Managing Complex Acute Otitis Media Infections
Michael E. Pichichero, MD
Children with complex AOM have become a focus of investigation by those doing research in the otitis media field, driven by the recognition that these children experience greater consequences from infections, and their medical management accounts for more than half the costs of care associated with AOM.
Complex AOM may be defined according to five differing clinical presentations: 1) recurrent AOM (defined as children with three AOM episodes within 6 months or = 4 AOM episodes within 12 months), ie, otitis prone; 2) treatment failure (second AOM episode occurring within 14 days from an initial AOM visit); 3) relapsed AOM (second AOM episode occurring > 2 weeks from the initial AOM visit but < 1 month from an initial otitis media episode; 4) eardrum rupture; and 5) AOM with local or systemic complications such as mastoiditis, intracranial abscess, or facial nerve palsy.
The frequency of the complex AOM types above are ranked from most to least frequent in the US and other high-income countries. In low- and middle-income countries — where AOM is infrequently diagnosed by clinicians — the frequency of presentation is quite different, with the more common being eardrum rupture and AOM with complications.
My group recently reported results of an 18-year longitudinal study of uncomplicated and complex AOM, spanning 2006-2023, during the 7-valent pneumococcal conjugate vaccine (PCV7) era and throughout the 13-valent PCV (PCV13) era. We enrolled 1537 children prospectively, usually at 6 months old, and followed them to 36 months.
When clinicians made the clinical diagnosis of AOM, tympanocentesis was performed for middle ear fluid culture in most cases. We used the electronic medical records retrospectively to identify uncomplicated AOM and complex AOM episodes. As an inclusion criterion, all children were required to receive the full primary series of PCV7 or PCV13 immunizations according to US Centers for Disease Control and Prevention schedule (doses at 2, 4, and 6, months; booster dose between 12 and 15 months).
Classification of complex AOM was made on an episode basis. If the child met the definition of recurrent AOM, all AOM episodes with middle ear fluid collection were included in the complex AOM group for analysis purposes. One hundred ninety-two children were vaccinated with PCV7 during 2006-2009. Children who received PCV13 immunizations were divided into two groups: 404 children in what we called the early PCV13 era (2010-2014), and 525 children in what we called the late PCV13 era ( 2015-2023).
Among the 1537 enrolled children, the first thing we found is that 591 never had an AOM episode (No OM group, 53%). In the 1980s, 80% of young children were said to have at least one AOM, compared to our new result of 53%. Whether the surprisingly low frequency of AOM was due to PCVs, or changes in the clinical diagnostic criteria for AOM promulgated by the American Academy of Pediatrics in their AOM guidelines, or because parents decreased the frequency of how often they sought care for ear pain in their children, is unknown.
Of the 530 children with at least one episode of AOM, we found that 53% had uncomplicated AOM, 34% had complex AOM, and 13% had both uncomplicated AOM and complex AOM. To our knowledge, this was the first comprehensive report from primary care practices in the US of this distribution of cases of uncomplicated vs complex AOM. Risk factors for complex AOM compared with uncomplicated AOM were male sex, family history of AOM, and daycare attendance.
We found that the frequency of isolating pneumococci from middle ear fluid in episodes of complex AOM decreased over time, between 2006 and 2023. The frequency of isolating Haemophilus influenzae and Moraxella catarrhalis did not change over time. Since pneumococci isolation went down and H influenzae isolation stayed the same, H influenzae became the predominant organism causing complex AOM throughout both PCV13 timespans we studied. Among uncomplicated episodes of AOM, pneumococcal isolation from middle ear fluid remained the same, whereas isolation of H influenzae went up and M catarrhalis went down. Isolation of H influenzae was 44% more likely in children with complex AOM vs uncomplicated AOM. This is consistent with the association between H influenzae and complex AOM, particularly recurrent AOM, as previously reported.
