Kids' Ear Infections: Antibiotics vs. Waiting

Less Aggressive Treatment for Otitis Media Gains Ground With Parents and Doctors

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June 6, 2005 -- U.S. doctors usually treat kids' middle ear infections -- otitis media -- with antibiotics. That may be changing, new studies show

The first study, a clinical trial, shows that immediate antibiotic treatment results in fewer symptoms in the first 10 days. But simply watching and waiting to see if the infection gets worse worked too -- and it cut antibiotic use by two-thirds. Thirty days after the first doctor visit, the cure rate was the same in the immediate treatment and watchful-waiting groups.

The second study surveyed parents and doctors in six Massachusetts communities. About a third of parents said they'd be satisfied with their kids' otitis media treatment if their doctors advised watching and waiting. But 40% said this would not be satisfactory. Meanwhile, 38% of doctors said they never used watching and waiting for otitis media. Only 6% said they did it most of the time, while 39% reported occasional use.

Both studies appear in the June issue of Pediatrics.

Can Ear Infections Just Go Away?

Most of the time, otitis media clears up all by itself. But it has to be watched very carefully. That's because otitis media is caused by fluid that builds up in a child's middle ear. That fluid gives germs -- bacteria -- a chance to grow in a dangerous place.

Standard treatment in the U.S. is to give children antibiotic treatment right away. It almost always seems to work, because kids' ears clear up. But this often happens without treatment too. In fact, two-thirds of the kids in the Pediatrics study got better without antibiotics.

Doctors and parents worry about simple earaches becoming more serious infections. That's why so many prefer early treatment. There is, however, a downside. Sixty percent of childhood antibiotic prescriptions are for otitis media. Such massive antibiotic use is leading to a germ counterattack. The bad bugs are becoming resistant to antibiotics. This means that in the future, effective treatment is going to be more difficult, and more expensive.

Can doctors really cut back on antibiotic treatment for otitis media? The American Academy of Pediatrics and the American Academy of Family Physicians have already taken a first step. Last year, they published treatment guidelines giving doctors the option of watching and waiting for nonsevere cases of otitis media -- only mild ear pain and no high fever -- in kids 2 years of age and older.

But does watching and waiting really work? And even if it does would parents and doctors really accept a strategy of watching and waiting to see if the ear infection gets better on its own?

Immediate Antibiotics vs. Watchful Waiting

David McCormick, MD, of the University of Texas Medical Branch, Galveston, led a study of 223 kids aged 6 months to 12 years with nonsevere otitis media. The kids had symptoms of a middle ear infection, had fluid in their ear but did not have a serious infection.

Half of the kids got antibiotics --10 days of twice-a-day amoxicillin. The other half were sent home, and their parents were told to wait to see if their children got better. If they didn't, they came back for antibiotic treatment.

In the first 12 days, the children in the treatment group tended to get over their symptoms more quickly. They needed fewer doses of pain medication. However, these kids were also more likely to harbor drug-resistant germs. And early treatment did not keep some of these kids from having recurrent otitis media within 30 days.

By day 30, the cure rate in both groups was almost identical: 77% in the immediate treatment group and 76% in the wait-and-watch group. Parents were equally satisfied with each form of treatment at both 12 and 30 days.

Importantly, 66% of watch-and-wait kids did not need antibiotic treatment.

The researchers identified key factors to making the watch-and-wait strategy work:

  • Doctors must assess otitis media severity.
  • Doctors must educate parents about the risks of untreated otitis media and the risks of overprescribing antibiotics.
  • Otitis media symptoms should be managed.
  • Parents must have access to follow-up care.
  • Effective antibiotics must be available when needed.

Watchful Waiting: Who Would Do It?

Is watchful waiting ready for U.S. prime time? Harvard researcher Jonathan Finkelstein, MD, MPH, and colleagues note that some experts don't think it's a good idea, despite the new treatment guidelines.

To see whether watching and waiting might really work for U.S. kids with otitis media, Finkelstein's team asked more than 2,000 parents and 160 doctors what they thought about holding off antibiotic treatment. Their findings:

  • 38% of parents say they'd be satisfied or extremely satisfied with watchful waiting.
  • 40% of parents say they'd be unsatisfied or extremely unsatisfied with watchful waiting.
  • 38% of doctors say they never or almost never try watchful waiting.
  • 39% of doctors say they "occasionally" try watchful waiting.
  • 17% of doctors say they "sometimes'' try watchful waiting.
  • 6% of doctors say they recommend watchful waiting most of the time.

For parents, the results are clear.

"Parental opinions in a community are likely to change as experience with successful treatment of acute otitis media without antibiotics becomes more common," Finkelstein and colleagues write.

For doctors, it's not so clear. While there are community-wide benefits such as a reduction in antibiotic resistance, watchful waiting isn't a very great benefit to an individual patient. Some experts don't think it's a good idea at all. And U.S. doctors tend to prefer active treatment over passive waiting.

"For all these reasons, one would predict that the practice of [watchful waiting for nonacute otitis media] will follow a slow adoption curve," the researchers suggest.

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SOURCES: Finkelstein, J.A. Pediatrics, June 2005; vol 115: pp 1466-1473. McCormick, D.P. Pediatrics, June 2005; vol 115: pp 1455-1465. News release, Harvard Medical School.

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