Antibiotics for Middle Ear Infections - Love 'Em or Leave 'Em

Antibiotics have only been in the medical arsenal for about 75 years, starting with sulfa drugs in the 1930s and penicillin in the 1940s. There are now dozens of different and more potent antibiotics, but very few new ones are patented. Since their discovery, antibiotics have saved umpteen millions of lives, and still do everyday. However, antibiotics have been heavily used and abused from their debut. Slowly but surely, they are become less and less effective.

As a child, our local, small town GP used to give injections of penicillin for just about any reason, it seemed. If you had a sore throat or tonsillitis, you got a shot of penicillin. If you had a fever for unknown reasons, you got a shot of penicillin. If you were uncooperative in his office, fearing that you will get a shot of penicillin, you got a shot of penicillin. He was such a shot-doctor, that kids would not even go to his door for Halloween.

In the U.S. as in many other countries, antibiotics are controlled by medical prescriptions. However, in places like Mexico, you can simply walk into a pharmacy and buy them - assuming they are "real ones" and not fake, counterfeit substitutes. With a Canadian doctor's prescription, you can easily buy large quantities in Canada. It is not uncommon for Americans to smuggle antibiotics in huge amounts across the borders, primarily for personal use, or share among friends. Some people have literally become Amoxiholics!

Antibiotics are only used to treat susceptible bacterial infections. They are completely ineffective against viruses - the main cause of most diseases. If they are self-administered indiscriminately for viral illness, not only will they be ineffective, they can make things worse. Sub-therapeutic doses of antibiotics help create resistant strains - the dreaded Superbugs. Primitive microorganisms can rapidly adapt to most antibiotics, even when given appropriately. There are bacterial strains out there that are completely resistant to EVERY known antibiotic. You really don't want an infection from these guys.

One of the major reasons antibiotics are prescribed for children is for the treatment of otitis media - the middle ear infection. Surprisingly, the vast majority of middle ear infections in children will resolve spontaneously in a few days, WITHOUT antibiotics. So, why do clinicians keep giving them and parents keep demanding them? That is the billion dollar question. Controlled, scientific studies in the U.S. and Europe have proven time and again, that antibiotics are only needed for the treatment of otitis media in very young children with immature immune systems, immunocompromised children (children with diabetes, cancer, etc.), or in children that are very toxic-appearing. These are the children who are very ill, in extreme pain, and not fighting off their infections naturally.


In Europe, children with otitis media are not routinely treated with antibiotics for at least the first week. That does not mean they are not treated in other ways for these painful afflictions. Children are routinely given pain medications - usually more than just acetaminophen or ibuprofen - to make them more comfortable while Nature orchestrates the cure. In the U.S., the typical care involves the early use of antibiotics, even in cases where the child does not even have signs of middle ear infection, and mild pain medications.

Over 90% of European children get better, on their own, with just pain medications, and tend to have fewer recurrent middle ear infections and need for surgical tubes. The U.S. kids tend to get better, too, but with potent and expensive antibiotics on board that more and more clinicians feel are unnecessary. Old treatment habits are hard to break.

I had a posting on the Ear, Nose, and Throat message board recently by a person inquiring about the proper dose of amoxicillin for her two children. She felt that the doctor's dosage was way too high, and that she would prefer to give half-doses. I really wanted to tell her that antibiotics are not really needed at all in most cases; but of course I knew nothing about her children and cannot blindly tell her not to use them. I assume that her children were properly examined, and probably treated with the appropriate dosage of amoxicillin. For most clinicians, treating otitis media is really routine stuff. However, most clinicians have not jumped on the "no antibiotic" bandwagon.

