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Time To Stop The Misuse Of Antibiotics
By Erdem I. Cantekin

This text originally appeared as a letter to the editor in the British Journal of Medicine 321, no. 7263 (September 23, 2000): 765.

Nearly 20 years after the first modern randomized clinical trial by van Buchem et al.,1 Damoiseaux et al. finally have dispelled the myth of mandatory antibiotic treatment for acute otitis media.2 They demonstrate that even in children at high risk (aged under two years) antibiotic treatment is ineffective, thereby extending the findings of van Buchem et al. to all age groups.

Though the results of van Buchem et al. were confirmed by Danish and Swedish clinical trials in 1981 and 1986, two misleading trials published in 1991 under the influence of antibiotic manufacturers perpetuated the myth of the effectiveness of antibiotics.3 In the US, consequently, the annual antibiotic consumption for otitis media has increased dramatically to over 30 million prescriptions. Antibiotic misuse in otitis media has contributed greatly to the current epidemic of multidrug-resistant Streptococcus pneumoniae.

During the first two years of life, American children spend an astounding 90 days taking antibiotics.4 This may be causally related to the current increase in chronic respiratory diseases such as wheezing and asthma in young children. Last year a research group from Boston reported that 32 percent of such children wheeze, 26 percent use bronchodilators, and 12 percent have asthma before the age of five years.5

Nine years after the two misleading 1991 articles (one was the subject of an extensive fraud investigation by the US government) there is finally an unassailable randomized clinical trial that supports the watchful waiting approach of withholding antibiotics for acute otitis media, even for young infants. Children under the age of two, who are considered to be at risk of a poor outcome, were the favored target for antibiotic advocates. These leading experts argued, without scientific evidence, that such children should always be treated with antibiotics for at least ten days and often with multiple courses of wide spectrum newer antibiotics for extended periods, up to months of antibiotic prophylaxis.6

Considering the alarming rise in the prevalence of drug-resistant bacterial pathogens and chronic lung diseases among children, doctors must lead the effort to curb misuse of antibiotics. It is time to switch to effective pain management such as local analgesia (20 percent benzocaine ear drops) and systemic pain relief (paracetamol) as the first line of treatment for acute otitis media and to stop dispensing ineffective drugs with proven serious adverse effects on both children and the community at large.

Editor's note: A parent who wants to make a child with an earache comfortable can use the treatment given to children in Switzerland, Holland, the United Kingdom, and Scandinavian countries. Buy an ear drop solution at the drugstore that is 20 percent benzocaine (a local anesthetic) and give the child NyQuil, which contains acetaminophen and a decongestant, to alleviate pain and congestion. 7

Notes
1. F. L. van Buchem, J. H. M. Dunk, M. A. van't Hof, "Therapy of Acute Otitis Media: Myringotomy, Antibiotics, or Neither? A Double Blind Study in Children," The Lancet 2, no. 8252 (October 24, 1981): 883-887.

2. R. A. Damoiseaux et al., "Primary Care Based Randomised, Double Blind Trial of Amoxicillin Versus Placebo for Acute Otitis Media in Children Aged under 2 Years," British Medical Journal 320 (February 5, 2000): 350-354.

3. E. I. Cantekin, "Aggressive and Ineffective Therapy for Otitis Media," Otorhinolaryngol Nova 8 (1998): 136-147.

4. J. L. Paradise, H. E. Rockette, D. K. Colborn, B. S. Bernard, C.G. Smith, M. Kurs-Lasky, and J. E. Janosky, "Otitis Media in 2,253 Pittsburgh-area Infants: Prevalence and Risk Factors During the First Two Years of Life," Pediatrics 99 (1997): 318-333.

5. A. L. Fuhlbrigge et al., American Lung Association/American Thoracic Society International Conference, San Diego, April 1999.

6. See Note 3.

7. Maryann Napoli et al., "Childhood Ear Infections: Treatments Worse Than Disease," HealthFacts Center for Medical Consumers (April 1995): 1-4.

Erdem I. Cantekin, PhD, is professor of otolaryngology at the University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh.