Do all ear infections need treatment with antibiotics?

Absolutely not. A majority of ear infections are self-limited, resolving within a few days without any treatment. In general, all a physician and parent need to do is treat the pain and stay out of the way while the body heals itself. I do advise treating the pain with benzocaine eardrops, acetaminophen, or ibuprofen, but I generally hold off on prescribing antibiotics at first.

In my practice, we’ve been using a “wait-and-see” approach since 1999 with great success, withholding antibiotics until it is clear they are needed. I’ve found that 65-70% of ear infections heal themselves with no after-effects. Although I do prescribe antibiotics early to children under one year, I otherwise withhold these powerful drugs for a day or two. If a child has not improved in that time or worsening, I’ll prescribe one of the simpler antibiotics such as amoxicillin. If there are other complicating factors such as recurrence or day-care exposures with recurrence, I might go to a stronger antibiotic, but this is now the exception rather than the rule in my practice.

Treating every ear infection with an antibiotic drug has contributed to the development of bacteria that are resistant to more and more antibiotics. Concern about this overuse of antibiotics is the reason why the American Academy of Pediatrics has endorsed and issued guidelines on this wait-and-see approach (the “observation option”). Unfortunately, a recent study in Pediatrics confirmed that the majority of pediatricians are not yet following the 2004 guidelines. Much of this is likely due to the continuing pressure from anxious, “antibiotic-trained parents”.

Follow-up is critical in the case of ear infections, whether treated or not. If your child’s health is worsening during a wait-and-see period, contact your primary-care provider immediately.