Ear Infections (Otitis Media) in Children

Description

Alternative Names

Medications

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

Major studies indicate, however, that in most cases of acute otitis media antibiotics are unnecessary. Between 80% and 90% of all children with uncomplicated ear infections ear recover within a week without antibiotics. (About 70% of even severe cases have been cured without antibiotics.) Antibiotics are rarely recommended for otitis media with effusion.

The intense and widespread use of antibiotics is leading to a serious global problem--which is bacterial resistance to common antibiotics. For example, according to reports in 2002 and 2001, in Canada 15% of S. pneumoniae strains are resistant to penicillin, in the US between 30% and 40% are resistant, and in Hong Kong between 70% and 80% of strains no longer respond to penicillin. Furthermore, in the US about 23% 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 heavily prescribed.

Current guidelines released by the American Academy of Pediatrics and the American Academy of Family Physicians recommend an initial observation period of 48 to 72 hours for select children. Pain relief can initially be given with acetaminophen, ibuprofen, or topical benzocaine drops. If there is no improvement or symptoms worsen, parents can schedule an appointment with the child's physician to determine if antibiotics are needed. (Parents should contact the physician 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 to 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 two to three days.

Duration. If a child needs antibiotics for acute otitis media, the following are some recommendations for duration of regimens.

• A 10-day course of antibiotics is usually recommended for children younger than 6 years of age, and for those with severe AOM.
• Five to seven 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 completes the drug regimen. Not completing it is a major factor in the growth of bacterial strains that are resistant to antibiotics.

What to Expect. Earaches usually resolve within eight to 24 hours after taking an antibiotic, although about 10% of children who are treated do not respond. Failure may be due to the following or other causes:

• In many cases in which the response to an antibiotic is incomplete, a virus is often present.
• In other cases, the bacteria causing ear infection may be resistant to the antibiotic and a different antibiotic may be needed.

Note: 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. Follow-up may involve the following steps:

• If the infection clears up with a single regimen in children less than 15 months old or in children with risk factors for reinfection, an examination should be scheduled two to three weeks after therapy.
• If the infection clears up with a single regimen in older children with no specific risk factors, they should be reexamined three to six weeks after treatment.
• If signs of infection are still present (e.g., pus is still present in the ear) within 48 hours of taking the last antibiotic dose, the child should be re-examined. (Parents are excellent judges of whether their child's condition has cleared up.)

In cases where complications are suspected, 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 a classification of a child's condition as 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 guidelines provide general recommendations based on the severity of a child's AOM.

Non-severe Diagnosis (mild to moderate pain and temperature less than 102.2 degrees Farenheit / 39 degrees Celsius).

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 administered orally. They may cause reactions in penicillin-allergic patients.

If the patient does not respond to amoxicillin or alternative antibiotic drugs after 48 to 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 cehpalosporin; clindamycin (Cleocin) is a lincosamide.

Severe Diagnosis (moderate to severe pain and temperature of at least 102.2 degrees Farenheit / 39 degrees Celsius).

First-line treatment for severe AOM:

• Amoxicillin-clavulanate (Augmentin). This agent 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 to 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.
• 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; patients should report to the physician all medications they are taking.