A new look at ear infections Antibiotics first defense against childhood ailment

September 01, 1992|By Cox News Service Staff Writer Sandra Crockett contributed to this report

Atlanta -- Not yet 2, Manny Major has taken virtually every

antibiotic doctors have for infections of the middle ear. With growing frustration, his parents have watched as each new prescription has failed to correct his problem.

"Every four to six weeks we would go back to the doctor and he would switch antibiotics," says Donata Major, whose older son, 4-year-old Zane, also has suffered a half-dozen middle-ear infections.

"But the antibiotics always seemed to stop working after a week or so. I got tired of giving it to them. They got tired of taking it."

Manny's ordeal has become almost a national rite of passage for young children. The same kind of ear infections that last year sent the Majors to the doctor nine times also prompted 30 million office visits nationwide.

Middle ear infections range in severity from the kind that require a 10-day course of amoxicillin ($5) to those that demand Pediazole ($22), Augmentin ($43), Suprax ($51) or, if all else fails, an operation to install tiny tubes in the child's ears ($2,000 and up).

Nationwide, middle-ear infections account for 20 million antibiotic prescriptions and more than $1 billion in medical expenses a year.

Dr. John Boscia, assistant chairman of the pediatrics department at Greater Baltimore Medical Center, explains: "The reason antibiotics are given is to treat a bacterial infection. When we diagnose an earache, we automatically give antibiotics."

Follow-ups are important, though, to see if the antibiotics are working, he says. "In the majority of the times we do see a resolution for ear infections."

However, sometimes middle-ear infection is a sign of something more ominous than earaches. Made increasingly resistant by repeated exposure to antibiotics, the bugs that cause these infections are fighting back. In some cases, there are simply no antibiotics that work anymore.

Not all persistent ear infections are because of antibiotic failures. Some result from underdeveloped Eustachian tubes, the passages between the nose and the middle ear, which can become blocked when a child has a cold.

"Kids are also in contact with more children at an earlier age these days, so there is more opportunity for the spread of infections," says Dr. Benjamin White, a pediatric otolaryngologist who inserted tubes in the Major children's ears at Atlanta's Scottish Rite Children's Medical Center.

But researchers say resistant germs play a large and growing role in this now nearly universal affliction of childhood.

A Centers for Disease Control study of children undergoing tube- placement surgery at Scottish Rite showed high-level resistance up to 100 percent -- among the three dominant bacterial causes of middle-ear infections.

"In kids with chronic ear infections, we found strains that could not be effectively treated with antibiotics," says CDC epidemiologist Ben Schwartz.

Resistance complicates an already difficult dilemma. When parents see their child in pain or discover pus oozing from an infant's ear, they want action. Neglected, such infections can lead to hearing loss, even life-threatening meningitis or encephalitis.

In more than half of all cases, the inflammation of the middle ear subsides on its own, making antibiotics unnecessary. Even the doctors can't be certain of the outcome.

"Most physicians rely only on a physical exam of the ear," says Robert Breiman, chief of epidemiology in the CDC's respiratory disease branch. "Antibiotics may not be warranted for inflammation due to an allergic reaction, a virus or structural problems, but when a mother wants something, it's difficult for a doctor not to prescribe an antibiotic."

Even when antibiotics are needed, the choice poses a second dilemma. Susceptibility of the microbes can be determined only by piercing the child's eardrum to sample the fluid -- a painful process -- so treatment usually involves an element of trial and error.

"On the first visit, a doctor usually puts the child on a 10- to 14-day course of amoxicillin," explains Dr. White. "But you don't know an antibiotic is working unless the child gets better. If it doesn't clear up after four to six weeks, you try a different antibiotic. You may switch two or three times before resorting to surgery."

Even if an infection subsides, doctors often prescribe low doses of antibiotics to keep it from returning. In the process, they may unwittingly encourage the remaining germs to become resistant.

That strategy is most likely to backfire in what doctors call the "culture clubs" -- day-care centers, where children swap germs like toys.

"Children who have recently received antibiotics -- even for something other than an ear infection -- are far more likely to have resistant organisms," says Dr. Schwartz. "The risk is

highest in day-care centers, where children may acquire resistant organisms from other children who are taking antibiotics."

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