When amoxicillin first came out, maybe twenty years ago, it was dirt-cheap - only a few dollars for a standard, ten-day course. Children were treated, based on body weight, at about 20-30 mg/kg per day, in three divided doses. Amoxicillin virtually replaced ampicillin - an antibiotic that had some nasty gastrointestinal side-effects (like explosive diarrhea) and had to be given four times per day, a dosage nightmare for busy parents. The bubble-gum flavored amoxicillin even tasted better. For nearly a decade this dosage seemed to work great. Later, studies started to show that amoxicillin can be given twice a day, even more convenient for busy parents, and for as little as five days instead of ten.

My wife and I used to teach an all-day pediatric class for child care providers. I remember putting my lunch in their refrigerator, only to be shocked by the dozens and dozens of bottles of amoxicillin, all lined up for the various kids.

As the years progressed, everyone started using amoxicillin (a lot), still the drug of choice for otitis media. Unfortunately, amoxicillin started to fail as resistant strains took over. Many clinicians would abandon using it after the first-failure, until studies showed that a higher dose was more effective. Now, the standard dosage for amoxicillin (in children) is 60-80 mg /kg - more than twice the original dosage.

There are now about two dozen different antibiotics that can be used for pediatric middle ear infections. Every day in my clinic, I encounter the otitis media frequent flyers, usually on their way to the surgery center for tubes. There is a better way, but it is going to take a partnership of parent and medical provider to change the way we treat these kids. We need to trust that our immune systems have protected us long before the advent of antibiotics, and will continue to do so, IF we give them a chance.

Parents can help by not insisting on antibiotics, especially when clearly told that the child does not have a middle ear infection at the moment. Sure, they may get one tomorrow or over the weekend, or while you are at Disneyland, but that never justifies giving antibiotics prematurely.

Medical providers need to stand their ground and resist antibiotic solicitation from worried parents. Instead of medication, a healthy dose of EDUCATION needs to be administered. Parents who have children with frequent ear infections need to have a home otoscope, and learn how to use it. Medical providers have an obligation to cooperate with these novice otoscope-users, and encourage, not discourage their use. Parents should choose a medical provider that allows for this type of participatory care.

I still feel that antibiotics are miracle drugs, but the real miracle is to know when and how to use them. The bugs are getting smarter, and we need to be smart, too - always staying one step ahead.

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• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
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Doing Your Part

Your Responsibilities as Member of a Community and of the Human Race

In the last two weeks, we are starting to administer the seasonal flu vaccine. You would be surprised how many people are refusing it because they do not think they need it. But, what about the rest of us?

We all share this small planet; a planet with limited natural resources, and a planet that is progressively becoming more polluted and damaged. Globally, steps are being made to limit greenhouse gases, preserving the protective ozone layer, finding cleaner fuel sources, and replacing some what has been exploited and raped over the centuries.

I grew up in a strip coal mining area, where beautiful topsoil was moved aside in order to get at a narrow layer of soft coal. Thanks to the efforts of environmentalists, much of that land has been restored. The air and our streams are no longer stinky and yellow. It was commonplace to run sewer lines directly into a pristine creek. A generation ago, people mindlessly dumped their trash along the side of rural roads, or simply threw out their fast-food bags from a moving car. Thanks to Lady Bird Johnson's efforts, our roadsides are no longer piles of discarded junk and rubbish. Little by little, America became more beautiful when people started caring.

A week ago, we were given evacuation orders when a wild fire threatened our neighborhood. Over eighty homes were burned to the ground. Had the wind changed directions, our home would have been lost, too. The cause of this fire is yet undetermined, but arson is a possibility. A few minutes ago, the Department of Forestry spotter plane buzzed and circled my house. There was another fire; this time only a mile away and the wind was blowing in our direction. The quick efforts of our local fire department quickly got this fire under control. According the Highway Patrol, a motorist threw a cigarette out of the window, starting a roadside brush fire. Throwing a burning cigarette out of a moving car deserves jail time, in my opinion. Of course, they will never catch the culprit.