PCV13 significantly reduced the isolation from middle ear fluid strains of pneumococci-expressing various capsular polysaccharide serotypes, throughout the entire timespan that PCV13 was used. The result was consistent with our earlier report in Lancet Child and Adolescent Health , when we studied the effectiveness of PCV13 shortly after its introduction in 2010. However, consistent with a wide literature, over time, pneumococci-expressing PCV13 serotypes were replaced by organisms expressing other serotypes not in the vaccine, especially serotype 35B in the late PCV13 era.
In terms of antibiotic susceptibility, the odds of antibiotic nonsusceptibility of pneumococci to penicillin were 2.65 times higher in children with complex AOM compared to children experiencing uncomplicated AOM. The proportion of H influenzae that was beta lactamase-producing (amoxicillin resistant) increased during the PCV13 eras compared to the PCV7 era.
Key Points:
Risk factors for developing complex AOM and uncomplicated AOM are similar.
PCV13 significantly reduced complex AOM and penicillin nonsusceptibility associated with pneumococci driven by near complete elimination of strains expressing serotype 19A.
H influenzae is the dominant cause of complex AOM.
is the dominant cause of complex AOM. Although non-PCV13 pneumococcal serotypes emerged in the late PCV13 era, the lower level of complex AOM caused by pneumococci remained lower compared to the PCV7 era.
Rochester General Hospital Research Institute was the study sponsor/co-funder and Pfizer provided additional funding for the study analysis that resulted in this paper: N Fuji et al. Eighteen-year longitudinal study of uncomplicated and complex acute otitis media during the pneumococcal conjugate vaccine era, 2006-2023. The Journal of Infectious Diseases , 2025.
Funding was provided by the National Institute on Deafness and Other Communication Disorders of the National Institutes of Health and the Centers for Disease Control and Prevention for the collection of middle ear samples leading to the publication.
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Bloomberg
4 days ago
- Bloomberg
Ultra-Processed Foods Make Up More Than 60% of US Kids' Diets
Americans get more than half of their daily calories from ultra-processed foods, with salty and sugary items accounting for an even bigger portion of kids' plates, a government study found. About 62% of childhood diets come from highly processed foods like burgers, pastries, snacks and pizza, according to the US Centers for Disease Control and Prevention 's nutrition survey released Thursday. The same foods have a similar grip on adults, making up about 53% of the calories they consumed during the study that ran from August 2021 through August 2023.
Yahoo
4 days ago
- Yahoo
Childhood verbal and physical abuse leave similar impacts, study shows
Cruel words can leave a mark on a child –– and may have as much of an impact as physical abuse, new research has found . People who experienced physical abuse as a child were at a 50% increased risk of reporting low mental health in adulthood compared with those with no abuse, according to the study published Tuesday in the journal BMJ Open. Those who experienced verbal abuse had a 60% increase in likelihood of low well-being. The prevalence of physical abuse in people in England and Wales has halved, from 20% in people born from 1950 to 1979 to 10% in those born in or after 2000, according to the study. Verbal abuse, on the other hand, has increased. In the United States, more than 60% of people participating in the US Centers for Disease Control and Prevention's Youth Risk Behavior Survey reported experiencing emotional abuse and 31.8% reported physical abuse. The survey listed emotional instead of verbal abuse, but asked about similar behaviors as the most recent study. In this latest analysis, researchers analyzed data from more than 20,000 adults across seven different studies in England and Wales. The study team evaluated childhood experiences using the Adverse Childhood Experiences tool and components of adult mental health using the Warwick-Edinburgh Mental Wellbeing Scale. The 'results suggest that verbal abuse in childhood can leave mental health scars as deep and long-lasting as those caused by physical abuse,' said lead study author Dr. Mark Bellis, professor of public health and behavioral sciences at Liverpool John Moores University in the United Kingdom. What is verbal abuse? Across the United States and the world, there has been an epidemiological shift of a greater burden of verbal abuse across populations, said Dr. Shanta Dube, professor of epidemiology and director of the department of public health at the Levine College of Health Sciences at Wingate University in Wingate, North Carolina. She added that emotional abuse is 'often tied to the act of verbal abuse and therefore verbal abuse can often get lost.' The rise of verbal abuse amid the decline of physical abuse highlights a need to raise awareness around spoken abuse, especially given the lasting impact, said Dube, who was not involved in the study. 