Pseudomonas otitis

Re: Pseudomonas otitis

Moira Hamilton — Sun, 04 Nov 2012 15:18:03 GMT

Also agree with starting on ear cleaning asap, in bad cases I usually end up using the sensitive cleanaural product, as it doesn't seem to cause as much irritation to the dog.

Re: Pseudomonas otitis

Moira Hamilton — Sun, 04 Nov 2012 15:10:33 GMT

Although the case I treated was very longstanding, not a new case, I ended up treating systemically with tobramycin, and then when had settled down used tobramycin drops, mainly since every time took a swab, was becoming resistant to the cascade antibiotics. Was quite expensive, but cleared up an infection that had been going on for 4 years, so at least the owner was happy. In your case, is it worth thoroughly checking the ear under sedation to see if the TM is ruptured? Presume it is quite a large breed if you're not wanting to use enro or marboflox. Good luck

Re: Pseudomonas otitis

mark packer — Sun, 04 Nov 2012 14:02:14 GMT

I recall Tim Nuttall from Liverpool Uni discussing ear cleansers and topical preps used together at BSAVA congress 3 years ago - work done by a research student there - and if I remember correctly they had no adverse effect.

I have used marbofloxacin at double dose in an uncooperative SBT with pseudomonas and it worked very well.

Re: Pseudomonas otitis

Kate Richardson — Sat, 03 Nov 2012 04:39:19 GMT

[quote user="Evelyn Barbour-Hill"]

The lab says it's sensitive to gentamicin.

This is a first-line case, not a refractory one.

I'd start it on Otomax or Ease-Otic right away.

Am I going to get flamed?

[/quote]

I agree, I think the sooner you treat a first line case effectively the better- chronic pseudomonas ears are a nightmare. Also an Easotic fan- once daily so compliance good and works quickly. Pseudomonas ears are painful. May even need a few days of oral antibiotics/steroids before you can get near ears to medicate- I usually go for marbofloxacin (based on C&S before anyone shoots me down). GA and flush a good plan if canals full of pus. I usually do cytology first on ears and if rods are seen I do send for culture, otherwise I don't usually bother unless ++++++cocci seen or ears particularly sore or recurrent problems. I have never seen ototoxicity from ear drops (yet....) but I believe the infection and inflammation is going to cause more damage than the treatment in these cases

Re: Pseudomonas otitis

Evelyn Barbour-Hill — Sat, 03 Nov 2012 00:19:06 GMT

The lab says it's sensitive to gentamicin.

This is a first-line case, not a refractory one.

I'd start it on Otomax or Ease-Otic right away.

Am I going to get flamed?

Re: Pseudomonas otitis

Richard Larkin — Fri, 02 Nov 2012 23:37:47 GMT

Anyone with experience of using flamazine cream infused into canals via wide bore catheter after ga flush and tris edta soak in cases of multi resistant (fluoroquinolone / gentamicin) Pseudomonas otitis? I have used it a couple of times successfully in cases refractory to other treatments, although 3-4 treatments generally required.

Re: Pseudomonas otitis

Rajat — Fri, 02 Nov 2012 18:25:14 GMT

Hi Chris

Yes that was an interesting article - and a good heads up that one should not automatically assume efficacy ;)

There has been some work done on compatibility of cleaners and abs. I will try to dig it up I dont for the life of me remember the journal or title but it was in the last year or 2. As mentioned previously, the obvious one is not to use low ph cleansers like malacetic with fluroquinolones.

Are there any derm cert holders or diplomates on these boards-a-lurkin?

Re: Pseudomonas otitis

Chris Barker — Fri, 02 Nov 2012 17:45:29 GMT

I hope everyone posting on the efficacy of their home made concoctions has bothered to read the article in this month's JSAP regarding the efficacy of aural cleansers against Pseudomonas. And its finding that the efficacy of Tris EDTA is variable... Great summary and a v useful guide for us 1st opinion guys trying to use EBVM rather than anecdote...

Now we need someone to do some experimental work regarding the compatibility of cleansers and the antibiotics present in our licensed polypharmacy products

Re: Pseudomonas otitis

Mark Holmes — Fri, 02 Nov 2012 16:21:57 GMT

People worry about the onto toxicity of topicals and pay very little attention to the ototoxicity of pseudomonas. If you have it treat it and if that needs topical meds use them.

