Are antibiotics always necessary in the treatment of ear infections? I am afraid of my son developing "super bugs" from all the antibiotics we've tried to clear the recurrent ear infections.

Most children with ear infections do not need antibiotics; some do. In acute ear infections, antibiotics do tend to decrease ear pain and speed healing by a day or two. However, pain can be treated in other ways, and most children with ear infections would recover completely without antibiotics. Even among those who would not, many would not be helped by the antibiotics. For some children, though, the antibiotics make a critical difference. Antibiotics can help ear infections heal that would not heal well on their own. They can also prevent severe complications, including meningitis.

Drug-resistant bacteria (the "super bugs" you mention) pose a very real problem. Streptococcus pneumoniae, or pneumococcus, is the most common cause of ear infections. Over the past two years, resistant strains of pneumococcus have been emerging and spreading rapidly in the United States. Unheard of only a few years ago, these strains are showing greater resistance to more and more antibiotics each month. Even resistance to Rocephin, or ceftriaxone, a powerful, injectable antibiotic, has been reported. Only one antibiotic -- vancomycin, an intravenous medication for life-threatening situations -- is still completely effective against all strains. If antibiotic use continues at the current pace, it is only a matter of time until resistance to vancomycin develops also.

Resistant strains are more common in children who have recently been treated with antibiotics stronger than amoxicillin, Septra, erythromycin, or Pediazole. They are also more common in children in group day-care settings. Resistant strains develop in response to antibiotic use, and unfortunately, these strains are the ones which survive the best and spread the fastest wherever antibiotics are used most. A report on the Rockefeller University Workshop, published in the New England Journal of Medicine (1994;330:1247), points to the massive quantities of antibiotics used in fisheries, animal husbandry, and other areas of agriculture as a major cause of the emergence of multiple-antibiotic-resistant bacteria. We in medicine, however, must take responsibility for the problem. Antibiotics are commonly used to treat colds and respiratory viruses. This must be stopped.

The most common bacterial infections treated with antibiotics are ear infections. Our current situation demands that we reevaluate what has been the standard medical approach to ear infections. The need for change is clear. The best approach for the future is still coming into focus.

When antibiotics were first discovered, they had such an immediate positive effect that their widespread use proceeded almost without thought. A prescription for antibiotics, however, cannot remain the knee-jerk response to an ear infection. On the other hand, antibiotic use in ear infections cannot be abandoned. Reports from Germany in 1994 indicate the return of mastoiditis and other serious bacterial infections as a result of lack of antibiotic treatment, or insufficient antibiotic treatment, of ear infections. We do not want to return to the pre-antibiotic era.