Customer conversations
Customer conversations
Otitis externa is not usually considered to be a serious medical condition, but it can be sufficiently unpleasant16 and may have a notable impact on quality of life.17 Showing empathy in your consultation is important. If treatment is initiated, symptoms of AOE usually improve within 48–72 hours.18
Further information and advice to share with your patient can be found below:
Provide advice on self-care measures for both symptom relief and to reduce the risk of recurrent infections,7 and thus the need for future antibiotic treatment. These could include:
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Avoid damage to the external ear canal
- Safely remove excess ear wax without using cotton buds or other objects
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Keep the ear clean and dry
- Avoid swimming and water sports for at least 7-10 days during treatment
- Wear ear plugs and/or a tight-fitting cap when swimming
- Keep shampoo, soap and water out of the ear when bathing or showering by using ear plugs or cotton wool with petroleum jelly
- Consider using a hair dryer on its lowest setting to dry the ear canal after washing hair, bathing, showering or swimming
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Those aged 12 years or older can consider using OTC acetic acid 2% ear drops or spray in the morning, evening and after swimming, showering or bathing. It acts as an astringent in the external ear canal by reducing the pH and reducing bacterial and fungal cell growth. It should not be used for longer than 7 days.12
These recommendations by NICE are appropriate for patients from age 3 months onwards:7
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Provide advice on sources of information and support
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Manage any underlying causes or contributing risk factors
- Manage associated skin conditions
- Avoid using products if they cause allergies or contact sensitivity, e.g. earplugs, hearing aids or earrings, or use alternatives where available (such as hypoallergenic hearing aids)
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If symptom relief is needed, advise on analgesia options such as paracetamol or ibuprofen
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Consider recommending cleaning the external auditory canal ('aural toilet') through dry swabbing or ear irrigation. Ear irrigation should not be recommended if the tympanic membrane is not intact or the patient is immunocompromised.
If possible, ask the patient to allow someone else to administer a topical ear preparation. They should start by warming the drops to body temperature by holding the container in their hands or pocket for a few minutes. This reduces the risk of adverse effects such as dizziness which can occur if cold drops are administered.
To administer the ear drops and ensure optimal delivery throughout the external ear canal:
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The patient should lie down with the ear to be treated uppermost
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The ear canal should be filled with ear drops. Gently pulling and pushing the ear helps to let air out of, and liquid into, the ear canal
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The patient should remain in this position for 3–5 minutes. If they cannot lie still long enough to allow absorption, a small cotton plug covered with petroleum jelly or moistened with the drops and placed at the external opening of the ear canal for about 5 minutes can be used to help retain the drops in the ear. A small cotton swab placed at the tragus can be used to catch any leakage from the ear when sitting up.
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Afterwards, the ear canal should be left uncovered to dry.
1 Independent prescribers
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If you are an independent prescriber in an area covering ear infections, access prescribing information on the treatment of choice in line with your training and consult your patient accordingly prior to supply of an appropriate product
2 Signposting to obtain a prescription
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You can refer patients who may benefit from antibiotic treatment to their GP to obtain a prescription
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You could also refer them to an online prescription service. Various services are available to obtain treatment for AOE without a face-to-face consultation. Your pharmacy may offer its own online service or you can provide advice on finding an appropriate service online
3 Use a PGD to prescribe antibiotics
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There is a PharmaDoctor Ear Infection Pharmacy Service Package that will enable you to offer antibiotic treatment to your patients. You can access more information here
You can further support patients whose infections are showing resistance to one or more antibiotic treatments by directing them to Antibiotic Research UK’s one-to-one patient support service below.
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Prescribing information(please refer to the full SmPC before prescribing)
Cetraxal: https://www.medicines.org.uk/emc/product/8847/smpc#gref
Cetraxal (ciprofloxacin)2mg/ml ear drops solution in a single-dose container
Indication: Acute otitis externa in adults and children older than 1 year with an intact tympanic membrane, caused by ciprofloxacin susceptible microorganisms.