Are we all doing our share? Do you turn out the lights in rooms that are unoccupied? Do you use energy-efficient bulbs? During the summer months, do you set that thermostat a little higher? Do you drive the speed limit and wear your seat belts? Do you recycle your aluminum cans, glass, and plastic? Are you immunized against vaccine-preventable illnesses? Do you wash your hands? Do you smoke? All of these seemingly little things help our planet and your community. As members of the human race, these are your responsibilities.

As a child, we did not have seat belts in our vehicles. Children were not restrained in infant car seats; they could freely jump from the back seat to the front if they chose. Motorcyclists were not required to wear helmets. So, how does wearing seat belts impact our role in the community or the human race? A non-seat-belted person is more likely to sustain serious head and neck injuries, assuming they are not killed. If they have health insurance, the bills could be astronomical for their care. This will raise rates for all of the other insured people who do wear seat belts. If the person does not have health insurance, the state and federal government will end up footing the bills, and of course, guess who pays the state and federal government through taxes?

Smokers feel that they have a right to smoke. Apparently, "Freedom to Smoke" is protected by our Constitution somewhere. Smokers pay the same insurance premiums as you and I, but of course, smokers tend to get more respiratory illness, such as pneumonia, asthma, or emphysema, use the emergency room more often, and have a higher rate of cancer, requiring expensive surgeries and cancer treatments. Smokers have higher absenteeism at work and lower productivity. Again, the insurance companies (and we non-smokers) foot the bill, as well as the government. When smokers flick their cigarettes out of a moving car and start a fire, someone else still has to pay for those damages. When a person chooses to smoke, they impact more than just their own lungs. They seriously impact ALL of us, directly and indirectly, in so many ways.

If people defend their right to smoke, do they also defend their right not to wash their hands? Is personal hygiene (or the lack of) protected by the Bill of Rights? Someone comes out of a public restroom and doesn't wash their hands. They put their contaminated (poopy) hands on the door handles. A little child touches that handle and becomes seriously ill. The simple act of washing your hands can have a major impact on the community.

There was a major public health effort in the 1950's. If people had the right to refuse vaccinations, no one really exercised those rights. Everyone felt that it was our community responsibility - our duty - to be vaccinated, so that people would not get polio, or measles, or whooping cough. In less than a decade, the incidence of these vaccine-preventable diseases plummeted. Everyone, by getting vaccinated, did their part. These public health efforts have saved millions of lives and billions of dollars, yet now, people feel they have the right to refuse vaccinations for personal reasons...stupid reasons. They don't care if they, or their children get the diseases, and they certainly don't care if they spread it to others in the community. You cannot achieve "herd immunity" unless all or most of the herd has been inoculated. Just like one bad apple making the others rotten, if there is an unimmunized person in a community, the disease will survive. An epidemic starts with one.

There are people in the community that count on "herd immunity". Our efforts to vaccinate ourselves and our children is their only protection. They want others to take any risks, but then expect the insurance companies and society to take care of them if they get one of these serious, preventable diseases. Medical care is God-awful expensive, not just in dollars but in emotional toll. Are their calculable risks to taking vaccines? Sure, very small ones. The risks of serious vaccine reactions are considerably less risky than the chance of getting struck by lightening, but yet people are afraid. Some of these fears are created and nurtured by the Internet, backed up by pseudo-science and charlatans.

Perhaps the real barrier is trust. Since the 1950's, Americans seem to have lost faith in their government, perhaps for good reasons. Remembering thalidomide and other recalled drugs, they do not trust the pharmaceutical companies. They do not trust the FDA that approved these drugs. Often, they do not even trust their medical providers - the people that they chose to participate in their health care. People do not trust banks, the post office, the military leaders, or our President. What happened? Right now, President Obama is trying to make a complacent and mistrusting population aware of the serious health threat that influenza can cause. Millions of Americans died in 1918 and it can happen again. Why don't people listen?

