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Recurrent acute otitis media occurring within one month from completion of antibiotic therapy: relationship to the
Eugene Leibovitz1, David Greenberg, Lolita Piglansky
1Pediatric Infectious Disease Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. eugenel@bgumail.bgu.ac.il
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 and by pulsed field gel electrophoresis for Streptococcus pneumoniae 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 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 relapses 14 days or later after completion of therapy.
Insights
Most acute otitis media (AOM) recurrences within a month are new infections, not relapses. True bacteriologic relapses are more common early after antibiotic therapy, particularly with Streptococcus pneumoniae.
Area of Science:
- Pediatric infectious diseases
- Microbiology of otitis media
Background:
- Acute otitis media (AOM) is a common childhood infection.
- Antibiotic resistance and treatment failures necessitate understanding recurrence patterns.
Purpose of the Study:
- To investigate the relationship between pathogens in recurrent AOM and initial infections.
- To determine if shorter intervals post-antibiotics correlate with higher true bacteriologic relapse rates.
Main Methods:
- 1077 infants and young children with AOM were studied.
- Middle ear fluid cultures were obtained during initial episodes and recurrences.
- True bacteriologic relapse was confirmed by identical pathogen identification using molecular techniques.
Main Results:
- Of 108 recurrent AOM cases, 81% had pathogens; most were new infections.
- True bacteriologic relapses occurred in 28% of patients.
- Relapses were more frequent within 14 days post-therapy (41% in days 1-7, 26% in days 8-14).
- Haemophilus influenzae rarely caused relapses after 14 days.
Conclusions:
- Recurrent AOM within one month is often a new infection.
- True bacteriologic relapses are more common early after treatment, especially with S. pneumoniae.
- H. influenzae is unlikely to cause late relapses.