Question #2: Is clindamycin a good option for outpatient treatment of chondritis/perichondritis of the ear in children?

This is a two-part question: 1) Does clindamycin penetrate the appropriate tissue (cartilage) adequately to potentially treat the disease? 2) Does it treat the appropriate bacteria?

Clindamycin does appropriately concentrate in bone, joints, and cartilage. Most studies demonstrating appropriate tissue penetration are animal studies. For example, an animal study by Eismont et al demonstrated adequate clindamycin concentrations in the nucleus pulposus of spinal intervertebral discs of rabbits.⁶

The most important question, though, is, does it treat the appropriate bacteria? The simple answer is no. There are a number of case reports on outbreaks of auricular chondritis/perichondritis that have occurred.^7–9 The majority of these cases have occurred in children and adolescents and have commonly involved Pseudomonas aeruginosa.¹⁰ A number of cases have required hospitalization with intravenous antibiotics. A common cause has been cartilaginous ear piercings at the mall. The bottom line is that practitioners need to cover for P. aeruginosa. What are our oral antibiotic options? Fluoroquinolones are a potential option, and these are discussed above.

As a side note, the culprit in most of these ear-piercing reports was contaminated cleaning solution used before the piercing was placed.

Summary

Clindamycin is not the appropriate antibiotic for outpatient treatment of chondritis/perichondritis of the ear. It does appropriately concentrate in cartilage but does not cover P. aeruginosa, the primary bacteria causing infection in cartilage of the ear. You need to give an oral antibiotic that covers Pseudomonas. That antibiotic is probably an oral fluoroquinolone.

Dr. Jones is assistant professor of pediatric emergency medicine at the University of Kentucky in Lexington.

Dr. Cantor is professor of emergency medicine and pediatrics, director of the pediatric emergency department, and medical director of the Central New York Poison Control Center at Upstate Medical University in Syracuse, New York.

References

1. Burkhardt JE, Walterspiel JN, Schaad UB. Quinolone arthropathy in animals versus children. Clin Infect Dis. 1997;25:1196-1204.
2. Patel K, Goldman JL. Safety concerns surrounding quinolone use in children. J Clin Pharmacol. 2016 Feb 10. [Epub ahead of print]
3. Hampel B, Hullmann R, Schmidt H. Ciprofloxacin in pediatrics: worldwide clinical experience based on compassionate use—safety report. Pediatr Infect Dis J. 1997;16:127-129.
4. Chalumeau M, Tonnelier S, D’Athis P, et al. Fluoroquinolone safety in pediatric patients: a prospective, multicenter, comparative cohort study in France. Pediatrics. 2003;111:e714-719.
5. Noel GJ, Bradley JS, Kauffman RE, et al. Comparative safety profile of levofloxacin in 2523 children with a focus on four specific musculoskeletal disorders. Pediatr Infect Dis J. 2007;26:879-891.
6. Eismont FJ, Wiesel SW, Brighton CT, et al. Antibiotic penetration into rabbit nucleus pulpous. Spine (Phila Pa 1976). 1987;12:254-256.
7. More DR, Seidel JS, Bryan PA. Ear-piercing techniques as a cause of auricular chondritis. Pediatr Emerg Care. 1999;15:189-192.
8. Keene WE, Markum AC, Samadpour M. Outbreak of Pseudomonas aeruginosa infections caused by commercial piercing of upper ear cartilage. JAMA. 2004;291:981-985.
9. Fisher CG, Kacica MA, Bennett NM. Risk factors for cartilage infections of the ear. Am J Prev Med. 2005;29:204-209.
10. Sosin M, Weissler JM, Pulcrano M, et al. Transcartilaginous ear piercing and infectious complications: a systematic review and critical analysis of outcomes. Laryngoscope. 2015;125:1827-1834.