Available strength 0.50 mg ciprofloxacin contained in 0.25ml of solution. See the Summary of Product Characteristics (SmPC) for a full list of excipients. Dosage and method of use: Adults and children aged one year and older: Instil the contents of a single ampoule into the affected ear twice daily for seven days. Children aged less than one year: Safety and efficacy not established. Method of administration: Warm the ampoule in the hand for several minutes. Patient should lie with affected ear upward and instil drops, pulling on auricle several times. Maintain position for 5 minutes to facilitate penetration. For further administration details, please see SmPC. If otowick/tampon is used for administration, double the first dose to two ampoules. Use immediately after opening the ampoule. Discard any unused contents. No dose adjustment required in those with renal or hepatic impairment. Contraindications: Hypersensitivity to ciprofloxacin, any member of the quinolone class or listed excipients. Special warnings and precautions for use: Not for ophthalmic use, inhalation or injection. Monitor use carefully to determine if other therapy may be required. If after one week of therapy, signs and symptoms persist, re-evaluate further. Safety and efficacy not established under 1 year of age. Weigh benefits against known and unknown risks of prescribing in those under 1. Use with caution if known or suspected perforated tympanic membrane and where there is a risk of perforation. Discontinue use at first appearance of a skin rash or any other sign of hypersensitivity. Some patients taking systemic quinolones have shown moderate to severe skin sensitivity to the sun. Serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported, some after the first dose of a systemic quinolone. Serious acute hypersensitivity reactions may require immediate emergency treatment. Overgrowth of non-susceptible organisms may occur from use including bacterial strains, yeast and fungi. If superinfection occurs, treat as appropriate. Interactions with other medicinal products: No interaction studies performed. Due to low plasma levels, systemic interactions unlikely. Recommendation not to use other ear preparations concomitantly. Pregnancy and breast-feeding: Can be used during pregnancy and breast-feeding. Effects on ability to drive and use machines: None or negligible. Side effects: For full list of side effects consult the SmPC. Ear pruritis, headache, application site pain, tinnitus, dizziness, dermatitis. Very rarely with locally applied fluoroquinolones: rash, toxic epidermolysis, exfoliative dermatitis, Stevens-Johnson syndrome, urticaria. MAH: Aspire Pharma Ltd, Unit 4, Rotherbrook Court, Bedford Road, Petersfield, Hampshire, GU32 3QG, United Kingdom MA number: PL35533/0130. Cost: Per pack of 15 ampoules £6.01 Legal Category: POM. Date reviewed: August 2023
Version number: 1010385675 v 4.0
Prescribing information(please refer to the full SmPC before prescribing)
Cetraxal Plus: https://www.medicines.org.uk/emc/product/9805/smpc#gref
Cetraxal Plus (ciprofloxacin and fluocinolone acetonide)3mg/ml + 0.25mg/ml ear drops solution in a single-dose container
Indication: Acute otitis externa and acute otitis media in patients with tympanostomy tubes, in adults and children aged 6 months and older, caused by ciprofloxacin susceptible microorganisms. Available strength: 0.75 mg ciprofloxacin and 0.0625 mg of fluocinolone acetonide, contained in 0.25ml of solution. Please refer to the Summary of Product Characteristics (SmPC) for a full list of excipients. Dosage and method of use: Adults, elderly and children aged 6 months and older: Instil the contents of one single-dose container into the affected ear canal every 12 hours for 7 days. Renal/hepatic impairment: no dose adjustment necessary. Warm bottle by holding in hand for several minutes. Lie with affected ear upwards - for patients with otitis externa, pull the auricle several times during instillation. For patients with acute otitis media with tympanostomy tubes, pump the tragus 4 times by pushing inward to facilitate penetration. This position should be maintained for around 1 minute. For further details, please refer to the SmPC. Contraindications: Hypersensitivity to ciprofloxacin, any member of the quinolone class, fluocinolone acetonide or listed excipients. Viral infections of the external ear canal, including varicella and herpes simplex infections and fungal otic infections. Special warnings and precautions for use: Not for ophthalmic use, inhalation or injection. Should not be swallowed. If otorrhea persists after full course of therapy or if two or moreepisodes occur within six months, evaluate further. If after treatment signs and symptoms persist, evaluate further. Discontinue at first appearance of a skin rash or any other sign of hypersensitivity. Serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported, some after the first dose of a systemic quinolone. Serious acute hypersensitivity reactions may require immediate emergency treatment. Overgrowth of non-susceptible organisms may occur from use including bacterial strains, yeast and fungi. If superinfection occurs, treat appropriately. Some patients taking systemic quinolones have shown moderate to severe skin sensitivity to the sun. Corticosteroids may reduce resistance to, and aid in, the establishment of bacterial, viral or fungal infections and mask the clinical signs of an infection, ineffectiveness of the antibiotic or suppress hypersensitivity reactions. If patient presents with blurred vision or other visual disturbances, consider referral to ophthalmologist for evaluation of causes e.g. cataract, glaucoma, central serous chorioretinopathy. Safety and efficacy not established in children under 6 months – only use after very careful benefit/risk evaluation. Interactions with other medicinal products: No interaction studies performed. Due to low plasma levels, systemic interactions unlikely. Systemic administration of some quinolones may enhance the effects of warfarin and its derivatives and has been associated with transient serum creatinine elevations in patients receiving concomitant cyclosporine. Recommendation not to use other ear preparations concomitantly; if more than one is needed, administer them apart. Pregnancy and breast-feeding: For full details please refer to the SmPC. Pregnancy – Assess whether benefits of the treatment outweigh the possible risk. Caution when administered to a nursing woman. Effects on ability to drive and use machines: None or negligible. Side effects: For full list of side effects consult SmPC. ‘Very Common’ ‘Common’ and ‘Serious’ side effects included in prescribing information: dysgeusia, ear pain, ear discomfort, ear pruritus. MAH: Aspire Pharma Ltd, Unit 4, Rotherbrook Court, Bedford Road, Petersfield, Hampshire, GU32 3QG, United Kingdom MA number: PL35533/0133. Cost: Per pack of 15 ampoules £6.01 Legal Category: POM. Date reviewed: August 2023. Version Number: 1010385676 v 4.0
Adverse event reporting
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for the MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Aspire Pharma Ltd on 01730 231148.