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Ear infections

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of ear infections.

Alternative Names

Otitis media

Medications

Until recently, nearly every American child with an ear infection who visited a doctor received antibiotics. In one region of the U.S., more than 70% of children received antibiotics before they were 7 months old, and the most common reason for these medications was acute otitis media.

Major studies now indicate that antibiotics are unnecessary in most cases of acute otitis media. Between 80 - 90% of all children with uncomplicated ear infections recover within a week without antibiotics. Antibiotics are rarely recommended for otitis media with effusion.

Antibiotic Resistance. The intense and widespread use of antibiotics is leading to a serious global problem of bacterial resistance to common antibiotics. In the U.S., nearly a quarter of S. pneumoniae are currently resistant to at least three antibiotics. High rates of resistance strains are even being observed in infants. In general, regions and institutions with the highest rate of resistance are those in which antibiotics are the most heavily prescribed.

Because of the high rate of antibiotic resistance, and the fact that non-severe AOM usually resolves without antibiotics, many pediatric guidelines recommend a “watchful waiting” period before antibiotics are prescribed. (See "Watchful Waiting" in the Treatment section of this report.) Current guidelines released by the American Academy of Pediatrics and the American Academy of Family Physicians recommend an initial observation period of 48 - 72 hours for select children. Pain relief can initially be given with acetaminophen (Tylenol), ibuprofen (Advil), or topical benzocaine drops.

If there is no improvement or symptoms worsen, parents can schedule an appointment with the child's doctor to determine if antibiotics are needed. (Parents should contact the doctor within the first 24 hours if their child is 6 months or younger and has fever or other severe symptoms.) Another option is to ask the doctor for a Safety Net Antibiotic Prescription (SNAP) that can be filled if symptoms do not improve within 48 - 72 hours.

Antibiotic Regimens for Acute Otitis Media (AOM)

When antibiotics are needed, a number of different classes are available for treating acute ear infections. Amoxicillin is a penicillin antibiotic and the drug of first choice. Other antibiotics are available for children who are allergic to penicillin or who do not respond within 2 - 3 days.

Duration. If a child needs antibiotics for acute otitis media, experts recommend they be taken for the following periods of time:

• A 10-day course of antibiotics is usually recommended for children younger than 6 years of age, and for those with severe AOM
• 5 - 7 days of antibiotic therapy is recommended for children 6 years of age or older with mild to moderate symptoms

Parents should be sure their child finishes the entire course of therapy. Failure to finish is a major factor in the growth of bacterial strains that are resistant to antibiotics.

What to Expect. Earaches usually resolve within 8 - 24 hours after taking an antibiotic, although about 10% of children who are treated do not respond. This may occur when a virus is present or if the bacteria causing the ear infection is resistant to the prescribed antibiotic. A different antibiotic may be needed.

In some children whose treatment is successful, fluid will still remain in the middle ear for weeks or months, even after the infection has resolved. During that period, children may have some hearing problems, but eventually the fluid almost always drains away. Antibiotics should not be used to treat residual fluid.

Follow-Up. Your child should return to the doctor's office:

• 2 - 3 weeks after therapy, if initial therapy cleared up the infection and the child is less than 15 months old, or has risk factors for reinfection
• 3 - 6 weeks after treatment, if initial therapy cleared up the infection and the child is older than 15 months old and has no specific risk factors.
• Within 48 hours of taking the last antibiotic dose if signs of infection are still present (for example, there is still pus in the ear).

In cases where complications are suspected, a consultation with an ear, nose, and throat specialist (called an otolaryngologist) should be strongly considered. This specialist may perform a tympanocentesis or myringotomy, procedures in which fluid is drawn from the ear and examined for specific organisms. But, this is reserved for severe cases.

Specific Antibiotics Used for Acute Otitis Media (AOM)

The selection of an antibiotic is determined in part by the severity of the child's condition as well as a history of response/non-response to antibiotic therapy. Treatment decisions take into account whether the child's condition is severe or non-severe.

Amoxicillin is generally recommended for first-line treatment of AOM. The combination drug amoxicillin-clavunate is prescribed for patients who have severe pain or a fever higher than 102.2 degrees (39 degrees Celsius). Other drug classes may be prescribed if a child is allergic to penicillins or does not respond to the initial therapy.

The following treatment guidelines provide general recommendations based on the severity of a child's AOM.

First-line treatment for non-severe AOM :

• Amoxicillin 80-90 mg/kg per day orally. Amoxicillin is a penicillin antibiotic.

If the patient has an allergy or a history of non-response to penicillin drugs, one of the following antibiotics may be prescribed:

• Azithromycin or clarithromycin. These drugs are in the macrolide class and are administered orally.
• Cefdinir, cefuroxime, or cefpodoxime. These drugs are classified as cephalosporins and are taken by mouth. They may cause reactions in penicillin-allergic patients.

If the patient does not respond to amoxicillin or alternative antibiotic drugs after 48 - 72 hours, one of the following drugs may be prescribed:

• Amoxicillin-clavulanate, clindamycin, or ceftriaxone. Ceftriaxone is injected intramuscularly. The other two drugs are administered orally. Each of these drugs is a different type of antibiotic. Amoxicillin-clavulanate (Augmentin) is classified as a penicillin; ceftriaxone (Rocephin) is a cephalosporin; clindamycin (Cleocin) is a lincosamide.

First-line treatment for severe AOM:

• Amoxicillin-clavulanate (Augmentin). This antibiotic is known as an augmented penicillin. It works against a wide spectrum of bacteria and is administered orally.

Second-line treatment for severe AOM:

• Ceftriaxone. Ceftriaxone (Rocephin) is an injectable cephalosporin that may be prescribed as an alternative to amoxicillin-clavulanate, especially for children who have vomiting or other conditions that hamper oral administration.
• Tympanocentesis or clindamycin. Patients with severe AOM who have failed to respond to amoxicillin-clavulanate after 48 - 72 hours may require the withdrawal of fluid from the ear (tympanocentesis) in order to identify the bacterial strain causing the infection. If tympanocentesis cannot be performed, clindamycin may be prescribed orally to treat penicillin-resistant pathogens that have not responded to prior drug therapy.

Side Effects of Antibiotics

• The most common side effects of nearly all antibiotics are gastrointestinal problems, including cramps, nausea, vomiting, and diarrhea. This can be a significant problem in infants and small children. One study reported that giving such children a soy-based formula that contained fiber (Isomil DF) was helpful in reducing these side effects.
• Amoxicillin use during infancy may lead to enamel defects and discolorations of permanent teeth
• Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening anaphylactic shock.
• Some drugs, including certain over-the-counter medications, interact with antibiotics; parents should tell the doctor about all medications their children are taking.

• Review Date: 3/6/2007
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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