Re: Pseudomonas otitis

Emma Middleton — Fri, 02 Nov 2012 14:25:12 GMT

[quote user="Martin Atkinson"]Lets get this all in perspective: I've been using commercially available ear drops for the past 37 years, I only use home-made concoctions when there isn't a product available with the antibiotics I want to use. In the vast majority of cases quite honestly I couldn't tell you whether the ear drum was intact or not. I have not ever had a case of ototoxicity. You lot are making life unnecessarily complicated for yourselves.[/quote] Martin I see your point and we shouldn't get carried away when the risk is small. I don't think anyone was advocating off-license or home made preps as first line treatment for any old case of OE. It was in the context of a case of pseudomonas with culture and sensitivity. Quite rightly, Catherine pointed out that Aurizon might be a suitable treatment from the sensitivities provided by the lab. Re the cascade, you'd have to have justification for using something else, but you could feasibly find a good reason here - e.g. Aurizon data sheet specifically says do not use in dogs where TM is ruptured or is not known to be intact. I think the point was that there may be some benefit in using triz-edta based preps (home made) over licensed products in certain cases.

Re: Pseudomonas otitis

patrick murphy — Fri, 02 Nov 2012 13:29:33 GMT

I would challenge anyone to show me proof of a proper psuedo with any TM.the whole point of this bug is it loves rotten tissue so it is an endgame bug.ototoxicty is quite over rated and if you look at the proper studies, in dogs it is quite hard to acheive.

Re: Pseudomonas otitis

Martin Atkinson — Fri, 02 Nov 2012 12:49:32 GMT

[quote user="Simon Neuhoff"] I think using fluoroquinolones as a first line treatment is just plain wrong.[/quote] Agree, but then Aurizon does have a nice long, soft, flexible nozzle - why don't they put that on Canaural?

Re: Pseudomonas otitis

Simon Neuhoff — Fri, 02 Nov 2012 11:59:07 GMT

[quote user="Martin Atkinson"]

Lets get this all in perspective: I've been using commercially available ear drops for the past 37 years, I only use home-made concoctions when there isn't a product available with the antibiotics I want to use. In the vast majority of cases quite honestly I couldn't tell you whether the ear drum was intact or not. I have not ever had a case of ototoxicity. You lot are making life unnecessarily complicated for yourselves.

[/quote]

This. As I understand it ear drums rupture very frequently - it is highly likely that we have all used topicals in ruptured ear drums on a vast number of occasions. I have seen ototoxicity symptoms on two occasions as I recall - both in animals where the ear drum looked intact on an exam under GA. I am not saying we should be totally blase about this - but as Martin says perspective is needed.

Also worth considering cascade here before we go stampeding straight for the home made stuff. Not to mention that fluoroquinolones should be reserved for cases where they are genuinely needed - based on culture and sensitivity results. I get the impression from some of the posts on here that some people go straight to these and this is going to make out lives very hard indeed in the future. I think using fluoroquinolones as a first line treatment is just plain wrong.

Re: Pseudomonas otitis

Martin Atkinson — Fri, 02 Nov 2012 09:57:39 GMT

Re: Pseudomonas otitis

Rajat — Fri, 02 Nov 2012 09:19:19 GMT

[quote user="Emma Middleton"]. And of course steroids have their place in these cases too.[/quote]

I agree totally thanks Emma I forgot to mention this- I always have these dogs on systemic steroids - preds at 0.5-1mg/kg then wean over 4-6 weeks- I usually start a few days prior to GA flush so I can see what's happening.As these dogs have had O.E for some time, Otitis media is quite common, and certainly all the ones I've had with pseudomonas have had ruptured TMs (tho not obvious signs of O media)the bit about them being ruptured then healed over+ bulging or otherwise subtly abnormal is an excellent point too

Re: Pseudomonas otitis

Emma Middleton — Fri, 02 Nov 2012 08:11:51 GMT

[quote user="Rajat"]Sue Patterson did an excellent video for dermapet re pseudomonas, an hour long, detailed and good info I can't find it since a year or so now, tho (prob taken off the website since dechra bought dermapet)[/quote] Yes, very helpful. Went to one of her CPD evenings where she talked a lot about Pseudomonas treatment. I remember her saying a lot of them have otitis media as well (and the TM can partially or even completely "heal" over - so check for bulging) and also most if not all are found to be atopic/hypothyroid/immunosuppressed for another reason. I'll dig the notes out at work today and see if there was anything else that might be of use to you. Rajat makes a good point about "soaking" the ear for 15 mins rather than just a normal flush as you would for other bacterial/fungal otitis cases. And of course steroids have their place in these cases too.

Re: Pseudomonas otitis

Utlendigur — Thu, 01 Nov 2012 23:05:49 GMT

[quote user="Rajat"]While malacetic aural does have activity against pseudomonas, it cannot be used with fluroquinolones as the low pH inactivates them so I have never used it this way. Also some derms think getting rid of all the yeasts (say one used malacetic daily long term) can predispose to pseudomonas infections. I do love malacetic for yeast infections. It rocks[/quote]

I think I was getting confused with a recent case - labrador with really horrible otitis and ruptured tymp membrane where Dechra advised malacetic - I was thinking it was Pseudomonas but was actually Malassezia when I looked back. Second comments about it working well.