'Verbal abuse may be eroding the mental health benefits we should expect from successful efforts to reduce physical abuse,' Bellis added. It can be hard to draw the line for sure on what language is harsh and what is verbal abuse, but it can include blaming, insulting, scolding, criticizing or threatening children, said Dr. Andrea Danese, professor of child and adolescent psychiatry at King's College London and adjunct clinical professor at the Yale Child Study Center. He was not involved in the research. 'Think about the use of derogatory terms or statements intended to frighten, humiliate, denigrate or belittle a person,' he said. 'It is often unintentional.' Comments can sound like 'Johnny can do it. Why can't you?' 'You always make mistakes,' 'You're stupid,' or 'You're worthless,' Dube said. 'Harsh, denigrating words spoken to children have lasting impacts. Children developmentally are concrete thinkers 'it is or isn't,' she said in an email. 'They can take things literally.' Children rely on the language of the adults in their immediate environment to learn both about themselves and the world, Danese said. Therefore, the way children are talked to can be very powerful in both positive and negative ways, he added. 'Being the subject of verbal abuse can twist a young person's understanding of who they are and their role in the world,' Danese said. Is it the impact or how you remember it? The study relies on observational data, meaning that researchers cannot say for sure that verbal abuse in childhood causes poorer mental health in adulthood, only that there is a connection between the two. It could be that people who experience verbal abuse in their younger years have trauma later, but it also could be that adults with worse mental health are more likely to remember their childhood more harshly, Danese said. However, the sample size was large enough and the approach was strong enough to add to the existing evidence around impacts of verbal abuse, Dube said. Language has power –– good and bad It is increasingly important that researchers and individuals pay attention to the factors that impact long-term mental health, Bellis said. 'Poor mental health is a major and growing global public health issue, particularly among adolescents and young adults,' he said. Part of the decline in physical abuse may be attributed to more awareness, data collection and campaigns focused on its reduction over the years, Dube added. 'Improving childhood environments can directly enhance mental well-being as well as helping build resilience to protect against the future mental health challenges individuals may face through adolescence and adulthood,' Bellis said in an email. 'We need to ensure that the harms of verbal abuse are more widely recognised.' Parents and caregivers with more information and support may be better equipped to create better home environments for their children, he said. 'This means helping build emotional regulation skills in parents and children, helping catalyse emotional attachment between them, developing their communication skills and encouraging modelling behaviours in parents so that they demonstrate the type of approaches to problems that they would like to see in their children,' Bellis said in an email. But the issue doesn't stop with parents –– all adults who interact with children need to understand the impacts of verbal abuse, Dube said. And the answer isn't just to shame adults, Danese said. Instead, he and other researchers are looking to support a cultural shift toward everyone being more mindful about the language used toward children and how it might affect them. 'It's not about dramatising times when we could have let negative comments on children slip,' he said in an email. 'It is about being mindful of them and trying to repair them with an apology, a correction, and an explanation.' Editor's note: If you or someone you know is struggling with mental health, help is available. Dial or text 988 or visit for free and confidential support.
