Antibiotic Stewardship and Pediatric Ear Infections
Andrea R. Gravatt, MD, FAAP, FAWM, Professor of Pediatric Medicine, University of Washington School of Medicine, Clinical Professor of Pediatric Medicine, Elson S. Floyd College of Medicine, Washington State University
Antibiotic stewardship is the careful use of antibiotics, ensuring they are prescribed when needed while avoiding unnecessary exposure. In pediatric ear infections, this can mean treating some children with antibiotics while recommending watchful waiting for others.
Key Takeaways
Antibiotics can be used to treat infections caused by bacteria but have no effect against viruses.
Acute otitis media (AOM) can involve bacteria, viruses, or both, and not every ear infection requires an antibiotic.
For some children with mild acute otitis media, clinical guidelines support watchful waiting before starting antibiotics.
Using the correct antibiotics and dosage helps to reduce unnecessary side effects and helps to reduce antimicrobial resistance.
Getting an accurate diagnosis is the first thing necessary if suitable treatment is to be determined.
What Are Antibiotics?
Antibiotics are drugs used to treat bacterial infections; they work by killing bacteria or stopping them from multiplying. They are not effective against viral infections, such as those that cause most colds and other respiratory infections. Most antibiotics used to treat Otitis Media (OM) are prescribed for oral use, whereas, in some specific instances, antibiotics are administered by injection into the muscle or given intravenously.
Although viruses cause AOM, antiviral agents are not prescribed for OM as most of these infections self-resolve.
Why should the difference between bacteria and viruses matter?
Antibiotics are useful to treat AOM in cases where there is a need to treat a bacterial infection, but they are not indicated to treat a viral infection. Unfortunately, the situation in the middle ear is not always easy to evaluate. Even on the basis of the clinical signs and symptoms, it is not possible to reliably differentiate viral or bacterial AOM.
For an overview of the condition, including the distinction between AOM and OME, see What Is Otitis Media?
Does every ear infection require antibiotics?
No. Many cases of AOM improve without antibiotics. In the first days of infection, pain medications, such as acetaminophen or Ibuprofen, help with pain management, not antibiotics.
The guidelines therefore permit watchful waiting in some cases of mild AOM. Antibiotics are more likely to be prescribed when the symptoms are severe or in certain higher-risk situations. If treatment is considered appropriate, amoxicillin is usually recommended as the first-choice antibiotic for uncomplicated AOM. In the case of a penicillin allergy, a different class of antibiotics will be used.
Why Might a Doctor Recommend Watching and Waiting?
The fact that an antibiotic is not given doesn't mean that an ear infection is not being treated.
Antibiotic stewardship is the practice of using antibiotics only when needed, selecting the appropriate medication, dose, and duration of treatment.
Stewardship programs are used in various healthcare settings to help ensure antibiotics are prescribed appropriately; the American Academy of Pediatrics notes watchful waiting and delayed prescribing for acute otitis media as one method that can reduce antibiotic use in specific settings and indications.
With watchful waiting, symptoms such as pain are managed while the child is monitored. If symptoms worsen or do not improve within the recommended period, the child can be reevaluated, and antibiotic treatment started when appropriate.
What Are the Risks of Unnecessary Antibiotics?
Antibiotics can cause side effects, including diarrhea, vomiting, rashes, and allergic reactions.
Using broader-spectrum antibiotics when narrower-spectrum treatments are appropriate, or inappropriate dosing, may also result in avoidable adverse events and contribute to antibiotic resistance.
What Is Antimicrobial Resistance?
Antimicrobial resistance occurs when microorganisms gain the ability to survive the administration of medicines which are meant to control them. Overuse of antibiotics leads to resistance, making certain bacterial infections more difficult to treat.
The aim of antibiotic stewardship is to safeguard both the individual patient and the community by using antibiotics carefully.
Why Accurate Diagnosis Matters
Antibiotic stewardship begins with an accurate diagnosis.
To diagnose AOM, there must be evidence of inflammation and middle ear effusion. The American Academy of Pediatrics guideline on AOM specifically states that you should not diagnose AOM without middle ear effusion.
Middle ear effusion without signs and symptoms of acute infection does not benefit from antibiotics, so distinguishing AOM from other middle ear conditions is important.
Better diagnostic information can support more informed treatment decisions, helping clinicians use antibiotics when they are likely to benefit a child, and avoid unnecessary antibiotic exposure when they are unlikely to help.
Appropriate treatment begins with an accurate assessment of the middle ear. Learn more about why ear infections can be difficult to diagnose.
Medical Disclaimer
This article is provided for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Patients and caregivers should consult a qualified healthcare professional regarding symptoms or treatment decisions.
Frequently Asked Questions
Do all childhood ear infections need antibiotics?
1
No. Some cases of acute otitis media can improve without antibiotics. Treatment depends on factors such as the child's age, symptoms, exam findings, and illness severity.
Do antibiotics work for viral ear infections?
2
Antibiotics work against bacteria, not viruses. Acute otitis media may involve bacteria, viruses, or both, which is why an accurate diagnosis matters.
Why might a doctor wait before prescribing antibiotics?
3
For some children with mild acute otitis media, clinical guidelines support watchful waiting while symptoms are managed and the child is monitored.
What is antibiotic stewardship?
4
Antibiotic stewardship means using antibiotics only when needed and, when treatment is necessary, selecting the appropriate medication, dose, and duration.
References
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Lieberthal AS, Carroll AE, Chonmaitree T, et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013;131(3):e964-e999.
Castelli Gattinara G, Bergamini M, Simeone G, et al. Antibiotic treatment of acute and recurrent otitis media in children: an Italian intersociety Consensus. Italian Journal of Pediatrics. 2025;51:50.
Gerber JS, Jackson MA, Tamma PD, Zaoutis TE. Antibiotic Stewardship in Pediatrics. Pediatrics. 2021;147(1):e2020040295. Reaffirmed September 2025.
Centers for Disease Control and Prevention. The Core Elements of Outpatient Antibiotic Stewardship Programs. 2025.
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Learn More About The Impact of Antibiotic Therapy
Early-life antibiotics increase the risk of allergy in adulthood. 50 Immunity
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