Should Ear Infections Be Treated with Antibiotics?

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Ear infections are one of the most common ailments in early infancy and childhood. Most children have at least one ear infection by age three. These ear infections are often treated with antibiotics. In fact, ear infection is one of the most common reasons for antibiotic prescriptions in children. (1) But is this treatment effective and safe?

Antibiotics provide limited benefit for ear infection

Ear infections are not always caused by bacteria. Research estimates that ear infections have bacterial origin in 51 to 78 percent of cases. (1) This means that 22 to 49 percent of cases are due to other causes, such as viruses or even food sensitivities. (2) When an ear infection is caused by a virus or food sensitivity, antibiotics will not help.

Whether caused by bacteria or not, ear infections usually resolve on their own without treatment. In fact, a recent systematic review found that 60 percent of children had recovered from their ear infection within 24 hours of treatment, even if they did not receive antibiotics. (3) Research suggests that over time, without treatment, 80 percent of ear infections clear on their own. (4)

A recent review analyzed a large collection of trials about antibiotics and ear infections. (3) Two main types of studies were looked at: those that compared antibiotic treatment to placebo treatment and those that compared immediate antibiotic treatment to an expectant watchfulness, or “watch and wait,” approach. In the watch-and-wait treatment, antibiotics were only given if symptoms and pain persisted or got worse after three to seven days.

In comparing antibiotic treatment to placebo, antibiotic prescription did slightly reduce pain at various follow-up times up to two weeks following the start of treatment. Instances of ruptured eardrums and infection of the originally unaffected ear were also decreased mildly in the antibiotic group compared to placebo. However, 20 percent fewer children had recurrent ear infections in the placebo group. (3) Perhaps a less damaged gut flora better protected the placebo-group children from subsequent infections.

In almost all cases, antibiotic treatment was not significantly more effective than a watch-and-wait approach. Antibiotics did not provide any additional benefit for reducing pain, hearing loss three months after treatment, or rate of ear infection recurrence. The only situation in which antibiotic treatment was more effective than watching and waiting was in children two years or younger with bilateral ear infection and discharge. Thus, in this specific case antibiotic treatment may be warranted. (3)

Overall, this review suggests that a watch-and-wait approach may be safest in most cases. Those in the placebo group who had severe infections eventually requiring antibiotics would have been identified within a few days and properly treated. And most children in the antibiotic group would have ended up NOT being given antibiotics, thereby preserving gut microbiomes whenever possible.

Despite all this data, 95 percent of ear infections were treated with antibiotics in the United States in 2001. (5) By almost any definition, this is a gross misuse. New guidelines by the American Academy of Pediatrics (AAP) reject immediately prescribing antibiotics for ear infections in favor of a watch-and-wait approach in most cases. (6) However, because this reversal occurred recently, and because of pressure from parents for immediate treatment, many doctors still jump to prescribing antibiotics.

Does your child need antibiotics for an ear infection?

Antibiotics come with serious long-term risks—especially for children

The limited benefit of antibiotics for ear infection must be weighed against the risks. Among children treated with antibiotics, one in 14 had symptoms such as diarrhea, vomiting, and rash. (3) However, the effect of antibiotic use on long-term health is even more serious.

Antibiotics are not a precise treatment; they kill both harmful and beneficial bacteria all over the body. This is especially true for broad-spectrum antibiotics, which destroy a wider range of bacterial species.

This widespread bacterial death can have detrimental effects. It is hard to overstate the importance of the beneficial bacteria that live in the human body and make up a healthy microbiome. A rapidly growing body of evidence shows that resident bacteria affect diverse systems in the body and are essential components of long-term health.

