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Ear Infection Superbug Discovered

Tough strain resists all approved drugs

October 19, 2007

• Ear Infection Superbug Discovered • Pacifier Overuse Can Lead to Ear Infections

Researchers have discovered a strain of bacteria resistant to all approved drugs used to fight ear infections in children, according to an article in the Journal of the American Medical Association (JAMA).

A pair of pediatricians discovered the strain because it is their standard practice to perform an uncommon procedure called tympanocentesis (ear tap) on children when several antibiotics fail to clear up their ear infections.

The procedure involves puncturing the child’s eardrum and draining fluid to relieve pressure and pain. Analyzing the drained fluid is the only way to identify the bacterial strain causing the infection.

Even after the ear tap and additional rounds of antibiotics, infections persisted in a small group of children in a Rochester, New York, pediatric practice, leading to ear tube surgery and, in one case, to permanent hearing loss.

The physicians realized they may be dealing with a “superbug” and tested the children's ear tap fluid at the University of Rochester Medical Center.

The tests showed that the superbug, called the 19A strain, could be killed only by an antibiotic (levofloxacin, Levaquin) approved for adults that had a warning in its label against use in children. With no other choice, they treated the children with crushed, adult-approved pills, and it worked.

Worst-case scenario

The 19A strain was most likely created by a combination of the speed of bacterial evolution and the overprescribing of antibiotics, the authors said.

They warn that, while it may very well never happen, the medical profession must now at least consider the prospect of a worse-case scenario: this multi-drug-resistant bacterial ear infection spreads to other communities, or invades the lungs and bloodstream, where it leads to cases of pneumonia or meningitis treatable only with unconventional antibiotics not approved for use in children.

Experts have been arguing for years that pediatricians need to determine the type of bacteria causing an ear infection before “throwing an antibiotic at it.” Most do not know, nor are the later generations of doctors required to learn, tympanocentesis, the technique that makes that determination possible, according to the authors.

The decision is made to treat with antibiotics regardless of whether the strain will clear up by itself, or whether the strain in question is resistant to the antibiotic used.

“Children with the new strain of superbug represented a small subset of those in our practice, but the results are worrisome, especially since there are no new antibiotics in the pipeline for ear infections in children,” said Michael Pichichero, M.D., professor of Microbiology, Immunology and Pediatrics at the University of Rochester Medical Center, and a partner at Legacy Pediatrics, the private practice involved.

“While we must be careful not to create undue alarm, the potential exists for newly evolved strains to spread to the ears of more children,” said Pichichero, an author of the JAMA article.

Using an antibiotic not approved by the U.S. Food and Drug Administration (FDA) in children is a concern because the FDA makes certain that the drug is safe and effective before granting approval, Pichichero said.

The ‘off-label’ use of drugs like levofloxacin, a fluoroquinolone antibiotic, has been an area of intense debate because of potential safety issues, and because its excessive use in children, if it came about, may create resistance to the only drug effective against the superbug.

“The solutions to this problem are clear,” said Janet Casey. M.D., co-author of the study, associate professor of Pediatrics at the Medical Center and a partner in Legacy Pediatrics.

“Many more physicians need to learn and use the ear tap technique and how to test for the strains once the sample is collected. They also need to resist pleas by parents to treat colds with antibiotics for comfort’s sake alone.”

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