Simple ear infections do not need antibiotics

Middle ear infections are common illnesses that cause significant discomfort, mostly for our children, but also in some unlucky adults. Most patients who have ear infections are prescribed an oral antibiotic by their provider, but what if I told you that most often this is unnecessary. You’d probably think that I’m crazy.

Yet this is the truth based on a number of research studies. In fact, there are specific criteria you can use to determine whether you or your child needs to be treated with an oral antibiotic for a middle ear infection.

Background

There are three parts of the ear that can become infected. The first is the external ear. This includes the opening of the ear and the canal leading to the tympanic membrane deep within the ear. An external ear infection is also known as otitis externa or swimmer’s ear, but can occur without swimming. Treatment with antibiotic eardrops is usually appropriate and the infection will generally improve within a week.

Beyond the tympanic membrane is the middle ear, the topic of this article. This is the typical infection (known in medical terms as otitis media) that we have historically treated with oral antibiotics.

We know when the middle ear is infected by looking at the tympanic membrane. Signs of a possible infection include redness, swelling, or bulging of the tympanic membrane. This occurs when the eustachian tubes in the middle ear become blocked, usually because of mucous from an upper respiratory infection. When this happens, viruses and bacteria can collect and infect this part of the ear.

Just as with typical colds, middle ear infections generally resolve on their own without treatment. Once the cold begins to improve and the mucous production decreases, the Eustachian tubes become unblocked, and this allows the infection to drain out, giving our bodies the chance to clear the infection on our own, without antibiotics.

There is also a part of the ear beyond the middle portion known as the inner ear. For the purposes of this article, we will not discuss this anatomic region. Just know that there is a third area, but issues here are much less prevalent than external and middle ear problems.

Normal middle ear

Middle ear infection

Treatment of middle ear infections

Most simple middle ear infections can be treated with pain control alone. Pain control can be accomplished using acetaminophen (Tylenol) or ibuprofen (Motrin or Advil). Even though both medications can help, studies have shown that ibuprofen may have a slight edge over acetaminophen. Proper pain management is important. If you decrease your symptoms, you’re less likely to go to the doctor to get an antibiotic, allowing the infection to heal by itself.

Number needed to treat (NNT) and number needed to harm (NNH)

In medicine, we use statistics to help explain and discuss recommendations for specific treatments. In otitis media, there is a previous analysis at the site thennt.com that discusses the number needed to treat for 1 person with a middle ear infection to benefit from an oral antibiotic and the number needed to harm for 1 person to have adverse effects from the oral antibiotic.

For middle ear infections, the NNT is 20 and the NNH is 9. This means that for every 20 people treated with an oral antibiotic, only 1 patient will benefit. The precise benefit is decreased pain within 7 days. There is no benefit for complications, recurrence, or improving pain within 24 hours of starting the antibiotic. On the flip side, 1 out of every 9 patients treated with an oral antibiotic will have harm, mainly diarrhea. However, I would say that there could also be unquantifiable harm to society by increasing antibiotic resistance.

For me, I believe the risk of oral antibiotic use clearly outweighs the benefit for many patients.

When to use oral antibiotics

Though many cases of otitis media will improve without the need for an oral antibiotic, there are cases that may require it. Based on evidence, these include children less than 6 months old, middle ear infections in both ears simultaneously, or those with significant white drainage coming from the ear. Severe symptoms such as moderate to severe pain for 48 hours without improvement or fevers over 102.2 degrees Fahrenheit are also potential reasons to start oral antibiotics.

Shared Decision-Making

Ultimately, an informed discussion between the physician and parents/patient is the best way to ensure understanding of the patient’s condition and whether an oral antibiotic is appropriate or not. Many times it is reasonable to wait 48 hours. If there is improvement, then no further treatment is necessary. However, if symptoms persist or worsen, an oral antibiotic may be a good choice. Close follow up with your primary care physician can help to reassure you if your symptoms or your child’s symptoms worsen or do not resolve.

When to get tympanostomy tubes

This is a common question for children who get recurrent middle ear infections. Recurrent infections are defined as 3 episodes within 6 months or 4 episodes in 1 year. The tubes that are placed make a hole in the tympanic membrane, which in turn gives a place for the infection to drain when it occurs. Studies have shown that there is only a modest benefit by placing tympanostomy tubes. The tubes do not prevent infections from occurring. However, based on research studies, they may improve quality of life by a small amount (decreased pain and less oral antibiotics).

Treatment for middle ear infections in patients who already have tubes

Infections can still occur with ear tubes in place. This usually results in pain and a whitish drainage coming from the ear. Recent studies have shown that oral antibiotics are not necessary for middle ear infections in patients with tubes. The recommendation is to use antibiotic eardrops. This can certainly be beneficial, preventing the antibiotic from affecting the rest of the body. Most physicians are well versed on this type of treatment.

Personal experience

I have 3 children who have had a number of upper respiratory infections in the past. Being a doctor and having an otoscope at home, I have the fortunate ability to look at their ears. My children have certainly had middle ear infections based on my examinations. We have made the decision in our home not to treat with oral antibiotics when not necessary, and each time, my children’s ear infections resolved without the need for any antibiotic treatment. Though this is only one example, I truly believe most patients can and will improve on their own, if given the time.

Conclusion

Otitis media is the most common reason for physicians to prescribe oral antibiotics in the United States. Many times, these are unnecessary. An approach of waiting 24-48 hours for resolution could benefit you or your child by preventing the adverse reactions from oral antibiotics without causing any harm from the infection. Try it out and you may be pleasantly surprised.

What do you think? Should we wait to treat middle ear infections with oral antibiotics? Comment below.