New Light On Antibiotic Use To Treat Ear Infections

Sometimes when a piece of research lands in a reputable journal, it is heralded and celebrated. At the very least, it makes the science section of the big newspapers. Other times, research arrives with more of a whisper than a yell. Of the two categories, this piece of news fits more with the latter: it appears the use of an antibiotic in treating infant ear infections is only slight [1].

It’s a rare and lucky parent who hasn’t had to nurse a child through a painful ear infection (technically called ‘acute otitis media’ or AOM). The condition, marked by pain and fever with the potential to affect hearing, is the most common reason antibiotics are prescribed for children [2].  Despite appearances, the proverbial jury is still debating how to best treat this common issue.

With concerns surrounding the over-prescription of antibiotics and drug resistant bacteria, questions have been asked whether antibiotics are indeed the best course of action to treat the condition.

In 2011, two papers published in the New England Journal of Medicine raised the issue once again. The studies were said to be ‘the best evidence yet’ that “toddlers who have been properly diagnosed with the condition recover more quickly when treated with antibiotics [2].” More recently, the same journal published research saying short courses of antibiotics were less effective in the battle against AOM than long courses of antiobiotics (10 days) [3].

If that raises your eyebrows, then it’s wise to read on. Despite numerous randomised control trials examining antibiotic use and AOM over the years, no consensus has actually been reached. Hence, one group of researchers felt a thorough systemic review was in order.

That review was published in the Cochrane Database of Systemic Reviews in April 2015. The data was pulled from high-income countries with a generally low risk of bias, and covered participant numbers well into the thousands. It looked at all the available literature on the condition, applied certain exclusion criteria and found this:

“We found that antibiotics were not very useful for most children with AOM; antibiotics did not decrease the number of children with pain at 24 hours (when 60% of children were better anyway), only slightly reduced the number of children with pain in the days following and did not reduce the number of children with late AOM recurrences and hearing loss (that can last several weeks) at three months compared with placebo.However, antibiotics did slightly reduce the number of children with perforations of the eardrum and AOM episodes in the initially unaffected ear compared with placebo [1].”

The authors of the review observed that antibiotics seemed to be most beneficial in children younger than two, with infections in both ears and in children with both AOM and a discharging ear. Furthermore, the review found:

  • No differences between immediate antibiotics and expectant observational approaches in the number of children with pain 3-7 days, and 11-14 days after assessment.
  • No differences in the number of children with hearing loss at 4 weeks, or perforations of the eardrum
  • No differences in late AOM recurrences were observed between the groups.
  • Combined results of the trials revealed that “by 24 hours from the start of the treatment, 60% of the children had recovered whether or not they had placebo or antibiotics. Pain was not reduced by antibiotics at 24 hours.” Of those on antibiotics, almost a third fewer had residual pain at 2 – 3 days, a quarter fewer had pain at 4 – 7 days and two thirds fewer had pain at 10 – 12 days compared with placebo.
  • The review failed to find enough information to know if antibiotics reduced rare complications such as mastoiditis, and the authors cited a lack of data populations in which progressions from AOM to mastoiditis is higher.
  • The review lead the authors to recommend further research when it comes to certain rare complications.

The authors commented on the risks associated with antibiotics, stating,

“Antibiotics caused unwanted effects such as diarrhoeavomiting and rash and may also increase resistance to antibiotics in the community. It is difficult to balance the small benefits against the small harms of antibiotics in children with AOM. However, for most children with mild disease in high‐income countries, an expectant observational approach seems justified.”

It also lead them to comment that, “clinical management should emphasize advice about adequate analgesia and the limited role for antibiotics.”

This study isn’t the first to critique antibiotic use in AOM. Others include the following:

  • Researchers in the Netherlands looked at 240 children aged 6 months to 2 years with acute OAM. They found that, compared with children who were given the placebo, patients who took amoxicillin were only 13% less likely to exhibit persistent symptoms at day 4. They found no significant difference in pain duration or crying. Middle ear condition and eardrum function in both (treatment and placebo) groups were similar at the 6-week follow up [4].
  • A study conducted by the Southern California Evidence Based Practice Centre also looked into the benefits of antibiotic therapy for the condition. They determined that nearly two-thirds of children with uncomplicated AOM recover within 24 hours without treatment by antibiotics. Additionally, they found over 80% recover from pain and fever within 1 – 7 days [5].
  • Another study, published in the British Medical Journal, found 60% of placebo-treated children were pain free within 24 hours. They found that, at 2-7 days after presentation, by which time only 14% of children in control groups still had pain, early use of antibiotics reduced the risk of pain by 41%. This represents only a modest benefit for acute AOM. “To prevent one child from experiencing pain by 2-7 days after presentation, 17 children must be treated with antibiotics early.” They also noted a near doubling of the risk of vomiting, diarrhea and rashes associated with antibiotic use [6].
  • Further references have been provided below [7,8,9,10]

So there you have it. It appears that antibiotics aren’t a shoo-in for best practice when it comes to treating AOM. Expectant observation, according to traditional medical paradigms, is still the best.

We are yet to see conclusive research on chiropractic care and AOM. However, the role of the Eustachian tubes in draining the fluid from the ears and relieving middle-ear pressure is well known. Adequate mobility in the cervical spine is linked to this. It is unfortunate that the role of safe, gentle cervical adjustments has not yet been explored.

Should that research eventuate, you can bet your bottom dollar that we will be letting you know about it.

 

Reference

[1] Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD000219. DOI: 10.1002/14651858.CD000219.pub4. Link to Cochrane Library.

[2] Johnson, C (2011), “Children, ear infections and antibiotics,”  ABC The Pulse, http://www.abc.net.au/health/thepulse/stories/2011/04/06/3183024.htm retrieved 16 January 2017

[3] Saint Louis, C (2016), “Full Course of Antibiotics is best for infant ear infections, study finds,” New York Times, https://www.nytimes.com/2016/12/21/health/antibiotics-ear-infections-babies.html?_r=0 retrieved 16 January 2017

[4] Damoiseaux RAMJ, van Balen FAM, Hoes AW, Verheij TJM, de Melker RA. British Medical Journal ­ 2000;320:350-4.

[5] Press Release, August 9, 2000. Agency for Healthcare Research and Quality, Rockville, MD.

[6] Christopher Del Mar, Paul Glasziou, Mauricio Hayem. 1997, British Medical Journal; 314 (7093) 24 May: 1526–1529

[7] Journal American Board Family Practice 2001 (Nov); 14 (6):   474-476

[8] Heubi JE, Bien JP. 1997. Journal Paediatrics  Feb;130(2):175-7

[9] American Journal of Respiratory and Critical Care Med., 2002;166:827-832

[10] Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. 2001 British Medical Journal 2001; 322(7282): 336-342