Recurrent Acute Otitis Media Occurring Within One Month From Completion of Antibiotic Therapy: Relationship to the Original Pathogen

Eugene Leibovitz, MD, David Greenberg, MD, Lolita Piglansky, MD, Simon Raiz, MD, Nurith Porat, PhD, Joseph Press, MD, Alberto Leiberman, MD, Ron Dagan, MD


Pediatr Infect Dis J. 2003;22(3) 

In This Article

Abstract and Introduction

Objectives: (1) To determine the relationship between acute otitis media (AOM) pathogens isolated in cases of early clinical recurrence of AOM (occurring within 1 month from completion of therapy) to the original pathogens causing the initial AOM episode; and (2) To determine whether shorter time intervals between completion of antibiotic therapy and clinical recurrences of AOM are associated with higher rates of true bacteriologic relapse.
Patients and Methods: From 1995 through 2000, 1077 infants and young children ages 3 to 36 months with AOM were enrolled in double tympanocentesis (performed on Day 1 in all patients and Days 4 to 6 in those initially culture-positive) studies. Of these, 834 (77%) completed successfully the antibiotic treatment [pathogen eradication on Days 4 to 6 of therapy or no pathogen on middle ear fluid (MEF) culture on Day 1 and clinical improvement at end of therapy]. Patients were followed for 3 to 4 weeks after completion of therapy, and additional MEF cultures were obtained if clinical recurrence occurred. True bacteriologic relapse was defined as the presence of a pathogen identical with that isolated before therapy by serotype and pulsed field gel electrophoresis for Streptococcus pneumoniae and by pulsed field gel electrophoresis and beta-lactamase production for Haemophilus influenzae.
Results: MEF cultures were performed in 108 consecutive patients with early recurrent AOM. One hundred pathogens were isolated at recurrence in 88 of 108 (81%) patients: 54 H. influenzae; 45 S. pneumoniae; and 1 Moraxella catarrhalis. Most recurrent AOM episodes developed during the first 2 weeks of follow-up; 39 (36%), 38 (35%), 21 (19%) and 10 (9%) recurrent AOM episodes occurred on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively. In most patients these episodes were caused by a new pathogen. True bacteriologic relapses were found in 30 (28%) of 108 patients whose MEF cultures were positive for 35 pathogens: 13 of 108 (12%) S. pneumoniae; 12 of 108 (11%) H. influenzae; and 5 of 108 (5%) both. When timing of recurrent AOM after completion of therapy was analyzed, true bacteriologic relapses were found in 16 of 39 (41%), 10 of 38 (26%), 3 of 21 (14%) and 1 of 10 (10%) of all episodes on Days 1 to 7, 8 to 14, 15 to 21 and 22 to 28 after completion of therapy, respectively (P = 0.01). The respective rates for S. pneumoniae were 11 of 17 (65%), 3 of 10 (30%), 3 of 13 (23%) and 1 of 5 (20%) (P = 0.02). For H. influenzae the respective rates were 8 of 19 (42%), 9 of 23 (39%), 0 of 8 (0%) and 0 of 4 (0%) (P = 0.02).
Conclusions: Most recurrent AOM episodes occurring within 1 month from completion of antibiotic therapy are in fact new infections. Most of the true bacteriologic AOM relapses occur within 14 days after completion of therapy, but even during this time interval most of the recurrences are caused by new pathogens. H. influenzae is very unlikely to cause true bacteriologic AOM relapses14 days or later after completion of therapy.

Recurrent acute otitis media (AOM) is encountered in a subpopulation of 5 to 30% of all children with AOM.[1,2,3] These otitis media-prone children may experience four or more episodes of AOM and spend ≥7 months with middle ear effusion after AOM in the first year of life alone. Although a familial predisposition occurs in recurrent AOM, epidemiologic, environmental and immunologic risk factors have also been properly identified and include early male gender, early occurrence of infection, parental smoking, low socioeconomic status, day-care center attendance and immune abnormalities resulting from early or frequent exposure to middle ear pathogens.[1,3,4,5,6]

Whereas the microbiology of AOM is well-known, the bacteriologic correlates of recurrent AOM have been much less investigated. In the few studies published on this topic, the patients were followed for various periods of time (1 to 9 months) from the original AOM episode, the number of diagnostic tympanocenteses performed when recurrence developed was small and some children received antibiotic prophylaxis during the follow-up period.[7,8,9,10,11] In addition, although a higher prevalence of antibiotic-resistant Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae should be anticipated among AOM patients recently treated with antibiotics compared with patients not recently treated,[12,13,14,15] a systematic analysis of the bacteriologic spectrum of recurrent AOM during the past decade of increasing antibiotic resistance has not yet been performed.

The purpose of this study was to determine the etiology, the temporal occurrence of AOM during the follow-up period and the proportion of true bacteriologic relapses vs. new infections in children with clinical recurrence of AOM occurring within 3 to 4 weeks after completion of antibiotic therapy.


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