Antimicrobial therapy for chronic suppurative otitis media

In chronic draining ear associated with a tympanic membrane perforation and/or cholesteatoma, the infection is that of bacterial contamination. Both aerobic and anaerobic organisms are found, notably Pseudomonas, Staphylococcus, and enteric organisms, particularly Bacteroides. The disease exists because of a structural defect in the middle ear cleft, which requires surgery as definitive treatment. Medical therapy is valuable as a temporary measure, in preoperative preparation, and in prevention and management of intracranial extension. Topical therapy with antibiotic ear drops is often helpful, but also important is local care with cleansing, drying, and antiseptic solutions or powders. Therapy is usually directed against the Pseudomonas organism with aminoglycosides and polymyxins, but Bacteroides fragilis now looms as an important pathogen in 13% of affected patients, requiring chloramphenicol. Since drugs directed against Bacteroides ae ineffective against Pseudomonas, and vice versa, there is no one agent we can rely upon for treatment of both. What we are all looking for, of course, is that brand new antibiotic the FDA hasn't released yet: "panaceamycin." It hasn't even been developed yet. None of the ones we have are a panacea; and until we get one, we will have to stick with what we have, exercise clinical judgment, and base our antibiotic selections on, if not proven culture results, then at least established microbial probabilities.