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favorable for treating a wide array of infections. The prototype quinolone All clinical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
antibiotic agent, nalidixic acid, was first approved by the US Food and revised, or retired at or before that time.
Drug Administration (FDA) for adults in 1964 and generally is considered
DOI: 10.1542/peds.2016-2706
to be the first generation of such agents. For more than 2 decades,
nalidixic acid represented the prototypic fluoroquinolone approved by PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
the FDA and was available for children 3 months and older, but it is no Copyright © 2016 by the American Academy of Pediatrics
longer available. Subsequent chemical modifications resulted in a series
FINANCIAL DISCLOSURE: The authors have indicated they
of fluoroquinolone agents with an increased antimicrobial spectrum of have no financial relationships relevant to this article to
activity and better pharmacokinetic characteristics. disclose.
Ciprofloxacin, norfloxacin, and ofloxacin have a greater Gram-negative FUNDING: No external funding.
spectrum (with activity against Pseudomonas aeruginosa). In 2004, POTENTIAL CONFLICT OF INTEREST: The authors have
ciprofloxacin became the first fluoroquinolone agent approved for use in indicated they have no potential conflicts of interest to
children 1 through 17 years of age. disclose.
tolerability, and cost. Other systemic therapy may be required for more severe infection.
f Available with and without corticosteroid.
concentrations are only 1 indicator of effective than acetic acid solutions. High-quality studies that evaluated
potential clinical efficacy, the utility Aminoglycoside-containing otic quinolone versus nonquinolone
of agents with higher concentrations preparations were reported to cause topical solutions are limited. A
is tempered by the observation of a ototoxicity if the tympanic membrane systematic review of 13 meta-
potential increase in ocular adverse was not intact; fluoroquinolone- analyses confirmed that topical
events, such as eye pain,35 and containing preparations represent antibiotic agents were superior to
slower corneal reepithelialization a safer alternative to treat both placebo and noted a statistically
with specific agents.36 Bacterial otorrhea associated with tympanic significant advantage of quinolone
eradication and clinical recovery membrane perforation and agents over nonquinolone agents
of 447 patients aged 1 through tympanostomy tube otorrhea. Eleven in the rate of microbiologic cure
17 years with culture-confirmed trials included aural toilet as a (P = .035). Safety profiles were
bacterial conjunctivitis were routine intervention, but the authors similar between groups.40 Similarly,
evaluated in a post hoc multicenter acknowledged that this treatment is Mösges et al42 reviewed 12 relevant
study investigating besifloxacin not likely to be available in a typical randomized controlled clinical
and moxifloxacin ophthalmic primary care office setting.38 The studies involving 2682 patients
drops.37 Although better clinical and paucity of high-quality studies of and concluded that quinolone
microbiologic response was noted for antimicrobial agent–based topical therapy achieved a higher cure
besifloxacin compared with placebo, therapy limited conclusions in rate (P = .01) and superior
similar outcomes were noted when this review. A small, prospective, eradication rate (P = .03) than a
compared with moxifloxacin. Both randomized, open-label study in 50 non–fluoroquinolone-containing
agents were reported to be well patients with tympanostomy tube antibiotic-steroid combination.
tolerated. otorrhea or a tympanic membrane The clinical significance of these 2
perforation showed comparable reviews is reduced, however, when
External Otitis, Tympanostomy Tube– outcomes with either topical considering that bacterial persistence
Associated Otorrhea antibiotic therapy or topical plus in the ear canal after treatment does
systemic antibiotic agents.39 For not necessarily imply persistent
Recommendations for optimal care
children with severe acute otitis
for patients with otitis externa acute otitis externa symptoms.
externa, systemically administered
are outlined in a review of 19 A conclusion that quinolone and
antimicrobial agents should be
randomized controlled trials, nonquinolone agents are similar in
considered in addition to topical
including 2 from a primary care both microbiologic and clinical cure
therapy.40
setting, yielding 3382 participants.38 rates was reached in a study in more
Topical antibiotic agents containing Which topical antibiotic agent is than 200 children, 90 of whom were
corticosteroids appeared to be more best for external otitis is unclear.41 evaluated for microbiologic response
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