Earaches 1 and 2: Some of Them Require Medicine, Do They All?

In Scandinavian countries, there is very little antibiotic-resistant bacteria. For example, Finland reported 0% resistance to penicillin in 1989. In Scandinavian countries, when a parent brings in a child complaining of an earache, the doctor takes a look and then typically sends the child home with pain medication, asking the parent to return the next day only if the earache is no better.

Because 80-90% of all earaches resolve by themselves within 24 hours, Scandinavian doctors work on the idea that by waiting to see if the body can do the healing by itself, the 10-20% of earaches that actually need antibiotics will be the earaches that return for a second appointment the next day. Those "un-better" earaches are the ones which are treated with antibiotics. (This is when "Take two Tylenol and call me in the morning," really is great advice!)

Earaches 1: Is Waiting an Alternative to Antibiotics?

Interestingly to me, I had seen this exact outcome just weeks before Dr. Rawstron's talk. It was a heavy, muggy kind of week, every night was foggy and every day cloudy.

My HIV+ son complained of an earache three times that week. I usually run to the doctors and specialists at any sign of something wrong but I really hated to drag him in to clinic again. I thought there might be some atmospheric pressure from the strange, heavy weather that was pressing on his eardrum and making it hurt.

My son has had allergic reactions to three classes of antibiotics and for years I've been concerned about running into problems with the antibiotics he has left. I'm afraid we'll use them up now when he's only a little sick and then we won't have them when he gets something really bad.

So I didn't take him to the doctor and, really unusual for us, I didn't even call the doctor to check! (I'm not advising this kind of behavior, lucky for my son, it turned out right this one time. Next earache I may run to have the ENT see him.) But this time I didn't call the doctors because I knew they would send a prescription or ask me to bring him in. I didn't want him to miss any more school; I didn't want to use another antibiotic and chance him becoming allergic to it too.

Each day I expected the school to call and send him back home, but no one called. A couple evenings he said his ear hurt and had hurt during school. I hoped he was just exaggerating. Heck, for the first time in his life I hoped he was lying!

I didn't ignore his complaint, I was cautious and worried that it would get worse, but since the pain was intermittent and responded to ibuprofen, I felt we could wait. Pretty soon -- within four days -- he completely stopped complaining and the earache just wasn't there anymore. I was relieved but still worried that my non-action might have caused some irreparable harm to his hearing or maybe the infection was going to come roaring back, having only sulked away to a deeper area of his inner ear. But nothing bad happened. He seemed to be cured.

After hearing Dr. Rawstron speak, I knew the reason my son's earache had cleared up: most earaches don't need antibiotics, they go away by themselves.

Earaches 2: What About When Antibiotics are Needed?

What about those 5 to 10% of the total number of earaches that do need antibiotics? The ones that are accompanied by fever, the ones that don't get better in a day or so, bad earaches with pus or fluid coming from the ear? With at least 3 common bacteria that cause ear infections all becoming resistant to antibiotics, what will a call to the doctor produce?

It is always best to use the narrowest spectrum antibiotics (that is the antibiotics that are active against the least number of types of bacteria). It is best of all to use the one exact antibiotic that kills the exact kind of bacteria causing the problem. With earaches this is usually a standard dose of Augmentin or amoxicillin (40 mg/kg) which still works for the majority (80%) of ear infections in New York City. Of the remaining 20%, about half (10% of total) have only partial resistance which respond to increased doses of the standard antibiotics: a doubled dose of amoxicillin (80 mg/kg) or a combination of Augmentin with amoxicillin at the regular doses (40 mg/kg each). This prescription for the stronger dosing of narrower-spectrum drugs completely destroys the bacteria while reserving some "big gun" broad-spectrum antibiotics for any more-resistant bacteria that your child may get later.

Only in ear infections that do not respond to the higher doses, approximately 10% of total, a broader spectrum antibiotic may be necessary.

This is good policy in a public health focus because it doesn't cause further antibiotic resistance and it's good for the patient because it "saves" the broader spectrum antibiotics for the worst situations.