Does using antibiotics increase the risk of a child getting recurrent ear infections?

Question

My son, thankfully, went about 18-20 months without getting an ear infection. His first one cleared up naturally.

The second one didn't seem so bad, but he was given antibiotics for it. I wasn't keen on the use, because I'd heard that treating a child's ear infection with antibiotics can increase their chances of getting recurrent ear infections.

Since then, he had another ear infection necessitating antibiotics. It was much more severe than the previous times, and I do agree medicine was needed. He's now currently suffering from another ear infection (and a URI, and the combo meant a late-night ER visit last night).

Of course, my son has been getting more colds/illness in general lately, which I largely attribute to his increased exposure to other children -- more playdates, and more active play at parks.

Anyway, I'm just wondering about the continued use of antibiotics to clear up ear infections. They seem to clear up the symptoms well enough, at least short-term, but he hasn't been not sick long enough for me to make any other determinations.

Does using antibiotics for ear infections really increase the chances of getting recurrent ear infections?

Could the earlier doses we gave to my child have caused antibiotic-resistant bacteria that keeps growing back? Or is this just a common way ear infections occur in children--low to no incidence followed by high incidence?

Here are some sites that mention the risks, although they're not where I first heard it: Choosing Wisely: Oral Antibiotics of for Ear Infections and WebMD: Antibiotics for Middle Ear Infections

From WebMD:

Doctors sometimes prescribe antibiotics to prevent infections in children who are prone to repeated ear infections (recurrent otitis media). But experts disagree on how helpful this is.

And

Use of antibiotics to treat ear infections increases the risk for antibiotic-resistant bacteria.

I've seen and heard the claim that resistant-bacteria don't get fully eradicated, so the "same" infection comes back. I'll try to find sources when I can, but I think I've mostly heard this in passing (and not as the main point of an article or discussion).

Please note: I'm not asking for medical advice. I am not asking you whether or not I should prescribe my child antibiotics. I think some of the relevant meta questions back me up on this not being a medical advice question:

• When are drug questions medical questions?
• Are questions about generic medical fundamental medical information on-topic?
• Medical questions: what is the line between on / off topic, and how should they be handled?

Answer 1

No, antibiotic use does not increase ones susceptibility to ear infections.

Correlation does not equal causation. It is a difficult concept to accept, because we seem to see it and experience it every day.

It is a bit like infections with a fungus (say tinea pedis): some people are predisposed to it, others are not. The fact that they take medications for it is entirely beside the point; this is a correlate to being ill. But use of the medication (even in resistant cases) does not mean it causes the resistant illness.

Some babies will have only one ear infection in their lives, some none. Other children, because of their particular anatomy or other local factors, will be predisposed to recurrent infections. The medication can be seen as a correlation (to the illness), but not a causation.

Of course, medications do cause illness. Antibiotic-associated diarrhea (a.k.a. C. diff) can't, by definition, occur without antibiotic use.

One effect of taking antibiotics for ear infections is that it may exert selective pressure for the proliferation of an antibiotic-resistant bacteria to colonize the oropharynx. Then a subsequent ear infection may be less responsive to the first antibiotic. Again, this must take into account that the child is prone to ear infections.

Are there risks to treating ear infections? Certainly. There are also risks to not treating ear infections. A good doctor will discuss the risk to benefit ratio with you.

Again, it's not that antibiotic use or resistance increases the incidence of ear infections, but that some infants and children are predisposed to developing them. When a child has established a predisposition towards developing them, doctors did use antibiotics prophylactically (which does contribute to antibiotic resistance.) It is however possible that such children's subsequent ear infections become more difficult to treat.

Answer 2

I've never seen anything reputable suggesting that it is substantially more likely to get a new ear infection after a properly used antibiotic regimen (ie, the child took it for the full length of treatment indicated by the doctor). There's a potential mechanism for that to be possible, which I'll mention later, but it seems unlikely to me.

There are several reasons antibiotics are no longer recommended for "mild" to "moderate" ear infections, particularly single ear infections.

• Antibiotic overuse can lead to the development of antibiotic-resistant bugs, particularly for bacterial infections that are otherwise fairly easy for your body to fight off given time. See the CDC page for more information.

• Antibiotics have side effects that are non-trivial. In particular, reducing the gut flora can lead to gastric distress and usually causes diarrhea, and in children in diapers this often leads to sometimes bad diaper rash. Antibiotics also have an impact on the skin biome. I've seen this blamed for increases in subsequent ear infections before, although I've never seen anything reputable - but I am not a doctor.

• Antibiotic use for moderate concerns like this can lead to further antibiotic dependence by parents wanting the best for their children and/or wanting to return them to school sooner. Discouraging their use for mild to moderate concerns and discussing why can help break this pattern.

The one reasonable path I have heard (but never read in a paper) that could suggest this is your immune response. Having a longer ear infection can lead to better development of "memory" T-cells, which could potentially fight an infection more effectively in the future. From what I understand of ear infections, they don't tend to be identical bacteria necessarily, and bacteria in general are fought with primarily other parts of the immune system (particularly, the innate immune system, which is not antigen specific). (This is why you can repeatedly get strep throat, for example.) That makes the memory response less important (though I haven't found any papers discussing this in specific).

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In the short run, I would expect antibiotics to help avoid reinfection. This is one of the main reasons you continue their use for the full length of treatment recommended by your doctor, often up to 10 days, even when the symptoms are gone within 24 hours; immediately after infection your body is weaker and more susceptible to developing a new infection (of a different type of bacteria, for example). It also helps to avoid reinfection from the same bacteria in some cases; streptococcus-based infections in particular often take the full ten days to prevent a recurrence.

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Just to be clear, this should not be construed as medical advice or "You should do this"; it only intends to describe some of the information your doctor uses to make their decisions and recommendations, and possibly inform your discussion with your doctor.