In order for people to share responsibility, we have to have trust. We have to trust that everyone will do their part and not opt out or make excuses. We have to trust our elected leaders and our scientists, and we need to come down hard on those who betray basic, human trust. It has been said that we can trust, but verify. It is perfectly normal to question recommendations, but at some point, it will come down to trust. Do you trust your government? Do you trust your medical providers? Do you trust your own judgments?

As a medical provider, I am on the front line. I had to take four nasal swabs for a pertussis test this week on a 15-month old. The mother does not "believe" in vaccines, so none of her children are immune. I can take care of her because I am immune to pertussis. I took my vaccine. Otherwise, I would be putting my own life at risk. I can take care of people with influenza and other life-threatening illness because I am vaccinated, and this is my job. Vaccines are not perfect; few things in life are perfect, but vaccines are and will remain one of our best defenses. It is much easier to prevent an illness than treat one, I can assure you.

Please do your part. Don't throw trash out of the window. Turn off unnecessary lights and use energy-efficient bulbs. Wear your seat belts or helmets, and secure your children in car seats. Don't smoke, and if you do, stop. Wash your hands. Unless you have a true contraindication, take the recommended vaccines. Be honest and learn to develop trust (again). We live in the same community; on the same planet. We are all in this together.

Related Topics:

• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
• Living Better Newsletter - Wellness news to keep you healthy and strong!

Interesting Tidbits from the Medical Literature

More on Losing Health Insurance
It is worse than I thought. Up to 14,000 Americans per day may be losing their health benefits during this economic downturn (a nice term for "crisis") according to a report by the Center for American Progress and Health Care for America Now.

"Approximately 2.4 million workers and their families have lost the health insurance their jobs provided since the current recession started in December of 2007, according to an analysis by Nayla Kazzi at the Center for American Progress. "

"More than 51 million Americans under age 65 do not have health insurance as of January 2009, and millions more drift in and out of coverage as their employment and financial situation changes. According to a March 2009 study from Families USA, approximately 87 million Americans under 65 - nearly one in three - went without health insurance for some period in 2007 or 2008."

(See "When You Have No Health Insurance or Money" blog post). More and more people are being qualified for the government's Medicaid program - millions of people are already enrolled and the number is growing. If families try to purchase private insurance, they need to expect rising costs there as well (assuming they are healthy enough to qualify and do not have any pre-existing health problems).

And More on COBRA... It Strikes Employers, Too
The economic stimulus package will subsidize 65% of the COBRA health insurance costs for up to 18 months. Some companies feel that this will be an additional (and costly) burden to companies who have to pay the administrative costs to manage this program for laid-off workers. Personally, I think the minor administrative costs are the least a company can do for these disadvantaged workers. In a way, it was nice for our government to help out.

Get Ready for the Upcoming Epidemics
Most young families have never seen measles or Hib-related diseases, but that may change soon. There have been pockets of Hib and measles cases popping up across the country. There were about 400 cases in the U.S. last year. Unimmunized families may see them first-hand, unfortunately. As more and more families opt not to vaccinate their children due to unfounded fears that they cause autism and other developmental disorders, those diseases will surely return - perhaps with a vengeance. Measles has never left and continues to be among the leading causes of death in children worldwide. I suspect that families without health insurance will also be skipping these important vaccines.

According to the CDC, there were 131 cases of measles in 2008, the most since 1996. Most experts feel that this resurgence of measles is due to the highly vocal anti-vaccine movement.

Swine flu may be less serious than we expected, but expect an unprecedented vaccine campaign in the fall. Not only should a swine flu vaccine be available, but we will still have our usual and customary annual strains that take about 35,000 lives each year. Anticipating the circulating strains is becoming more and more difficult as these ancient viruses mutate and change. The World Health Organization fears that up to two BILLION people could be infected by swine flu if the current outbreak turns into a true, global pandemic

Speaking of Vaccines
The pneumococcal conjugate vaccine, Prevnar, which has been protecting infants and children against seven of the more common streptococcal strains is now going to be even better. A newer, improved vaccine called Prevnar 13 will be adding protection against six additional strains, offering even more protection against pneumonia, meningitis, and yes, even the dreaded middle ear infection.

