A Family with a Variety of “Flu” Symptoms
A 34-year-old female patient requests an office visit after experiencing flu-like symptons for the last few days. She was never febrile but had a sore throat along with nasal congestion. She is asking for an antibiotic to hasten the resolution of her illness. She is accompanied by her 3-year-old son and is also requesting an antibiotic for him. He, too, had been ill, but with a fever and left ear pain for the last 2 days. He is currently afebrile but otoscopy demonstrates a dull, tympanic membrane with a middle ear effusion (MEE).
Which of the following is the most accurate advice for this situation?
A. The risk of antibiotic-related diarrhea outweighs any benefit from an antibiotic for the child.
B. Antibiotics may resolve his symptoms but will have no effect on his hearing.
C. Appropriate antibiotic treatment can effectively reduce his MEE and concomitant hearing impairment.
D. Any beneficial effects from antibiotics will be short-lived, with no benefits compared to no antibiotics after the first 2 weeks.
(Answer and discussion on next page)
Correct Answer: C, appropriate antibiotic treatment can effectively reduce his MEE and concomitant hearing impairment.
How to approach children’s middle ear infections has long been the subject of discussion and controversy since the advent of antibiotics. On the positive side for antibiotic usage, is the shortening of symptoms (especially pain) and duration of illness in these young patients. On the negative side, however, is the perceived overuse of antibiotics with its resistance and public health issues as well as antibiotic-related diarrhea, a frequent side effect.1 However, 2 recent well-done studies have demonstrated significant, meaningful benefits accruing to properly chosen patients.2,3 In the most recent of these,2 a placebo-controlled study was performed in 84 young people, half of whom received typical and appropriate antibiotics (amoxicillin with or without clavulanic acid), while the other half received placebo. Of importance was patient selection. Diagnosis required either acute symptoms of respiratory infection and/or ear-related symptoms and signs of tympanic membrane inflammation together with MEE detected in pneumatic otoscopy. Thus, there was no dilution of antibiotic effect due to treating large number of “colds” which would not benefit from antibiotics.
When analyzed, this study demonstrated that indeed there was the expected 1-day (3.2-2.2) improvement in disappearance of earache in the antibiotic group. Further, and more importantly, there was meaningful and significant improvement and resolution times in the primary outcome parameters of resolution in MEE—2 weeks sooner (P=0.02); as well as significantly quicker time to normal ear otoscopy. These benefits continued past 2 months out from diagnosis. Since MEE is known to impair hearing with its attendant problems with language and learning, one can postulate very important positive effects accruing to the antibiotic related rapidity and depth of resolution.2 Thus Answer B, that antibiotics induce symptom relief but will have no effect on hearing, is incorrect. Further, Answer D, that antibiotics’ net positive effects for symptom relief and otherwise, are short-lived, is incorrect.
A key issue when evaluating antibiotics in acute otitis media in general, and the results of this study in particular, is accuracy of diagnosis. The authors insisted on firm exam criteria—demonstration of MEE and abnormal otoscopy—to accrue their study groups. Many previous studies had far less stringent criteria, likely resulting in the inclusion of large numbers of children who did not have acute otitis and thus would not and could not benefit from antibiotics (yet were just as likely to get antibiotic-related diarrhea!). Therefore, these factors would dilute and mask any beneficial effect of antibiotics.2. An accompanying editorial stresses that benefits of antibiotics rely on accurate diagnosis of acute otitis rather than indiscriminant use for a variety of less specific complaints and situations.1
A major difficulty associated with antibiotic usage is antibiotic-associated diarrhea as mentioned in Answer A. This toxicity can be expected in about 10% of treated cases.2,3 Although indeed troublesome, the diarrhea is rarely severe and usually resolves within 3 days of cessation of antibiotics.1 The low incidence and mild severity of this adverse effect seems quite acceptable in the face of a shorter duration of illness across the larger group of treated patients and the documented anatomical benefit in the middle ear and functional benefit in hearing. Therefore, Answer A is incorrect.
Patient Follow-Up
Based on the clinical findings, a 1-week prescription for amoxicillin- clavulanate was provided for the child. Within 2 days all of his symptoms had resolved, he was well and back at daycare. A follow-up exam 10 days later revealed resolution of the MEE and a normal tympanic membrane. He never developed diarrhea.
Take-Home Message
Despite a background of controversy with waxing and waning enthusiasm for the use of antibiotics in pediatric acute otitis media (AOM), most recent data suggests that appropriate and accurate diagnosis of AOM provides notable benefit to antibiotics—not just in duration of illness, but also in rate and extent of resolution of illness in middle ear effusion and tympanometry, with potential for less hearing impairment. There is a 12% diarrhea rate associated with this strategy, which is usually mild and self-limited.
Ronald Rubin, MD, is a professor of medicine at Temple University School of Medicine and chief of clinical hematology in the department of medicine at Temple University Hospital, both in Philadelphia, PA.
References:
1.Tapiainen T, Kujala T, Renko M, et al. Effect of antimicrobial treatment of acute otitis media on the daily disappearance of middle ear effusion: a placebo-controlled trial. JAMA Pediatr. 2014;168:635-642
2.Pichichero ME. Antibiotics for Acute Otitis Media. Yes or No. JAMA. 2015;313:294-295
3.Tahntinen PA, Laine MK, Huovinen P, et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med. 2011;364:116-126