Recent advances in otitis media.

Otitis media (OM) is a pervasive illness in infants and children, and many children suffer multiple episodes during the first years of life. High rates of acute otitis media (AOM) are reported in developed and emerging countries. Early onset is common in both settings. Recurrent OM is associated with several factors, including early onset of disease, having a sibling with a history of AOM and absence of breast-feeding. Early onset disease has been hypothesized to result from Eustachian tube dysfunction, immunologic naivete and immaturity, and viral upper respiratory tract infection. Nasopharyngeal colonization with bacterial otopathogens increases the likelihood of AOM and the disease is most frequent in children with viral respiratory tract infection colonized with multiple otopathogens (Streptococcus pneumoniae, nontypeable Haemophilus influenzae [NTHi], Moraxella catarrhalis), potentially as a result of inflammation resulting from competition among the bacterial species within the nasopharynx. Epidemiologic observations and studies of pathogenesis suggest that successful strategies for reducing the burden of disease will be best accomplished by targeting multiple viral and/or bacterial pathogens and preventing early onset disease. Guidelines (2004) for the treatment of AOM in children establish a clear hierarchy among the various antibacterials for the treatment of this disease. Failure to achieve early bacterial eradication during antibiotic therapy for AOM increases the clinical failure rates in AOM in young children. Most recurrent AOM episodes occurring within 1 month after successful completion of antibiotic therapy are due to new otopathogens. Failure to eradicate middle ear and/or nasopharyngeal pathogens is associated with higher rates of clinical recurrent AOM, even when the patients show clinical improvement or cure at the end of therapy for the initial episode. Optimal strategy for the prevention of AOM recurrences requires sterilization of the middle ear and eradication of nasopharyngeal carriage of otopathogens during antimicrobial therapy.