UR Pediatrician Calls For Major Change in Treatment of Ear Infections
June 02, 1998
In an editorial in the June 3 issue of the Journal of the American Medical Association (JAMA), University of Rochester pediatrics professor Michael Pichichero, M.D., says that ear infections in children are over-diagnosed, often mismanaged, and physicians should change the way they diagnose and treat the disorder.
The editorial accompanies a study conducted by researchers at the University of Manitoba, Winnipeg, that challenges the widely accepted pediatric practice of prescribing a 10-day course of antibiotics by demonstrating that uncomplicated ear infections can effectively be treated with five days of short-acting oral antibiotics. Currently, over 90 percent of children diagnosed with ear infections are treated with a 10-day course of antibiotics. Anita L. Kozyrskyj, BScPhm, MSc, of the Department of Community Health Sciences and Pediatrics and Child Health at the University of Manitoba is the study's lead author.
The Kozyrskyj, et al, report is based on an analysis of 32 studies comparing the outcomes of 1,549 children with acute otitis media (ear infections) who received short-acting antibiotics for 5 days with 1,569 children treated for 10 days with standard antibiotics. When the two groups were studied at 8-19 days after treatment began, the researchers found that the shorter treatment course was 7.8% more likely to fail, a difference that disappeared when studied at 30 days after treatment began. Further, when only the better quality studies were considered, this minor risk of treatment failure was not found.
The researchers also compared a group of children treated with intramuscular antibiotic injections and found no outcome difference in the children treated with three or five days of oral antibiotics or with injectable antibiotics when compared with the 10 days of treatment with other antibiotics. Despite their conclusion that shortened treatment is equally as effective as the traditional, 10-day course, the authors caution that their findings do not apply to children with underlying disease, or those with recurrent or chronic ear infections. In addition, further research is needed to determine whether a shortened treatment course is effective in children under the age of two, those with perforated eardrums, or other high-risk children.
"This is a landmark study that challenges physicians to rethink the way that we've diagnosed and treated ear infections," Pichichero said. "Physicians should receive renewed training to ensure that we are providing effective care that doesn't trigger other problems." A strong advocate for shortened treatment, he points out that short-course therapy is less likely to cause children to develop resistance to antibiotics, a serious concern among physicians. Pichichero also points out that parents are more able to comply with shorter courses of treatment, since patients tend to stop taking medications once symptoms disappear anyway.
In the editorial, Pichichero points out that ear infections can be difficult to diagnose, since the symptoms are very general and found in children without ear infections. "When a parent brings a child to the physician reporting sleeplessness, irritability, runny nose, and perhaps fever, the temptation is great to see a little bit of redness or fluid behind the ear drum as justification for an antibiotic prescription," he said. As a result, Pichichero estimates that between 40 and 80 percent of the children prescribed antibiotics don't in fact suffer from an ear infection.
According to Pichichero, doctors should use a technique known as tympanocentesis or an "ear tap" to accurately diagnose an ear infection on certain children. By entering a tiny needle into the child's eardrum, physicians can draw off fluid to test whether or not the ear is infected with bacteria. "More primary care physicians must learn and practice the use of tympanocentesis to improve diagnostic accuracy and prevent overuse of antibiotics," he said.
"Children with bulging eardrums, crying in pain and with fevers of 102( F. or more should receive an ear tap. Also, after two different antibiotics have been used to treat an ear infection and yet it persists, then an ear tap should be done by the pediatrician or family doctor," Pichichero said. Resistant bacteria can be specifically identified with an ear tap, allowing specific antibiotic therapy with the most effective drug. Sometimes no bacteria are found after the tap and antibiotics can be stopped.
Acute otitis media (AOM) is an inflammation of the middle ear, the cavity between the eardrum and the inner ear. Symptoms include severe earache, a feeling of fullness in the ear, deafness, fever, and a ringing or buzzing in the ear. Between 65 and 95 percent of children experience one or more episodes of AOM before the age of seven.
Ear infections are among the leading reasons children are brought to health care providers, and are the most common indication for antibiotic prescribing in the United States. It has been estimated that more than $3.5 billion are spent annually on managing ear infections in this nation.