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Malignant Otitis Externa
OPAT - Nottingham University Hospitals NHS Trust
DrFionaAndrewarthaConsultantMicrobiologistandInfectiousDiseasesPhysician
BSAC-OPATConference2017
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Background • Externalauditorycanalandskullbaseinvasiveinfection• 86-90%casesindiabetics(RubinGrandis,Branstetteretal.2004)• Pseudomonasaeruginosa>90%cases(RubinandYu1988)• AuralwaterexposurelinkedtoMOE(FordandCourteney-Harris1990;Zikk,Rapoportetal.1991)
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• Clinicalfeatures• Intractableheadache• Otalgia• Otorrhea• Inflammation,floorofearcanal• Unresponsivetotopicalantibiotics
• Complicationsofinvasiveinfection• Cranialnervepalsies• VenousSinusThrombosis• Meningitis• BrainAbscess
LiftedfromRubinGrandisJ,BranstetterBFt,YuVL.Thechangingfaceofmalignant(necrotising)externalotitis:clinical,radiological,andanatomiccorrelations.TheLancetInfectiousdiseases.2004;4(1):34-9.
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Diagnostic Challenges
• Nosinglepathognomonicfeature• Typicalsignsofinfectionoftenabsent• Diagnosisoftendelayed–6.9monthstodiagnosis(JacobsenandAntonelli2010)• ESRreportedtobeuseful(Rubin,Stoehretal.1989)• Radiology:
• CT• MRI• Bonescans–sensitivebutnotspecific• Galliumscans–morespecific• Imagingcannotdistinguishcancerfrominfection
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Diagnostic Challenges
Highindexof
suspicion
Diabetesorother
immune
compromise?
Pseudomonas
aeruginosa
isolatedfromear
canal
Supportive
clinicalfeatures
Radiological
features
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Treatment
• LackofRCTstoguidetreatment• 50%mortalitypre1960s.20%aftersemi-syntheticpenicillins(Chandler1968)
• Ciprofloxacinrevolutionisedtreatment(WisemanandBalfour1994)
• Treatmentlengthvaries–6-8weeksminimum• Ciprofloxacinremovesneedforradicalsurgery• Hyperbaricoxygen–noevidencetoshowefficacy(Davis,Gatesetal.1992)
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Management Algorithm
LiftedfromRubinGrandisJ,BranstetterBFt,YuVL.Thechangingfaceofmalignant(necrotising)externalotitis:clinical,radiological,andanatomiccorrelations.TheLancetInfectiousdiseases.2004;4(1):34-9.
Suspicion
Diagnosis
Treat
Monitor
Follow-up
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NUH OPAT experience
• 23patients-16male,7female• 76-meanage(range47-95)• 8weeks-meantimetodiagnosis(range2-24)• Co-morbidities:
• 78%Diabetes• 9%other-CKD,renaltransplant• 13%none
• August2013–October2016
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NUH OPAT experience
1916
14
20
2
4
6
8
10
12
14
16
18
20
Otalgia Otorrhoea Headache CranialNervePalsy Other
ReportedSymptoms
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NUH OPAT experience • 91%sampled–mostsuperficialswabs
• 70%tissuesentforhistology• 1/23fungalbiomarkers• CRPmean52(range<5-156)• 52%normalCRPatdiagnosis• 91%CTatdiagnosis• 26%nofollow-upimaging• 30%serialimaging
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0123456789
10
1stLineAntibioticRegimens
Meantreatmentlength9.4weeks(range4.4–31.6weeks)
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NUH OPAT experience
• 61%sufferedadverseeffects
17%
6%
6%
18%29%
6%
6%6%
6%
AdverseEffects
CNSeffects
DerangedLFTs
DrugInducedFever
RenalImpairment
Rash
Anaphylaxis
C.difficile
Blooddyscrasia
Vomiting
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NUH OPAT experience • 1yearmortality17%
• 1diedasaresultofMOE• Remaining3diedfromco-morbidities
• OPATOutcomes• 65% cured• 26% improved• 9% failed
• Radiologicalimprovement• Yes 41%• No 47%• Unclear 12%
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NUH OPAT MOE Summary
• Complexinfectioninacomplexgroup• Challengesindiagnosisandmanagement
• 17%mortality• Nostandardisedimagingprotocol• Nostandardisedantimicrobialprotocol• Highrateofadverseeventstoantibiotics