Antibiotics and Ear Infections

Dr. Greene's Answer

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. We need a wise, thoughtful, new approach.

Ear infections fall into two major categories: acute otitis media (AOM) and secretory otitis media (otitis media with effusion (OME)). Children with OME have fluid filling the middle ear. Children with AOM have fluid in the middle ear and ear pain,. They may have marked redness of the eardrum and distinct bulging of the eardrum, often with fever. These two different conditions call for different treatment.

Since the fluid in OME is known to contain bacteria, it became common practice for well-meaning pediatricians to prescribe antibiotics for otitis media with effusion (OME). However, a recent set of guidelines by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology advises against the common use of antibiotics for treatment of OME. For the majority of healthy children, no treatment is necessary for 3 months. A single trial of antibiotics can be tried prior to considering surgical ear tubes, but repeated courses of antibiotics are not recommended.

Even in the treatment of acute otitis media (AOM), antibiotics are commonly overused. In 2004, the American Academy of Pediatrics and the American Academy of Family Physicians published a recent set of guidelines for the treatment of acute ear infections. These new guidelines recommend limiting the majority of antibiotic treatment for AOM to children under 2 years of age. They adopt an antibiotic-free approach for most older children with AOM. In these guidelines, they recommend treating with pain relievers and initial observation for healthy children 2 years old or older with uncomplicated, nonsevere AOM. Antibiotics are recommended for these children only if they do not improve on their own in 48 to 72 hours, or if they develop severe symptoms (fever greater than or equal to 39 C or moderate to severe ear pain)

Advancing vaccine development may also help reduce the need for antibiotics in ear infections. The pneumococcal vaccine is now widely used and routinely recommended for children under 2 years of age. This vaccine has been shown in large clinical trials to reduce the risk of middle ear infections, and their complications.

Antibiotics are a wonderful, life-saving tool. During the first half of the 20th century, we keenly felt their lack as we helplessly watched bacterial infections rage. During the last fifty years, we erred in their overuse. As we enter the 21st century, we are beginning to appreciate the importance of balance in all that we do. I share your concern for your son, and all of our children. Antibiotics are not necessary in the treatment of all ear infections.