Antibiotics And Ear Infections

What's the big deal about antibiotics?

It's the crux of the matter.

Worldwide, we have used enough antibiotics, inappropriately, to "educate" bacteria, the  concept of "antibiotic resistance." Some of them, like streptococcus pneumoniae, have learned enough to beat lots of antibiotics, and we are facing the real problem of not having a medicine to kill this bacteria in the future. The inappropriate use of antibiotics means treating infections other than those caused by bacteria with antibiotics. Antibiotics treat bacteria. Nothing else. And when we use the antibiotics during a viral illness, we just make bacteria smarter. (For those of you who are trekkies, bacteria are kind of like the Borg: we show them our weapons, and they adapt.)

In places like Holland, antibiotics are not standard of care for the initial treatment of ear infections , and they have much less of a problem with antibiotic resistance. And more importantly, they don't have any more problems with complications of ear infections.

What happens if we don't use Antibiotics for an Ear Infection?

More pain?

No. Antibiotics have no effect on pain in the first 24 hours of treatment. And regardless of whether we are going to use antibiotics, some type of pain reliever will be necessary (you may want to consider this before taking your child to the ER in the middle of the night for ear pain-even if you get the antibiotic, it will not make them feel better for awhile and may not even be necessary).

Longer duration of illness? Increased risk of complications?

There are a bizillion articles on the treatment of ear infection. Really. There are studies using every method of checking, all different types of medicine, in all sorts of cultures and all sorts of patient populations. However, the evidence that antibiotics decrease the length of illness or the complication risk is lousy.

In the days prior to the development of antibiotics, children with bacterial ear infections were at risk to have that infection extend to the brain and to the structures surrounding the middle ear. Since the use of antibiotics in ear infections, that doesn't happen anymore, but it also doesn't happen in countries where they don't use antibiotics (like Holland). If you want data: In Holland, among 4860 consecutive patients with ear infection not given antibiotics, 2 developed mastoiditis and none developed meningitis.

The point here is that we give antibiotics to prevent bad things, but bad things aren't really happening anymore. In fact, about 80% of ear infections go away whether we treat with antibiotics, do a rain dance or dip your child in finger paint.

Do antibiotics help the kids at greatest risk?

The kids at greatest risk are those in day care, who are bottle feeding, have a family history of frequent ear infections, who use a pacifier and those who have parents who smoke. We know that these are the children at highest risk for complications of ear infections, but we have no real evidence that says that antibiotics help those kids prevent the complications. What is clear is that we should have day care providers ( and all of us really) wash our hands frequently to prevent the spread of infectious disease. We need to increase the rate of breastfeeding in this country and we need to have families create smoke free environments.

How about the length of treatment?

Recent studies indicate that the level of antibiotics in the area that we want them to go (the middle ear) drops off significantly after 2 days or so. That means that the 10 days for which we are traditionally treating the infection may be unnecessary, and that a course of 3, 5 or 7 days might be fine.

So when should we treat?

Your child should look sick before we treat them. The presence of fever and or ear pain doesn't really help, believe it or not. What I'm in favor of is waiting, treating symptoms in the meantime, and seeing what happens:  "masterful inactivity." If the symptoms persist, we treat. What I have been doing is sending you home with the prescription and asking you to wait to fill it. If your child is still symptomatic after 48 hours, then fill the prescription. We'll have closer follow up with kids who are less than 2 and we'll need to check kids under 2 (this is the age group that can't tell me that they have pain or aren't hearing well) for persistence of fluid after the acute infections. That's what we do at the one month follow up. All ear infections leave a bit of fluid behind as they heal. That fluid does not have bacteria in it usually, so careful observation is all that's needed. Presence of that fluid for more than 3 months is the thing correlated with hearing loss and need for tubes, and if it's there after 3 months, I send you to a fine ENT doctor for evaluation for tubes.

prevention of ear infections

treatment in the middle of the night