Monday’s blog post, “When Nothing Is Something,” provoked these thoughtful questions from a reader:

Can you address antibiotics for ear infections (caused by viral illnesses)? I brought in an infant with a virus with concerns about her breathing. She did have an ear infection but the doctor said I could wait and fill the prescription “at my discretion.” It did clear up on its own after a few days but it left me wondering, why prescribe them at all? Are there times when viral illnesses cause ear infections that do need antibiotics? How can one tell the difference? How do you balance the risk of a child’s hearing vs. the various problems that antibiotics cause?

 

Ear infections are perhaps the most common diagnoses pediatricians make as they reach for their prescription pads to prescribe antibiotics. (Okay, pediatricians today use computers and electronic health records and don’t “reach for their prescription pads” anymore!) The medical term (in latin) that pediatricians use is “otitis media”, meaning inflammation of the middle ear. An upper respiratory viral infection in the form of a common cold is the typical trigger causing inflammation of the cells lining the middle ear. The cellular inflammation causes fluid to be released into the middle ear space, leading to more inflammation to occur, more fluid to be released, impaired hearing in the affected ear and, very often, pain. The events at this early point of the illness are caused by the virus that is causing the cold symptoms (most often a strain of rhinovirus). There is a very good chance that if the cold runs its typically mild course and resolves over several days, the inflammation and fluid (and hearing loss and pain) will go away as well, without the need for antibiotics. And that is good news because, as we rediscovered on Monday, antibiotics don’t treat viruses.

But this isn’t the end of the story. Bacteria like to grow where it’s warm, wet, and remote. The longer fluid persists in the middle ear space — some reasons why that might happen include the cold lasting longer than usual; a sinus infection settling in after ten days; the anatomy of the middle ear preventing rapid drainage of the fluid (true especially in infants); and other exogenous factors that allow the inflammation to persist (exposure to secondhand tobacco smoke) — the more likely bacteria will find it, settle in, and multiply. In this case, the viral ear infection that needed no antibiotic treatment has transformed into a bacterial ear infection that may require antibiotics.

The question is, then, “How can one tell the difference [between a viral and bacterial ear infection]?” The answer is, unless you want your pediatrician to insert a needle into your (screaming and thrashing) child’s eardrum to suck out the fluid and send it for a bacterial culture (and not have results back until 2-3 days later), there really isn’t a practical way to tell the difference for certain. This is where the science takes a backseat to the art of medicine, where experience and intuition trump book-smarts and data. Even without definitive proof, however, there are times when pediatricians will prescribe antibiotics for ear infections and times they won’t. For example, because of their age and their immature immune systems, most infants under 6 months of age will receive antibiotics for their ear infections. In most children, significant ear pain accompanied by fever will also likely tip our hand to prescribe antibiotics. Unless their clinical findings or symptoms are compelling, older kids are more likely to receive “wait-and-see” instructions, but no prescription, from their pediatrician.

The American Academy of Pediatrics updated treatment guidelines for ear infections in 2013. Most pediatricians were already onboard with the new recommendations, as I pointed out on The PediaBlog at the time:

The goal is to minimize the chances of bacteria developing resistance to antibiotics by providing fewer antibiotics to children who may likely resolve their ear infections without them. It’s preaching to the choir for pediatricians, but hopefully, it will sink in for providers at community emergency departments and the proliferating urgent care businesses, who don’t have the experience and/or comfort level with caring for sick children.

 

I summarized the AAP’s updated treatment guidelines for otitis media this way, beginning with the criteria needed to make an accurate diagnosis:

  • The ear had better look infected in order to make a diagnosis of acute otitis media (ear infection). Simply having fluid behind the tympanic membrane (ear drum), or simply having a red ear drum is not enough. The ear drum should be sufficiently inflamed (red) and bulging — if not perforated and draining — to be deemed acutely infected.
  • The diagnosis can also be made if the ear doesn’t look so bad but the child is having pain within 48 hours of the visit. In other words, complaining of pain 3 days ago but not now may not buy an antibiotic.
  • In young children ages 6-23 months, treatment of acute ear infections with an antibiotic is recommended most of the time. If only one ear is infected — and not severely — in this age group, the choice of watchful waiting with close follow-up vs. antibiotics should be made as a joint decision between provider and parent.
  • Children older than two with non-severe symptoms of an acute ear infection can also be given the option of antibiotics vs. observation. Here the symptoms dictate the management. Kids with moderate-to-severe pain or fever greater than 102 should receive an antibiotic, while those with less pain or low-grade fever can be given the option.
  • High-dose amoxicillin should be the first-line antibiotic used for acute otitis media in children who are not penicillin-allergic, haven’t had amoxicillin in the past 30 days, or who don’t have a purulent conjunctivitis (pink-eye) with their ear infection. Cefdinir is the first-line antibiotic for those who are allergic to penicillin. Azithromycin (Zithromax) isn’t even mentioned due to its tendency to cause bacterial resistance.
  • Placement of tympanostomy tubes by an ENT surgeon should be considered after three acute ear infections in a six month period, or four acute ear infections in a year.
  • Prevention of ear infections should be attempted by giving pneumococcal and influenza vaccines to all children per the standard immunization schedule. Breastfeeding infants exclusively for the first six months should be encouraged. Exposure to tobacco smoke should be avoided.

 

How long treatment with antibiotics should go on for was also covered:

Also, the duration of antibiotic treatment can be considered age-dependent, dictated by  the clinical situation. For instance, children under 2 years old should get 10 days of antibiotics. Those between 2-5 years old can get 7 days of antibiotics, and kids older than 6 years old should be able to get by with as little as 5-7 days of antibiotics. Longer therapy does not produce a better outcome.

 

The last point of that blog post more than 5 years ago deserves repeating:

So there it is. If your child has an acutely infected ear causing significant pain and/or fever, an antibiotic should be offered. All others may be given the option of antibiotics vs. observation. Ears that simply have fluid (middle ear effusions) are not acutely infected and should not be treated with antibiotics. It will be up to us to explain what we are seeing and why we think an antibiotic should or shouldn’t be used. It will be up to parents to help us determine what is best for their child. As it should be.