In the last decade, the insertion of tympanostomy tubes for recurrent ear infections has increased 35%; a whopping 85% increase since 1996. Although there has been an active campaign to reduce the astronomical amounts of antibiotics used in the management of pediatric ear infections, the overall usage has not drastically improved. Many parents feel that tubes are a less-risky alternative to frequent antibiotic use.

Cell Phones May be Contributing to Hospital-Acquired Infections
First they blamed dirty hands, then stethoscopes (rightfully, so). A few years ago, a study proved that our neckties (I stopped wearing them and I have a great collection of medical ones) may be spreading dangerous pathogens. Now, cell phones are being blamed for the spread of MRSA (Methicillin-Resistant Staphyloccoccus auerus) - the superbug in a study of Turkish hospitals. It doesn't surprise me at all. Since I do not carry a cell phone with me during clinic hours, this does not pertain to me. Computer keyboards and other hospital equipment may also be contaminated. Personally, I consider EVERYTHING in the hospital potentially contaminated. I hate touching elevator buttons ("Can you push three from me, please?) and I never touch stairway banisters.

Electronic Medical Records (EMR) "Depersonalize" Medicine
I read a New York Times story about how EMRs are going to transform medicine into a highly-efficient machine, saving billions in healthcare costs. This is not without a big price, however, in the social arena. Not only do medical providers have to spend additional time documenting their medical records (not all medical providers are good typists!), but computers have created yet another depersonalized barrier in the medical relationship.

We have used EMRs for several years in our office, but I rarely use the computers in the exam room during the encounter unless I am just briefly checking lab results, etc. I just do not want a flat screen between me and making eye contact with the patient, I am sorry. I find it terribly disruptive to have a medical provider typing away as a patient is talking. I experienced this as a patient with my own medical provider. As in the past, I still jot down my notes, only to type the later, in the comfort and quiet of my own office.

We get less than 15 minutes allotted for each patient visit. I am not going to waste 12 minutes of that precious time by typing notes.

Related Topics:

• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
• Living Better Newsletter - Wellness news to keep you healthy and strong!

The Media and the Worried Well

Every morning I watch the local news to see what kind of medical problems and issues I will be discussing that day. If there is a story about a new case of West Nile Fever in the area, I will be getting calls as soon as the phones open. A Lyme disease case was diagnosed thirty miles from here, so I will get a few of those calls, too. These calls come from a large group of media-inflamed people called the "Worried Well" - well people that think they might be ill, or at least, exposed.

A rash that would have been otherwise ignored is now a target lesion characteristic of Lyme. A fever that would have been previously attributed to a viral infection is now the H1N1 (swine) flu. I saw two, perfectly-well boys, ages 7 and 9, last evening because the father felt they had swine flu. Apparently, they had a particular rare type of swine flu - one that had no symptoms. They have not traveled to Mexico, although they were in Venezuela last year to visit relatives. They had no contact with others who were ill at school; and there were no reported cases in that particular school or city. The answers to all of the H1N1 medical screening was a flat negative. No symptoms. No contacts. Well kids. I literally had to argue with the parents that a screening test was not only not indicated, the Health Department would refuse to run it.

This recent influenza pseudo-pandemic is a prime example of media hype, not unlike yelling "Fire" in a crowded theater. I really can't fault the CDC and the Health Departments for going on alert, even high-alert, but the media fed the fires of fear that drove people into a frenzy. Tents were set up to screen people outside of standing-room-only emergency rooms. People, whose only contact was with a cooked pork chop, demanded to be tested and treated. A local Catholic school was closed after one case was found (not a bad idea), but several more schools were closed in neighboring communities "just in case". There were no firm guidelines on school closures. Each hour, I would get an email from our lab or from the Health Department on how to collect and store the viral swabs and where we should send them. Our clinic ended up sending several dozen cultures of suspected cases over the last two weeks. We have yet to hear about any of them.

