolite in alveolar
macrophages and pulmonary epithelial
lining fluid of dogs. J Vet Pharmacol
Ther 21:18–23, 1998.
11. Meinen JB, McClure JT, Rosin E: Phar-
macokinetics of enrofloxacin in clinical-
ly normal dogs and mice and drug
pharmacodynamics in neutropenic
mice with Escherichia coli and staphylo-
coccal infections. Am J Vet Res 56(9):
1219–1224, 1995.
12. Walker RD, Stein GE, Hauptman G, et
al: Pharmacokinetic evaluation of
enrofloxacin administered orally to
healthy dogs. Am J Vet Res 53:2315–
2319, 1992.
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