September 2019 HSC Section 1 Congenital and Pediatric Problems

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H. Yankey, G. Isaacson

There are only a few studies addressing the otologic safety and ef- fectiveness of topical mupirocin. Park and Lee [ 28 ] found a low in- cidence of post-tympanostomy tube otorrhea in 67 patients (98 ears) where the tympanostomy tube was coated with topical mupirocin. Hearing results were not reported. Furukawa et al. [ 11 ]. compared topical mupirocin ointment to o fl oxacin drops for control of MRSA otorrhea in 16 of 26 adults. They reported complete elimination of MRSA from the ears in all patients in the mupirocin group, compared with 40% improvement or cure in the o fl oxacin group. They found no new hearing loss “ in any patients who were evaluated by pure-tone audiometry before and after treatment. ” Rutherford et al. [ 12 ]. com- pared 7-day intratympanic injection of solutions of mupirocin and vancomycin in a mouse model. They found no evidence of mupirocin ototoxicity at one month by auditory brainstem response testing. In our small series, topical mupirocin appeared both e ff ective in controlling MRSA TTO and free of observed local reactions or sub- sequent hearing loss. Microscopic debridement by suctioning followed by a single application of mupirocin ointment resulted in resolution of MRSA otorrhea with (8 ears) or without (4 ears) the concurrent ad- ministration of culture-directed systemic antibiotics. Ears treated with mupirocin were less likely to develop MRSA recurrence than those treated with systemic antimicrobials ± ototopical drops. (0% vs 40%; p =0.015). There was no similar e ff ect on future TTO caused by or- ganisms other than MRSA (50% vs 36%; p =1.0). Only one child was found to have a new sensorineural hearing loss after treatment. This was in the control (non-mupirocin) group and involved both ears, making a topical ototoxicity less likely. There are some concerns that should be addressed before re- commending mupirocin ointment for general use. This retrospective study is small and thus has limited statistical power. Further, the mean follow-up was considerably shorter in the mupirocin group compared to controls (6.8 months vs 24 months). This could contribute to the lower overall incidence of MRSA recurrence in the mupirocin group. The lack of ototoxicity in a murine model and a few dozen patients does not mean mupirocin is safe in all children. Finally, topical mupirocin is FDA indicated for the treatment of “ secondarily infected traumatic skin le- sions (up to 10 cm in length or 100 cm 2 in area) due to susceptible isolates of Staphylococcus aureus and Streptococcus pyogenes. ” [ 29 ] Its use in draining ears must be considered “ o ff -label ” .

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5. Conclusion

Topical 2% mupirocin ointment delivers a high dose of an e ff ective agent for several days duration. In combination with mechanical deb- ridement, it controlled infection by CA-MRSA without evidence of local reaction or subsequent hearing loss in this small series. Its role in treatment of MRSA TTO merits further investigation.

Funding

None.

Financial disclosures

None.

Con fl icts of interest

None.

References

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