Should children always be given antibiotics for acute ear infection?

If this question were put to doctors in the U.S. or Australia, 98 % would say yes. But only 31% of doctors in the Netherlands would prescribe antibiotics to children with acute otitis media (ear infection). The difference demonstrates one country's commitment to reducing the excessive use of antibiotics which has contributed to the emergence of drug-resistant infections. (See box insert below.) Some experts believe that the overuse of antibiotics in children under the age of three years will impair their immunity.

Childhood ear infection is the major reason for the out-of-hospital prescription of antibiotics in the U.S., but a new analysis found that antibiotics provide only "a modest benefit" to children with acute otitis media (AOM). This conclusion came from the combined results of six clinical trials in which children had been randomly assigned to receive either antibiotics or placebos (British Medical Journal, 24 May 1997). The trials were analyzed by Christopher Del Mar, M.D., and colleagues at the University of Queensland, Brisbane, Australia. Noting that in the majority of cases, AOM will go away without treatment, the investigators set out to discover what benefit, if any, was associated with immediate use of antibiotics.

They found that antibiotics were not any better than the placebos in making the pain disappear in the first 24 hours, but 14% of the untreated children were still experiencing pain 2-7 days after they were taken to the doctor. In this small group with continued pain, the analysis showed that early use antibiotics would reduce the pain by 41% and the rate of AOM in the other ear by about 43%. To prevent one child from experiencing pain by 2-7 days, 17 children would have to be treated with antibiotics. Or to put it another way: 16 children whose pain would disappear spontaneously will be subjected to the risk of drug side effects, including diarrhea, vomiting, and rashes. Most important, the analysis found that antibiotics did not reduce the incidence of subsequent ear infections or deafness. (Ironically, earlier research shows that antibiotics are implicated in causing ear infections to become chronic. See HealthFacts, April 1995.)

A temporary, but often prolonged hearing loss, can occur if AOM becomes chronic. It develops when repeated infection causes fluid accumulation in the ear (glue ear). Many experts believe that the hearing loss in a preschool age child will have an adverse effect on speech. But the new analysis found antibiotics had "little effect on deafness, particularly deafness that is not prolonged." This finding contradicts that of a 1996 trial which found antibiotics are helpful to children with glue ear.

Ear pain and hearing loss are not the only reasons why doctors prescribe antibiotics to children with AOM. They want to avoid complications like mastoiditis. But Dr. Del Mar and colleagues found that mastoiditis is rare in the Netherlands where physicians prescribe less risky treatments for acute otitis media. In one study, published in 1985, 60 physicians prescribed nose drops and painkillers instead of antibiotics to their young patients with AOM. Only 3% of the nearly 5,000 children were still sick after 3-4 days or had ear discharge for more then 14 days. "Two children developed mastoiditis, but this settled uneventfully after treatment with amoxicillin," wrote Dr. Del Mar and colleagues.

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