CNN
6 days ago
- CNN
A warmer, humid world where ticks thrive is increasing spread of Lyme and other diseases
This year, people are seeking emergency care for tick bites in the highest level since 2017, according to data from the US Centers for Disease Control and Prevention, and reported cases of Lyme disease have continued to rise through the years. Experts say the increases are driven by warmer temperatures due to climate change and the expanding presence of ticks in more areas in the US and Canada — including places where people are less familiar with the risks and how to prevent disease. 'When we first started doing this [in the mid-1980s], there were very few cases of Lyme disease reported in Canada. Lyme disease is pretty well established in Canada at this point,' said Dr. Thomas Daniels, the director of the Louis Calder Center, Fordham University's biological field station. Lyme disease-carrying deer ticks are mostly active when temperatures are above 45 degrees Fahrenheit, and they thrive in areas with at least 85% humidity, according to the US Environmental Protection Agency. 'It likes to be in humid areas, not wet areas, but humid areas,' said Daniels. 'If you sample on a lawn that gets baked in the sun all day, you're not going to find ticks. You go 20 feet into the woods where it's shady and the temperature's generally lower and there's more ground cover, you will find ticks.' The threat from ticks and mosquitoes, which drive transmission of diseases such as West Nile, dengue and malaria, is already increasing. 'Because of increases in temperature that we've already seen, because of human impacts on the climate, the temperature is already getting more suitable for transmission of disease here in the United States and North America,' Dr. Erin Mordecai, an associate professor of biology at Stanford University, said at a news briefing on Monday. And while climate change is contributing to the expansion of tick habitats, it's not the sole driver. Human changes to landscapes also shape where ticks are found. 'It's never just one factor, right?' Dr. Jean Tsao, a professor at Michigan State University who studies disease ecology, said at a news briefing. 'In the continental US, most of the changes in the range is probably due to land use change affecting wildlife communities. Also management of wildlife populations, such as the white-tailed deer. That plays a major role for many of these ticks.' Deer ticks, also known as black-legged ticks, are the primacy ticks that carry Lyme disease. During the nymph stage, when they are most active, the ticks are about the size of a poppy seed and are easy to miss. As they feed on blood, they can transmit pathogens, including the bacterium Borrelia burgdorferi, which causes Lyme disease. This transmission occurs through the tick's saliva, which enters the host's bloodstream during feeding. Brian Fallon, director of the Lyme and Tick-Borne Diseases Research Center at Columbia University, told CNN on Friday that infection can cause a range of multisystem symptoms. Once in the bloodstream, the bacteria can go to various parts of the body including the heart, central nervous system, the brain or peripheral nerves. The onset of Lyme disease may also present in different ways. 'Most people think of the Lyme rash as a bull's-eye target rash. In fact, that's not the most common presentation,' said Fallon. 'The most common presentation is more of a pinkish, reddish rash. But the main thing is that it expands in size from a small rash to five centimeters or larger.' Fallon notes that some people may also see more than one rash on different parts of their body. As the disease develops without treatment, more serious symptoms may emerge. Symptoms may last for months or even years, said Fallon. 'It's recognized mainly by the rash early on, if you're lucky enough to see it, and then later, by symptoms such as the neurologic symptoms that may manifest as a facial palsy or a meningitis causing severe headaches with stiff neck or shooting pains or severe stabbing pains,' Fallon said. There may be cardiac symptoms such as palpitations or slow rhythms; muscle pain and fatigue. 'It can be profoundly debilitating,' he said. Daniels says that although there are measures that can be taken to decrease the likelihood of a tick bite, prevention methods are not foolproof. The most important protection against Lyme disease is tick removal as soon as possible, he said. 'The key is to get the tick off you as quickly as possible. None of these [tick-borne] pathogens are transmitted very quickly, except for Powassan virus, which can be transmitted in as little as 15 minutes. But the infection rate for [humans] is very, very low,' said Daniels. 'For Lyme disease, you've got a 24 to 48 hour window of opportunity there to get the tick off, because it takes some time for the tick to gear up through its feeding to actually transmit the bacteria.' Daniels advises people to wear more clothes in the summertime. 'The longer we can keep the tick on the outside of our bodies and not on our skin, the less likely it is to find a place to attach.' Clothes can also be treated with permethrin, an insecticide that repels ticks. When hiking, Fallon advises people to stay on the trail, as ticks roam in leafy areas and wood piles. Daniels advises people to conduct a 'tick check' for themselves and each other if they're in an area with ticks. 'It's helpful because the ticks may go behind your knee, or they may go and bite you in the back, and you can't see your back or reach your back. Take a shower at the end of the day, because that may help to wash off some ticks that haven't fully attached yet,' he said. If a tick is attached for a prolonged period of time, Fallon says that it would gradually 'blow as big as a raisin' from continuously sucking blood. If you do find a tick, experts advise people to use tweezers to take out the tick from underneath its body. 'Don't try to burn it off with a cigarette. Don't try to put anything toxic on it. Remove it with a tweezer,' he said.
