Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.See all posts »
Antibiotics or No Antibiotics for Ear Infections
Ear infections are the bane of childhood and can spoil many outdoor adventures. One of the most common infections of childhood, they provoke long nights of miserable children, sleepless parents, and unhappiness all around. They may be recurrent, and can also progress (rarely) to more serious medical problems, such as meningitis.
What Are Ear Infections?
Acute otitis (inflammation of the ear) media (“middle”) infection is caused by bacteria or viruses. When it occurs, there is redness and inflammation of the eardrum, frequently with a collection of blood, serum, or pus behind the drum. To know whether or not this has occurred, and to precisely determine the anatomic diagnosis and severity, one needs to see the eardrum, which is what the healthcare provider does with an otoscope.
With otitis media (middle ear infection), there is no drainage from the external ear canal (unless the eardrum ruptures, which is unusual in an adult and more common in a child) and the victim has a fever, sometimes with an accompanying sore throat. In many cases, the victim has a history of prior similar ear infections. Most often, otitis media occurs in children; when it occurs in an adult, it may be associated with a sinus infection or functional obstruction of the eustachian tube (the pressure-release mechanism from the middle ear into the throat).
It is interesting to note that children who chew sugarless gum containing xylitol (or who ingest syrup or granules containing xylitol), which is derived from birch trees, may have fewer ear infections. This is supposedly because xylitol inhibits the growth of certain bacteria that cause the infections. It is reasonable to advise children prone to ear infections to avoid sugar-containing gum or candies.
Antibiotics vs. No Antibiotics
A commonly-debated issue among doctors is whether and when to use antibiotics, which are only effective against certain bacterial infections. For the purpose of outdoor medicine, this is the approach I recommend. Although many cases of otitis media in children are caused by viruses, such as respiratory syncytial virus, and resolve without antibiotic treatment, if you are distant from physican care and suspect otitis media, treat the child victim with an antibiotic.
Adults and children should be treated with the following medications, including:
- amoxicillin (80 to 100 mg per kg [2.2 lb] body weight per day in three divided doses)
- amoxicillin-clavulanate (same dose of the amoxicillin component as for amoxicillin)
- cefdinir (14 mg/kg once daily or in 2 divided doses)
- cefpodoxime (10 mg/kg once daily or in two divided doses)
- cefuroxime (15 mg/kg in two divided doses)
- clarithromycin (for 10 days)
- azithromycin (for 5 days)
An additional antibiotic choice for children is erythromycin-sulfisoxazole for 10 days.
Other antibiotics that have been approved for treatment include:
Ibuprofen or acetaminophen should be used to control fever. To avoid Reye syndrome (postviral encephalopathy and liver failure), do not use aspirin to control fever in a child under the age of 17.
New evidence supports this empirical approach to treatment. It is not definitive, but suggestive. Researchers at the University of Pittsburgh and at the University of Turku, Finland did a study and determined that amoxicillin-clavulanate taken for 10 days in children aged 6 to 23 months with acute otitis media showed a measurable short-term benefit when compared to children treated with placebo (e.g., no antibiotic).
The clinicians were very certain of their diagnoses, because they could use otoscopes to view the eardrums to determine such indicators of infection as bulging, redness, and retained fluid. They did not rely upon less precise symptoms, like tugging on the ears, fever, and fussiness. The benefits of antibiotic treatment included more rapid clearance of the infections, maintenance of symptom resolution, and lower rate of clinical failure (e.g., antibiotics worked better than no antibiotics). There were more side effects noted in the antibiotic-treated group, which is what one would expect.
So, what to make of this? Acute middle ear infection is a treatable disease and responds to antibiotics. This assumes that the diagnosis is correct and that the antibiotic chosen is effective against the culprit germs. When you have the luxury of being in a hospitable environment and perhaps waiting a few days to see if the situation improves on its own without adding medications, that may be a reasonable approach. If you are on a trip or expedition where resources are limited and observation time is not practical, it is certainly reasonable to administer antibiotics.
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