Grommets no better than antibiotics at stopping recurrent OM: Research

Evelyn Lewin

25/05/2021 4:57:02 PM

However, if antibiotics are chosen as the treatment modality, continuous low-dose prophylaxis is preferred to episodic therapy.

GP inspecting child’s ear.
Parents often have firm views about whether to treat recurrent otitis media with grommets or antibiotics.

There is little difference in treatment outcomes between inserting tympanostomy-tubes (or grommets), and giving episodic antibiotic treatment to prevent recurrent otitis media (OM), a new randomised controlled trial has found.
The study, published in the New England Journal of Medicine, examined the effects of these treatments in children aged six months to three years who had experienced at least three episodes of acute OM within six months, or at least four episodes within 12 months with at least one episode within the preceding six months.
The recorded rate of repeat infections was 1.48 per child over a two-year period for grommets, compared with 1.56 per child in those given antibiotics.
Although the trial randomly assigned children to either treatment with grommets or with antibiotics, 16% of the children in the medical group underwent grommets insertion at parental request, while 10% of those in the grommets group did not have them inserted.
Mr Stephen Kleid, an ENT and head and neck surgeon at Peter MacCallum Cancer Centre, told newsGP there are no hard and fast rules about whether to treat recurrent OM in children with either grommets or antibiotics.
But if the decision is made to use antibiotics, he advises a six-week course of continuous low-dose antibiotics to try and ‘break the cycle’ of repeated infections, using amoxicillin once a day.
‘If [children] don’t recover in six weeks, there’s only a 10% chance they’ll recover in the next six months,’ he said.

Mr Stephen Kleid says he allows parents to make the decision about how to treat recurrent otitis media.
However, during the trial antibiotics were only used to treat acute flare-ups, rather than being given prophylactically – an approach that Mr Kleid does not support.
‘When you’re using conservative management with intermittent antibiotics, the child has pain and fever before they go on antibiotics,’ he said.
‘And then they go on five days of antibiotics and they get side effects sometimes, they get diarrhoea and rashes, and sometimes they need a second course of antibiotics.’
He says there are pros and cons to both approaches for treating recurrent OM.
While grommets ‘will fix the problem’, there are risks associated with the procedure.
‘It’s a general anaesthetic, but I look at it as [being as] safe as driving to and from the hospital,’ Mr Kleid said.
Instead, ‘the biggest risk’ of putting in grommets is discharge from the ears, but Mr Kleid notes it is preferable to have ears drain their discharge, rather than having that fluid build-up behind the eardrum.
Grommets are also only a time-limited solution as they stay in for a year and can ‘wash out early’, but Mr Kleid says the long-term effects of recurrent insertion of grommets are ‘miniscule’.
Using antibiotics, on the other hand, brings concerns about antimicrobial resistance and Mr Kleid says ‘most GPs and parents are somewhat reluctant’ to use antibiotics for this reason.
HANDI Chair and GP Paul Glasziou, Professor of Evidence-Based Medicine at Bond University, told newsGP he agrees antimicrobial resistance is an issue to consider when discussing use of antibiotics.
‘Obviously the more antibiotics you use, the greater the risk of resistance,’ he said.
‘A lot of that resistance is in the individual, so the individual child develops resistance and [in the case of continuous low-dose prophylactic medication] this would be to amoxicillin.
‘That resistance can eventually wear off, [but] sometimes that gets transmitted to other people, so you get increased community resistance as well.’
However, when it comes to antimicrobial resistance Professor Glasziou says the ‘major problem’ is the unnecessary use of antibiotics, such as for bronchitis or upper respiratory tract infections, where antibiotics are ‘rarely indicated’.
‘In the scheme of things, they’re the big picture problem that we could be reducing to reduce [antimicrobial] resistance,’ he said.
Conversely, Professor Glasziou is not overly concerned about these issues when it comes to using antibiotics for recurrent OM, and is actually more concerned that they may be underutilised for this indication.
‘Because of the number of children [affected], in the scheme of things, this is a pretty minor problem,’ he said.
‘I imagine the major indication for this in Australia is in Aboriginal children … [and] the Australian quality commission’s variations in practice shows that there’s actually underuse in antibiotics in some areas like the Northern Territory, or Arnhem Land.
‘In remote communities, we’re probably underusing antibiotics, so we need to get to the right level of antibiotic use and if it’s an appropriate indication, [such as for recurrent OM], I think we just have to wear the little bit of resistance that we get.’
Professor Glasziou therefore believes concerns regarding antimicrobial resistance should not stand in the way of treating children with recurrent OM.
‘I don’t think we should stop using antibiotics just because there’s some resistance in a very small number, where there’s an appropriate indication,’ he said.
‘To me, the critical thing is [determining] who are the kids that really need to have [antibiotics], who have got a sufficient problem with their recurrent OM that we would like to give them antibiotics.’ 
The research notes that even after grommets are inserted, children may still experience recurrent OM, but Mr Kleid says the type of infection they experience differs from that in a child without grommets.
When a child develops OM with grommets in, he says the treatment is antibiotic drops, not systemic antibiotics.
Children are also unlikely to be unwell during such infections, but may simply have a discharging ear.  
‘The mum will say, “He’s perfectly well, he’s just got pus coming out of his ear”,’ Mr Kleid said.
‘That’s not the same as being up all night with a screaming child with a fever, so they’re comparing apples and oranges, because once you put the grommets in, the nature of the infection changes.’

Professor Paul Glasziou believes the benefits of using antibiotics for recurrent otitis media outweigh the risks of antimicrobial resistance.
When trying to decide which treatment to use, parents often enquire about potential long-term issues associated with undertreating OM.
But Mr Kleid assures that the risk of mastoiditis, facial nerve palsy or brain abscess from OM are all ‘really rare’ in the majority of first world countries.
Mr Kleid also says there are no additional long-term risks in choosing to wait to treat recurrent OM, as studies have shown that if you wait six months, or put the grommets in early, children’s educational skills are the same at age 12.
‘So they don’t have an educational handicap, but you’ve got a child with a 30% hearing loss who’s uncooperative, doesn’t play nicely with other children, especially with noisy backgrounds, misbehaves and often feels uncomfortable, which you can solve,’ he said.
Mr Kleid says parents often have firm views on which treatment modality they prefer, but that if a child with recurrent OM is given low-dose continuous antibiotics, the parent may consider switching strategies and inserting grommets if: 

  • the child suffers frequent, recurrent infections
  • the child has hearing loss as a result of infections
  • the child is experiencing side effects from antibiotics
  • the issue is causing significant disruption to the family.
‘If the child is suffering with recurrent attacks – so they’re getting an attack every month – and they’re waking up screaming, if it was my child, I wouldn’t let them suffer; I’d solve the problem,’ Mr Kleid said.
‘[And putting grommets in] is like flicking a switch: you put the grommets in, and [children] stop getting painful infections with fever.’
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antibiotics antimicrobial resistance glue ear grommets otitis media recurrent ear infections

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