Necrotising (malignant) otitis externa
- Sampling for histopathology and microbiology should be performed.
- Consult ENT and Micro/ID for advice
- Typically, initial treatment is intravenous (usually 1-2 weeks). Timing of oral switch is based on MRI and clinical response. Total treatment duration is usually 6 weeks.
- Recommended antibiotic therapy listed below is empiric. Treatment should always be tailored to culture and sensitivity.
- For patients with penicillin allergy label consider penicillin allergy assessment and delabelling
Non-severe NOE or oral follow-on
ciprofloxacin 750mg po bd
Moderate/severe NOE - Preferred IV therapy
piperacillin-tazobactam 4.5g iv stat (first dose) THEN one of the following regimens should be used, choose from:
piperacillin-tazobactam 4.5g iv qds (six hours after the initial stat dose)
OR
extended infusion piperacillin-tazobactam 4.5g iv tds infuse each dose over 3-4 hours (six hours after the initial stat dose)
OR
If eligible for ambulation and have central access (e.g midline): Elastomeric pump piperacillin-tazobactam 13.5g over 24 hours (elastomeric device should be attached straight after the initial stat dose)
Moderate/severe NOE - Alternative IV therapy
For penicillin allergy (non-severe):
ceftazidime 2g iv tds
Note: if patient is over 80 years of age the usual daily maximum dose is 3 g; this can be increased up to 6g daily on advice documented by Micro/ID Consultant. E.g., 2g bd may be recommended for OPAT
or
ceftazidime 3g iv bd via OPAT
For penicillin allergy (severe):
ciprofloxacin 750mg po bd (or 400mg IV tds if NBM)
If NOE with gram positive infection suspected (including MRSA)
ADD either linezolid 600mg po bd (or 600mg iv bd if NBM) OR if inappropriate, teicoplanin iv