Re: Pseudomonas otitis

Rajat — Thu, 01 Nov 2012 22:08:53 GMT

Hi Catherine

Aurizon and all other ear products have 'carrier's eg propylene glycol which can be oto/neurotoxic

For a few years now I make up this recipe like others have suggested with triz aural and 10mls colvasone (=20mg dexamethasone) and between 1-1.4grams Baytril.

This has the advantage of giving you higher topical concentrations of enrofloxacin in the ear with while being safe in the middle ear. You cannot achieve as high concentrations using tablets or aurizon /other preps etc.

It's not guaranteed you'll get ototoxicity with commercial preps, its just much more likely.

While malacetic aural does have activity against pseudomonas, it cannot be used with fluroquinolones as the low pH inactivates them so I have never used it this way. Also some derms think getting rid of all the yeasts (say one used malacetic daily long term) can predispose to pseudomonas infections. I do love malacetic for yeast infections. It rocks.

It's worth having these dogs in for a GA flush at the beginning, - flush the ear gently but thoroughly, soak with triz aural 15 minutes, dry then examine and assess TM (use rigid endoscopy if needed/available and culture middle ear if only a tiny tear).

The soak with Triz does help to get the thing started. I'd never treat pseudomonas with just Triz or malacetic.

I reculture every 2 weeks. Pseudomonas can change its sensitivity patterns very quickly so one needs to stay on top of it.

My last case(waiting for final culture after being off topicals for 2 weeks! fingers crossed..) I had to eventually put onto canaural. I took the risk because I had run out of abs I could use. I did check with RVC derm dept and they said even if it did get ototoxicity it would be reversible and they had found less risk of this with canaural. Initially tho it had been on the above baytril mixture and then it went and became resistant to fluroquinolones AND was symptomatic while on tx, so the higher local doses weren't killing the psuedomonas. And it was only sensitive to Canaural. Go figure - I end up using the oldest ear drops on the toughest bugs. I don't think I've reached for Canaural in something like 2 or 3 years!! I usually err on the side of caution and use systemic abs too- usually a fluroquinolone as initially most of these are sensitive to them. Especially if there is any canal ulceration or neutrophils on cytology.

It can be expensive treating this disease properly, so worth having the owners on board for the long haul

If you need more info, I can send you some fun reading material on ear dzs and pseudomonas

Sue Patterson did an excellent video for dermapet re pseudomonas, an hour long, detailed and good info I can't find it since a year or so now, tho (prob taken off the website since dechra bought dermapet)

hope that helps a bit

Rajat

Re: Pseudomonas otitis

CatherineThomas — Thu, 01 Nov 2012 21:43:05 GMT

So isn't it the same as using triz EDTA and Aurizon?

Re: Pseudomonas otitis

mark packer — Thu, 01 Nov 2012 21:12:59 GMT

I think it's the triz EDTA which punches holes in the gram negative cell wall letting the marbocyl in.

I got the recipe from Dermapet, who marketed the triz range, originally ,Sue Paterson was very involved with developing the products I think. She works for Rutland House vets in Cheshire.

Re: Pseudomonas otitis

mark packer — Thu, 01 Nov 2012 21:12:58 GMT

I think it's the triz EDTA which punches holes in the gram negative cell wall letting the marbocyl in.

I got the recipe from Dermapet, who marketed the triz range, originally ,Sue Paterson was very involved with developing the products I think. She works for Rutland House vets in Cheshire.

Re: Pseudomonas otitis

CatherineThomas — Thu, 01 Nov 2012 20:41:11 GMT

What is the advantage of a homemade preparation with baytril or marbocyl over using aurizon?

Yes it is a cocker spaniel, how did you know?

Re: Pseudomonas otitis

Emma Middleton — Thu, 01 Nov 2012 20:33:35 GMT

A home made preparation may be the way to go, but I would also be thinking about an ear flush under GA. You can then establish the TM status and if there is a possible otitis media to deal with as well. Is it a Cocker Spaniel?

Re: Pseudomonas otitis

Claire Fisher — Thu, 01 Nov 2012 20:16:39 GMT

[quote user="mark packer"]

I often use a home made off licence prep of triz aural with 5-10ml dexadreson 2mg/ml injection and 5ml of 10% marbocyl injection (or 25ml of 2% marbocyl injection) added - - it works really well high concentrations delivered to the site of the problem.

Ring Dechra, they should give some advice on this off licence preparation or chat to a dermatologist.

[/quote]

We have been advised the same, there is an article somewhere by Sue Paterson using a similar idea but with Baytril rather than Marbocyl.

Re: Pseudomonas otitis

mark packer — Thu, 01 Nov 2012 17:52:41 GMT

Ring Dechra, they should give some advice on this off licence preparation or chat to a dermatologist.