Study says antibiotics not always necessary.

Byline: Tim Christie The Register-Guard

Doctors write more antibiotic prescriptions for ear infections than any other childhood ailment - about 15 million a year in the United States - even though 80 percent of ear infections will clear up on their own if left untreated.

A new study led by an Oregon doctor may bolster the case for doctors and parents to take a wait-and-see approach to ear infections, rather than automatically turning to antibiotics.

"In this study, we found taking a wait-and-see approach is as safe, effective and quick as antibiotics in resolving most childhood ear infections," said Dr. David Spiro, the study's principal investigator and assistant professor of pediatrics and emergency medicine at Oregon Health & Science University.

Reducing the use of antibiotics in children is important because antibiotic resistance has become a global public health concern, Spiro said. When antibiotics are overprescribed, the bacteria they're meant to kill can mutate and become resistant to drugs.

Spiro led the study, published in this week's Journal of the American Medical Association, when he was practicing in the pediatric emergency department at Yale-New Haven Hospital in Connecticut. He and his colleagues examined 283 children from 6 months to 12 years of age during a one-year period.

The children were randomly assigned to two groups: Parents of 145 children got a prescription for antibiotics and were told to fill it immediately. The other group of 138 children received a "wait-and-see" prescription, in which their parents were instructed to wait 48 hours and to fill the prescription only if their child's condition was not better or got worse. All patients were given medication for ear pain.

Spiro found that two-thirds of the wait-and-see group did not fill their prescriptions and the children got better at the same rate as children whose parents did fill the prescription. There was no significant difference between the two groups in terms of fever, ear pain or return visits for medical care.

Doctors don't change the way they practice medicine based on a single study. But pediatricians say the study published in an influential journal such as JAMA should make doctors and parents more comfortable with the wait-and-see approach,

"I think it's another piece of the puzzle that will help in promoting the appropriate use of of antibiotics for ear infections, which are the most common reason a child ever receives an antibiotic," said Dr. Richard Rosenfeld, director of pediatric otolaryngology at Long Island College Hospital in Brooklyn and a spokesman for the American Academy of Pediatrics on ear, nose and throat issues. "It may help increase the popularity and acceptance of doing this among parents and other doctors."

"I think it's a great study to reinforce to doctors as well as parents that maybe antibiotics aren't needed nearly as often as we have been prescribing them," said Dr. Tom Diehl of Oregon Medical Group's Westmoreland Pediatrics in Eugene. "This gives us knowledge and reassurance if we hold off for 48 hours, it will probably get better on its own."

Most pediatricians were trained in medical school to treat all ear infections with antibiotics. Before antibiotics were developed, about 20 percent of ear infections resulted in serious complications such as mastoiditis, an infection of the mastoid bone in the skull, and meningitis, an infection of the lining of the brain, Rosenfeld said.

The advent of antibiotic therapy in the 1940s and 1950s reduced those complications to 1 or 2 percent, he said. Randomized trials conducted in the 1960s found that antibiotics cured ear infections 90 percent of the time, compared with 80 percent of cases that resolved without treatment. That 10 percent margin made antibiotics the standard treatment for ear infections, he said.

But that thinking began to change in 1990s amid concern about drug-resistant bacteria.

"If we're dealing with a very common infection of childhood, in which 80 percent get better on their own, do we need to give every single child antibiotics right away?" Rosenfeld said.

In 2004, the American Academy of Pediatrics and the American Academy of Family Physicians released new clinical practice guidelines, which recommend the wait-and-see approach for children 2 and older, who have no pain or mild pain, and no high fever. It also recommended that all children with ear infections be given ibuprofen or acetaminophen for pain.

The JAMA study found that the wait-and-see approach is effective as well on children as young as six months.

Persuading demanding parents to hold off on antibiotics can be difficult, pediatricians say, but more parents now know antibiotics are not always appropriate.

Dr. Jimmy Unger, a PeaceHealth Medical Group pediatrician, said he finds that many of his parents already are educated on the dangers of overprescribing antibiotics. "So it's usually not a hard sell to convince them to watch and wait when that approach is appropriate," he said.

"The biggest battle is convincing parents of the wait-and-see approach," said Dr. Todd Huffman of McKenzie Pediatrics in Springfield. "Parents are impatient and want treatment started now. It's easier to hand out a prescription, but it takes time to explain the wait-and-see approach."