If this potential pandemic was a test of our public health system's response to a biological emergency, I am not sure we passed. The first day that I sent the proper viral swabs to the local health department, they were closed due to budget constraints! Millions of doses of Tamiflu - an antiviral flu medication - were sent to the border states for possible public distribution. The federal government had bought tons of these expensive drugs during the last flu scare - the bird flu - when it was assumed that we would see millions of cases of a deadly strain spread by birds along their migratory routes. It didn't happen, obviously. It was sure financially-convenient to have this new swine flu emerge since those medications were due to expire anyway. I had two courses of Tamiflu in my medicine cabinet from the bird flu that I didn't take; it was expired, too. Oh, by the way, the companies that make Tamiflu and Relenza (another anti-flu medication) are ecstatic.

This morning, I had a heated thirty-minute counseling session with a mother who did not want to give her healthy five-year old any more vaccines in preparation for kindergarten for fear that he would get autism. Yes, autism exists, and yes it is being diagnosed more and more in the U.S. (Although not so often in other countries where the exact, same vaccines are used.). There is absolutely no scientific evidence that autism is directly or indirectly caused by any of the vaccines, or combination of vaccines, or the preservatives in the vaccines (which, incidentally, no longer exists). Of course, these medical claims vindicating the vaccines, made from years of controlled studies, reviewed by experts in their respective fields, must be wrong. Why? Because someone disputed it on the Internet claiming that the studies are wrong - motivated by vaccine-manufacturer's greed and profit, or a neighbor told her that she had a cousin that got autism from the vaccine. Rumors, anecdotal claims, and unsubstantiated personal testimonials appear to have more credibility than a published study in the New England Journal of Medicine. In the end, the mother agreed to get the MMR vaccine, but did not want to get the other three required, school-entry vaccines at this time. Okay, one vaccine (three, actually) is better than none at all.

I feel sorry for the media. Unless they have a good story, no one will watch the news or read the paper. If readership goes down and people stop watching, advertisers will not buy time or space. If advertisers stop advertising; newspapers and television stations will go under. It has already happened with the economic downturn.

There are some days, when I am getting my morning "Disease of the Day" briefing on television, that there are no good stories. They may have a "breaking news" story about a new meat-slicer at the local market that is safer than the older, finger-amputating model. A few years ago, I turned on the news to see live helicopter footage of a local swimming pool. Someone (unnamed) had pushed the wrong button to automatically chlorinate the pool, and several people had become sick from the chlorine fumes, while others had bleached-out Speedos. I could see ambulances with light flashing. Paramedics ran dragging gurneys with people on oxygen. It was chaos. Two hours later at work, I saw an endless dance of potential chlorine victims. A few hours after that, it was determined that the chlorine levels in the pool were really not that high; certainly not toxic.

About 12 years ago, when I was teaching in Michigan, another chlorine incident happened. The people doing the laundry at the Indian Casino used concentrated chlorine instead of Clorox. The fumes wafted through the casino, much to the horror of the semi-drugged gamblers. Some became nauseated. A few vomited. The rest fled in a wild panic. The rumor was that there was a terrorist, nerve gas attack. The local fire department quickly set up a make-shift decontamination area for the many victims before transporting them to the local emergency room. Totally-naked gamblers stood in the freezing weather and were systematically hosed down with even colder water. Once they were blue and placed in paper gowns, they were sent to the ER. I can tell you that this was big news for Mt. Pleasant, Michigan. I was puzzled all day why anyone would think that terrorists or a disgruntled loser would consider an Indian casino in Mt. Pleasant to be a target.

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• Worried Sick? Help for Hypochondria
• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
• Living Better Newsletter - Wellness news to keep you healthy and strong!