No antibiotics for ear infections

It's that time of year again … and we're seeing kids in the office with otitis media. With each pasing year, more parents seem to understand that antibiotics for acute otitis media in children are largely unnecessary.

Several years ago, I developed a guideline that was part of a regional effort to reduce antibiotic overuse.   I still print out the patient information that we developed as part of this project, but these days I find that parents already know much of the contents.

When making the decision of how to treat a child with otitis these days, I find myself sharing the decision with the parents. 

JMR:  "Well .. 80% of kids in this situation will get better by themselves."

Mom: "Yes .. it seemed to work last time.  Johnny got better in 2 days .. but the time before that, he needed the antibiotics."

JMR: "Well, that's the problem .. we don't yet have a way to twll which kids are going to be that 20%"

Mom: "Let's wait and see.  I'll call you in 2 days if he's not better."

On Fridays and before holidays, I usually write the prescription, and ask the parents to hold on to it for a day or two.  It's not uncommon that they bring it back to demonstrate proudly all was well without the antibiotics.

In this process, I always focus on the concept that otitis media, like sinusitis, is a problem with obstruction .. rather than one of infection.  There's a nice monograph on this topic.   Te bugs are there anyway.  A little H. flu, S. Pneumo and Moraxella are components of the normal flora of the nasopharynx and therefore the eustacian tube.

But as the mucosa thickens in the context of a cold, the bugs are trapped.  A system that is usually dynamic and flushed on an ongoping basis .. is now stagnant.  Warm, moist place with bacteria.  Infection?  Duh.  But as with any abcess .. we need to enhance drainage FIRST .. not necessarily treat with antibiotics.

Too bad we can't just pop open the eustacian tubes with a remote control.  Hmm … maybe I'm not the only one with this idea.

Reviewing the last 20 cases of otitis media that I saw in the office .. I wrote prescriptions for antibiotics in 6 of them within 48 hours of the visit.  Many of these prescriptions were on Fridays .. so I don't really know how many kids actually got the antibiotics.   I wonder how Chris Bradley or Enoch  or Bhavesh handle this in urgent care settings. 

In our area .. urgent care and ERs have been the biggest problems for us in curbing antibiotic oversue.  Patients seem to get what they ask for in such settings .. which then builds the expectation that antibiotics are indicated for sinusitis, otitis or bronchitis … and of course, this is a concept that I don't agree with.

In the context of the recent flu scares .. and a rather persistent "flu-like-illness" that has been quite prevalent in the past 2 weeks (though waning now, it seems) … I spoke on the phone with a friend in the ER the other day:

JMR: "How are you guys dealing with this high-fever/cough viral thing going around?"

ERDOC: "Man .. it's bad.  Clearly not flu .. but most people think it is … which is just semantics, I guess.  The worst part is that many of the urgent care docs are prescribing Azithromycin for it … so the patients come here 3 days later because the z-pak isn't working and they want us to give them a stronger antibiotic"

JMR: "yikes."

One thought on “No antibiotics for ear infections”

  1. Jacob asks how i manage parents’ demands for antibiotics for otitis media, sinusitis and bronchitis. Although he’s loathe to prescribe them since they’re largely useless for the predominant viral causes, he mentions that he sometimes will prescribe on a friday or before a holiday (like today!) and ask the parents to hold onto them for a few days to see how it goes. Kudos to Jacob, that’s savvy parental soothing.

    Here’s how it goes for me, with my own child as an example. Natalie started sniffling 12 days ago, and coughing alot 10 days ago with fevers from 102-104. That went on until 8 days ago i started getting worried about her cough being more productive and with the 3 days of high fever, brought her in. Her pediatrician confirmed my exam that there wasn’t anything focal (no obvious bacterial infection) and that we could continue tylenol or ibuprofen. Well, her cough got progressively worse and continued with high fevers, and we were leaving for Monterey with the in-laws here from Singapore, so we went in again. Again Natalie’s exam was normal, so just to be safe we got a cbc, blood culture, bagged urinalysis and chest xray since she’d had 6 days of fevers to 104 by then. Everything was normal, we had a pretty tough vacation, but her fever broke yesterday, and her cough and appetite is improving.

    The short of it: i rarely prescribe antibiotics, and ask the patient to return for a recheck since we’re open every day regardless of weekend or holidays. We operate a high acuity urgent care, so if we’re wrong and the patient really needs antibiotics, we can administer them, either orally or intravenously. I feel pretty supported in my quest to prescribe appropriately, and since our prescription rates are published to share among all the providers, so there’s some peer pressure to prescribe appropriately.

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