Ear infections
Next, let’s address treatment of acute otitis media – ear infections. There are at least six reasons to treat ear infections with antibiotics. Worldwide, the No. 1 cause of acquired deafness in children today is ear infections. This is rarely seen in the United States because we rarely have patients with chronic suppurative otitis media since antibiotics are typically prescribed.
Second, ear infections have suppurative complications such as mastoiditis, labyrinthitis, malignant otitis, brain abscess, sepsis, and meningitis. The World Health Organization attributes 20,000 deaths per year to complications from ear infections.
Third, ear infections can lead to eardrum rupture and subsequent chronic middle ear drainage.
Fourth, untreated otitis more often progresses to a nonsuppurative complication – a cholesteatoma.
Fifth, while earache is a self-limited illness, antibiotics shorten the acute symptoms by a day or 2 and lessen the duration of middle ear effusion after infection that can cause temporary hearing loss. Once again, as a child advocate, I would point out that pain from an ear infection is often severe and the lingering effects of a middle ear effusion are annoying to say the least.
Lastly on this topic, if a clinician makes the diagnosis of an ear infection in a patient and does not treat with antibiotics, the decision should be within the guidelines of the standard of care as described by the American Academy of Pediatrics2 with decision-making based on patient age and severity of symptoms.
I am not advocating wholesale antibiotic treatment of all ear pain or presumed ear pain. With this clinical condition we currently do not have a diagnostic test, and therein lies the conundrum. Most acute otitis media occurs among children age 6-24 months old, and this leads most clinicians to overdiagnose the infection. A child in that age group is nonverbal and in the context of a viral upper respiratory illness the symptoms of acute otitis media overlap completely with those of a viral URI. Therefore, an adequate examination is necessary. Confronted with an irritable child who is uncooperative with a challenging otoscopic examination, an ear canal with wax blocking an adequate view of the tympanic membrane, and a parent in a hurry to get back to work or home, the inclination is to observe a “little bit of redness” and prescribe unnecessary antibiotics. Even though redness is not a good diagnostic indicator, whereas a full or bulging eardrum is for the diagnosis of acute otitis media, I shudder at how often I see in a medical record a description of redness of the eardrum and no comment on the fullness that occurs when an authentic infection is most likely.
I could extend this column discussing acute sinusitis and cough illnesses as they are two other conditions associated with infection where antibiotics have their important place and where antibiotics are also overused. Instead, I will end by summarizing my viewpoint that judicious antibiotic use is of high importance for prevention of antibiotic resistance at the individual patient level and the community level. However, we should not become complacent about the risks to untreated children experiencing common respiratory infections because there are many justifiable reasons to treat children as discussed here.
Dr. Pichichero is a specialist in pediatric infectious diseases, Center for Infectious Diseases and Immunology, and director of the Research Institute at Rochester (N.Y.) General Hospital. He has no conflicts of interest to disclose.
References
1. Schwartz RH et al. A reappraisal of the minimum duration of antibiotic treatment before approval of return to school for children with streptococcal pharyngitis. Pediatr Infect Dis J. 2015 Dec. doi: 10.1097/INF.0000000000000883.
2. Lieberthal AS et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar. doi: 10.1542/peds.2012-3488.