CLINICAL NEED FOR OTOTOPICAL FLUOROQUINOLONES OUTWEIGHS MINISCULE RISK OF ANTIBIOTIC RESISTANCE

Abstract

5 January 2006 Dear Editor The National Aboriginal Community Controlled Health Organisation (NACCHO), in a double-blind randomized controlled trial, showed that the use of topical ciprofloxacin to treat chronic suppurative otitis media (CSOM) among 111 Aboriginal children improved the odds of clinical cure three fold compared with the current standard of topical aminoglycoside. Treatment did not lead to resistant isolates when followed up for 21 days, even among those with persistent discharge.1 Given the demonstrated efficacy and concerns about ototoxicity of aminoglycosides, it was recommended that ototopical ciprofloxacin be used as first-line treatment (in conjunction with ear toilet) for CSOM. Dr Coates correctly concludes in his review article that the theoretical concerns of resistance emerging from ototopical fluoroquinolones in this setting were considerably outweighed by the risk of bacterial resistance emerging from oral use.2 In a recent hospital case series, Jang and Park speculated that ciprofloxacin resistance in Pseudomonas aeruginosa arose from ototopical use in CSOM.3 As there were no controls, no information on prior use of ciprofloxacin, no pretreatment antibiotic sensitivity testing nor information on patient adherence and with potential selection bias and confounders, this report neither confirms nor refutes the hypothesis that ototopical use of ciprofloxacin for CSOM was the cause of the bacterial resistance. The international evidence suggests that if there is a risk at all of antibiotic resistance from ototopical fluoroquinolone use in CSOM, it must be very small. The consistent view is that resistance arising from ototopical fluoroquinolones use for CSOM is negligible when compared with its use for systemic disease. We argue that favouring ototopical fluoroquinolone use for CSOM can lead to less oral and systemic use, by reducing the need for preoperative intravenous therapy, and avoiding complications from poorly treated CSOM.4 The response to the antibiotic resistance debate thus hinges on a risk to benefit analysis. Among Aboriginal children, CSOM is a major public health problem, with substantial otologic complications if untreated.4 Providing ‘no treatment’ should be considered unethical. The provision of ‘tissue spears’ or other forms of dry mopping without other treatment is the ‘same as doing nothing’.4 The alternative (to continue using ototopical aminoglycosides in a population of children for whom little or no monitoring of adverse events occurs and who are less likely to initiate medicolegal action because of disadvantage) is no longer acceptable to either the medical profession5 or Aboriginal representatives now that safer and more effective alternatives are available. For some, the fear of antibiotic resistance in Australia is magnified because the problem of CSOM mostly affects Aboriginal children. It has been declared to us that ototopical fluoroquinolone use may be tantamount to ‘throwing around fluoroquinolone drops in the bush’ because the infection is so prevalent. If such views influence social institutions (e.g. in decisions on the registration of therapeutic goods or subsidy schemes) the outcome can be discrimination against a disadvantaged population group and, in effect, institutionalized racism.6 Health policy based on spurious notions of the ‘greater good’ that has the effect of restricting access to best practice by vulnerable sub-populations are reminiscent of the white Australia policy, when decisions of public health were made not for the benefit of Aboriginal peoples, but to prevent the spread of disease to Europeans on the frontier.7 Proponents arguing that Aboriginal children should be denied access to this medication should also be aware that ototopical fluoroquinolones are widely used ‘off-label’ in Australia by those who can afford it.2 Thus, current supply arrangements ‘ration’ ototopical fluoroquinolones on the basis of who can afford to pay – which is obviously unacceptable. Fluoroquinolones have replaced ototoxic aminoglycosides as treatment for CSOM in the USA, Japan, Spain and other countries,8 and it is high time that Australia did the same.