Given that this condition is basically a cellulitis and we so easily prescribe a course of oral antibiotics for that, why not follow suit with this condition? My concern here is price. As you said, a bottle of Ciprodex can be $250-$300, while a course of Augmentin is about $15. You mentioned that oral antibiotics have “adverse effects, can generate resistant organisms, and seem to be associated with recurrence.”
Can you elaborate on the recurrence part? A $15 course of orals just seems like a far better option to me, and I am confused why we still recommend a $250 topical.
I know Cipro otic without steroid is far cheaper in the United Kingdom. Since I learned that, I have been prescribing Cipro ophthalmic 0.3% to be used in the ear for otitis externa. It is available for about one-tenth of the price. I just put on the “sig” to the pharmacist, “yes, I do want them to put it in the ear.” Thoughts?
Jeremy Gabrysch, MD
Austin
Dr. Roberts responds: Thanks for the letter. It seems that topicals deliver much higher concentrations of antibiotic to the superficial skin surface where the infection of otitis externa exists, plus topicals don't have systemic effects. Because oral meds don't seem to get concentrated on the skin surface, their presence does not totally eradicate the bugs, so resistance can develop, and the cure is not total, hence recurrence. Maybe I made that up, but at least that makes sense to me. None of the literature I read recommends oral antibiotics for simple otitis externa. Cure rates with topicals are very good plus the diarrhea of Augmentin can be avoided.
Thanks so much for the fantastic suggestion of using ciprofloxacin eye drops for the ear. I was not aware of that use, and although eye drops are not licensed for ear infections, recommendations for such use can be found in the literature. The cost difference between eye and ear ciprofloxacin preparations is gigantic. I agree that it's best to write “OK to use eye drops in the ear” for the pharmacist and to tell the patient, so they don't think you made a mistake. Also, don't forget that the internet has some amazing coupons for almost any medication (simply Google ciprofloxacin), and anyone can join GoodRx.
Prevent these injuries by reading labels carefully, every time you use a medicine or household product. If you mistakenly use glue instead of ear drops or eye drops, call Poison Control right away for advice at 1-800-222-1222. Help is available 24 hours a day, every day of the year.
Sometimes, eye drops can be safely used as ear drops because there are relatively few medicines for ears. However, ear drops should never be used in the eyes. Eye tissue is much more sensitive than ear tissue. Thus, eye drops are specially made to be gentle and germ-free, yet effective.
In your home, ear drops that are used to clear wax out of the ears are most often confused with eye drops. However, mix-ups between other types of ear drops and eye drops have been reported. We even have a reported case in which ear drops for a pet were accidentally put into the eyes of the pet owner's child. See Check it out! to the right for ways that you can avoid making this common mistake.
Problem: When eardrops are accidentally instilled in a patient's eyes, it's usually obvious: patients quickly let you know that something is very wrong. They immediately complain of burning and stinging; later they may notice redness, swelling, or blurred vision. Typically, these patients have their eyes flushed with copious amounts of water or saline and may have warm or cold compresses applied. Some patients may require immediate care in the emergency department or ophthalmology clinic.
As with other sound- or look-alike terms, "optic" and "otic" can be confused. Often, the vials also look alike. The fact that ears and eyes are relatively close together adds a "human anatomy factor" to the equation. Further risk is introduced by misuse of the term "eye-dropper" to administer both eye drops and eardrops (as well as oral liquid medications). The most common medications instilled in patients' eyes were those used to clear the accumulation of earwax (cerumenolytics), such as carbamide peroxide. Errors with other eardrops, however, have also been reported.
While bar-coded drug administration systems can help prevent administration to the wrong patient and confirm that the right product has been selected, it cannot prevent eardrops from being instilled in the eyes. Thus, the Veterans Administration (VA) reports that one-third of VA facilities, which employ bar-coded drug administration, have documented cases in which eardrops had been placed in patients' eyes.
Seventy-nine percent of the cases were actual events and 21% were close calls:
- 68% occurred when staff administered ear medications into patients' eyes
- 11% took place when patients administered ear medications into their own eyes
- 19% involved erroneous instructions from the pharmacy
- 2% originated with the prescriber who ordered eardrops to be instilled into the eyes.
Examples of factors contributing to these events included the following:
- Eardrops and eye drops were stored side-by-side in the pharmacy and the wrong vial was dispensed.
- Instructions for use were read as "1 drop optic" rather than "otic."
- Eardrops were dispensed as eye drops following cataract surgery.
- Instructions indicated using drops to treat an affected eye, which conflicted with correct verbal instructions to use the drops in the ear.
- Patient took eardrops from the top of a medication cart and instilled them in his eyes while the nurse was checking the electronic medication administration record (MAR).
One unit devoted to blind patients reported a low incidence of placing eardrops in the eyes. Staff surmised that the low incidence was driven by the need for attentive review of medication labels on a routine basis because patients were often prescribed multiple medications for each eye.
Safe Practice Recommendations
To reduce the risk of harming patients due to administration of eardrops into the eyes, consider the following recommendations:
- Place an auxiliary label on the actual dropper bottle to specify "ear" or "eye" drops.
- Scan the bar code on the actual vial if this technology is available.
- Keep medications in their original cartons, as pictures of an eye or ear are often on boxes but not on vials.
- Consider providing eardrops in snap-top pharmaceutical boxes or in distinctive vials with ear symbols or pictograms. This will keep eardrop containers physically distinct from eye drops.
- Separate eardrop and eye drop vials on pharmacy shelves and in unit-based medication carts or supplies. Sometimes the same "topical" drug is formulated for use in both eyes and ears. Even though drugs may have different brand names, storing them together increases the likelihood of a mix-up. Separate storage sections for otic and ophthalmic drugs are preferred.
- Remove discontinued eye and ear medications from units to prevent a future mix-up with another patient's medications or a future prescription for the same patient.
- Confirm the medication with the patient before administering eardrops or eye drops.
- Administer eye drops and eardrops on different schedules if possible (e.g., if given once daily).
- Make sure the route of administration for eye drops and eardrops is programmed in the pharmacy computer so that it appears on computer-generated MARs.
- Emphasize OTIC and OPHTHALMIC, or EAR and EYE, on MARs by using bold letters and/or increased font sizes.
- To reduce the risk of harm in the event of an error, consider using less caustic substances for earwax removal. A Cochrane1 review of studies indicates that water and saline drops may work as well as other cerumenolytics.
Since there are so few otic medications, sometimes eye drops are used for the ear. Thus, staff may be lulled into a comfort zone with interchanging these products. However, eardrops should never be used in the eyes. Eye tissue is much more sensitive than ear tissue. Thus, eye medications are specially buffered and formulated for ophthalmic use. Mix-ups when dispensing or administering eardrops and eye drops are not uncommon, considering the number of reports from individual facilities and the number of facilities reporting. From a human factors perspective, we must do more to create barriers to prevent this type of adverse drug event.
We thank Carol Samples, from the Veterans Administration (VA) Center for Patient Safety, and Mary Burkhart, from Medco Health (formerly with the VA), for providing the content for this article, which originally appeared in Topics in Patient Safety, VA National Center for Patient Safety, in the September/October 2006 issue.