ASK DR. BAUGHAN                                                         September 10, 1999

EARACHES AND SHIFTING SANDS

If we can send a man to the moon (though we haven’t bothered to for 30 years), you would think we would know how to best treat ear infections.  But there is a big difference between engineering in outer space and human biology here on the Water Planet.  The feature article in the June 15, 1999 issue of the new journal Medical Crossfire addresses several ongoing controversies regarding the treatment of otitis media (ear infections).  The article reported on a round table discussion among five prominent physicians from universities around the country and the Centers for Disease Control.  What’s to debate?  A child has a fever and an earache, give the kid some antibiotics, the stronger the better, right?  Oh, that it were so simple!

ARE ANTIBIOTICS NECESSARY?  Otitis media is the most common reason for the prescription of antibiotics in the U.S.  How do we know it is a bacterial infection?  To prove it in research studies, some fluid from the middle ear must be drawn out with a needle through the eardrum and then cultured.  In those studies, about 20-30% of the time, no bacteria is grown.  Of the remaining 70-80% of bacterial cases, two-thirds to three quarters of them may get better without treatment.  So not everyone needs antibiotics to get better.  How can we tell which ones really need them?  If a child has a temperature of 103 degrees, severe pain, a history of ear infections, and particularly if they are less than two years old, then antibiotics are more likely to be helpful compared to watchful waiting.  For older kids, the side effects of medicine or the risk of resistant bacteria might be more troublesome than no treatment at all.

HOW LONG TO TREAT (IF YOU TREAT AT ALL)?  Some studies have concluded that five days of antibiotic treatment works as well as the usual 7-10 day course.  Others articles have suggested that this might decrease the development of resistant organisms, but one study found the resistance to increase!  The panel was divided on this issue.  For the higher risk kids under two, most still favored the 10 days.  For older kids, some favored not treating right away, others leaned toward the five-day course.  Everyone agreed that follow-up was key.  If the child was not doing well after 3 days, then all agreed that antibiotics were appropriate.  If  the child had been started on an antibiotic, a change to another antibiotic was indicated.

WHICH ANTIBIOTIC IS BEST?  The Center for Disease Control recently published guidelines in response to the growing resistance to penicillin of Strep pneumonaie, the most common bacteria found in otitis media.  They said that good old Amoxicillin is still the best first choice, but we should probably use a dose twice as high as we used to.  If that doesn’t work, they said the most evidence to date was for using oral Augmentin, Ceftin or Zinacef, or using shots of ceftriaxone for three days in a row.  The panel debated the second choice drugs, and all agreed that among the 17 different antibiotics that have been approved for treating otitis media, the doctor and family will probably decide based on their experience of which medicines have worked before, what side effects a child has, and how good or nasty a medicine tastes.

One of my medical school professors described the typical medical student as not “brilliant,” but “a bright plodder.”  This is certainly the approach that seems to be necessary with otitis media.  There will not be the great “Eureka!” that is likely to send me running, like Archimedes, naked through the streets of town with a dazzling insight of how to cure ear infections.  Instead, I shall remain discretely clothed discussing difficult choices with parents patient by patient.