We already know gut bacteria play a role in:

• Immune regulation
• Metabolism
• Nutrient status
• Detoxification
• Inflammation
• And more

Unfortunately, there is evidence that a person’s microbiome may never fully recover from antibiotic use. Lasting reduction in beneficial bacteria may increase our susceptibility to deadly pathogens like C. difficile and may play a role in the dramatic rise of conditions like obesity, type 1 diabetes, inflammatory bowel disease, allergies, and asthma. (7, 8, 9)

Children are especially susceptible to these potential dangers. As one example, a single course of amoxicillin or a macrolide antibiotic—most commonly used to treat pediatric ear infections—may eradicate H. pylori in 20 to 50 percent of cases. Unfortunately, the loss of this protective bacteria in children is associated with greater likelihood of developing asthma, hay fever, or skin allergies. (7)

On top of all these risks, overuse of antibiotics for ear infection may unnecessarily contribute to antibiotic resistance in the community. (3)

Antibiotics absolutely have a place in medicine and should be prescribed in certain cases, but over-prescription has been detrimental to patient health and has contributed to widespread antibiotic resistance.

Tubes for recurrent ear infections have limited effectiveness and high risk

For patients with chronic ear infections, inserting grommets, or ear tubes, into both ears is common practice. The tubes are meant to help fluid drain from the ears before an infection occurs. But the community is split on how effective they are at preventing future ear infections, especially beyond six months after insertion. (10, 11, 12) Furthermore, even though ear tubes did decrease overall time with ear infections compared to watchful waiting in one study, it increased instances of infection in the opposite ear, ear discharge, and eardrum scarring. These are some pretty severe and uncomfortable side effects. (13)

If you have a patient who is experiencing ear infection after ear infection, a bigger underlying health issue is probably present and should be addressed. I would advise trying some of the health-boosting recommendations below before resorting to ear tubes because the research on their effectiveness is mixed, side effects are possible, and any surgery requiring general anesthesia carries its own separate risks. However, some patients who already have severe, chronic ear infections may benefit from having tubes inserted while they also work on any underlying health issues.

A safer approach to treating ear infections

Of course, the safest approach is to avoid ear infections altogether. You can help your patient reduce the likelihood and severity of ear infection by taking steps to address health issues that may make a person susceptible:

• For infants, choose breastfeeding over formula whenever possible. Introducing formula in the first six months of life is associated with more ear infections in early childhood (14)
• Eat a nutrient-dense, whole-foods diet

• Identify food sensitivities and remove problematic foods from the diet. Dairy is the most common culprit in recurrent ear infection (2)
• Ensure adequate vitamin D levels (15, 16)
• Strengthen the immune system

For more strategies to promote overall health and help prevent illness, check out my free eBook 9 Steps to Perfect Health.

However, if your patient does get an ear infection, research dictates that a watch-and-wait approach is best in most cases. Have the parent keep an eye on illness progression and schedule a follow-up in a day or two. Most ear infections will clear on their own in a few days without much added discomfort.

In the meantime, you may recommend low-risk remedies to help ease symptoms and shorten duration:

• Use xylitol nasal spray to break up biofilm to make it easier for the immune system to remove any pathogens (17, 18)
• Use garlic and mullein oil ear drops, warmed gently, to provide antimicrobial and soothing effects. This remedy is safe as long as the ear drums are not ruptured and has been shown to alleviate ear infection pain as well as an anesthetic drop (19)
• Consume probiotics and prebiotics in the form of fermented foods, fermentable fiber, or supplements to support gut and immune health
• Take supplemental nutrients that help support the immune system
• Consider additional botanical support to strengthen the immune system and provide symptom relief

You may also consider treating with herbal antimicrobials, especially if the infection is viral. See my previous article, 7 Tips for Preventing (and Shortening) Colds & Flus, for tips on how to use botanicals and other nutrients to fight viruses and support the immune function. These do affect the microbiome, but not as dramatically as broad-spectrum antibiotics, and the risk of antibiotic resistance is much lower.

Despite the risks, antibiotics may be necessary in some cases. If you determine antibiotics are the safest choice for your patient, all hope is not lost. There are steps you can take to limit the negative impact of antibiotics.

Now I’d like to hear from you. Did you know antibiotics are usually unnecessary to recover from ear infection? What forms of prevention and treatment have you found most useful? Let us know in the comments below.

Filed under: Fitness