Antibiotics

Aren't all these antibiotics bad? Yes...and no. The major concern these days is antibiotic resistance - a problem that is clearly worsened by community usage of antibiotics. If a child has been on several antibiotics, and is still having ear or sinus infections, the bacteria are most likely resistant to many or most commonly prescribed antibiotics. The patient does not really "become immune to the antibiotics", rather the bacteria are more tolerant. Antibiotics (especially those containing amoxicillin) are still recommended for most ear infections because... if the infections are untreated, a small percentage (perhaps 1/400 patients) will have a severe or life-threatening complication of the untreated infection, and many more patients will have prolongation of symptoms. Of course, some patients are very poorly tolerant of antibiotics, with gastrointestinal side-effects or rashes.

What about resistance to antibiotics? This is one of the major challenges facing those of us treating otitis media. Interestingly, the problem is not as visible to many families and clinicians as it might be because most of the infections (unfortunately, not all) improve regardless of whether antibiotics are used and whether antibiotics really work well or not. Therefore, several companies are still able to sell hundreds of millions of dollars of antibiotics that are not very effective in killing the bacteria about which we are concerned.

The major risk factors that increase the chance that a child is infected with a drug-resistant strain of bacteria include young age (less than 2), prior antibiotic consumption (the more, the worse), exposure to other children (especially in daycare), and the winter months (when more antibiotics are prescribed). Most of the problem resistance is seen in the two bacteria: Streptococcus pneumoniae (also known as "pneumococcus") or Hemophilus influenzae. Antibiotics that seem to be having problems killing either organism include sulfa drugs, azithromycin (Zithromax), clarithromycin (Biaxin), cefaclor (CeClor) and loracarbef (Lorabid). Hemophilus failures are relatively common with cefprozil (Cefzil). Pneumococcal failures are most likely with ceftibuten (Cedax) and cefixime (Suprax). Among the more active agents against these two bacteria are amoxicillin-clavulanate (Augmentin), cefuroxime axetil (Ceftin) and cefpodoxime proxetil (Vantin), and the injectable drug ceftriaxone (Rocephin). Still, these may fail against some strains of bacteria...and they generally have more gastro-intestinal side effects than some of the "weaker" choices. The bottom line: There are no perfect antibiotic choices for otitis media, but some are more effective than others.

Amoxicillin is still considered the most appropriate initial choice, even though it does not work in all cases. The pneumococcus, which can be a very dangerous bacteria, remains relatively more susceptible to amoxicillin than most of the other choices; and amoxicillin has a long record of safety. Recently, we have recommended that it be prescribed in higher doses...in an effort to combat some of the resistance. Other combinations of antibiotics may prove to be somewhat more effective that a single choice.

Finally, many parents feel like antibiotics aren't working when the child suffers several different infections within a short time. This may not reflect a treatment failure at all; just a new infection...often as a result of increased exposure to other children and the viral infections that set the child up for an ear infection.