What are the Guidelines for Preventing Recurrent Acute Otitis Media

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Antibiotics

Antibiotics have been used for prevention of acute otitis media in children under the following circumstances:

If the child has had three or more separate ear infections every six months.
If the child has had four or more ear infections within a year.

Almost all physicians are moving away from this practice, however, because of concerns about resistance and questions on their value. The following are some observations on this issue:

Most recurring ear infections stop completely in children older than 16 months whether or not they were given preventive antibiotics. For this reason, some experts recommend that preventive therapy is not warranted at all in children over 16 months.

Although one large study reported that preventive antibiotics decreased the frequency of new episodes of acute otitis media by 44%, some experts believe that this figure does not represent a significant drop in the actual number of episodes.

One study reported that amoxicillin was no more effective in preventing recurrent ear infections than a placebo (so-called sugar pills).

In Finland, where very few children are treated with antibiotics for otitis media, a long term study found that after an initial diagnosis of recurrent acute otitis media, only 12% had three or more episodes afterward and only 4% developed otitis media with effusion. All the other children had only two or less attacks after the diagnosis.

Specific Antibiotic Choices.

When preventive antibiotics are prescribed, the following may be used:

One or two daily doses of amoxicillin or sulfisoxazole (Gantrisin).
Azithromycin (Zithromax) may be an effective alternative for children who are allergic to penicillin, who live in regions with high rates of bacteria resistant to penicillin, or who have family conditions in which complying to a daily regimen is difficult. A single weekly dose may be sufficient.

Timing and Duration.

Physician opinion varies as to the best timing and duration for taking preventive antibiotics. The following are some options:

Prescribed for a consistent three- to six-month period following the last acute episode.
Prescribed only in winter and spring when the risk for respiratory infections is high.

Prescribed at the onset of any respiratory infection.

Vaccines

Children who are susceptible to recurrent ear infections should probably be given vaccinations against influenza viruses and pneumococci.

Viral Influenza Vaccines.

Vaccines are designed to recognize foreign agents (called antigens) in the body and to attack them. Vaccines against influenza currently employ inactivated (not live) viruses to produce an immune response that will then attack the active virus. Vaccines are given by injection in the fall, usually between October and December. A live but weakened intranasal vaccine (FluMist) should be available soon. It is engineered to grow only in the cooler temperatures of the nasal passages, not in the warmer lungs and lower airways. The vaccine boosts the specific immune factors in the mucous membranes of the nose that fight off the actual viral infections. It is employed using a nasal spray and in one study provided protection against the flu in up to 93% of children.

The following children over six months should be vaccinated against influenza:

Any child with a condition that requires regular medical care.
Any child who has been hospitalized for a serious illness (particularly lung, kidney, diabetes, sickle-cell, or immune deficiencies.)
Children who are receiving long-term aspirin therapy should also be immunized against the flu because they are at higher risk for Reye's syndrome, a life-threatening disease, if they get the flu

.

Possible negative responses include the following:

Newer vaccines contain very little egg protein, but an allergic reaction still may occur in people with strong allergies to eggs.
Almost a third of people who receive the influenza vaccine develop redness or soreness at the injection site for one or two days afterward.
Other side effects include mild fatigue and muscle aches and pains; they tend to occur between six and 12 hours after the vaccination and last up to two days. It should be noted that these symptoms are not influenza itself but an immune response to the virus proteins in the vaccine. Anyone with a fever, however, should not be vaccinated until the ailment has subsided.
Some studies have reported more severe asthma symptoms in children with the lung condition. A 2000 study of asthmatic children, however, reported no increased risk. In fact, there was some indication that the vaccination helped reduce asthma attacks over time. More research is needed to confirm or refute these results.

Pneumococcal Vaccines.

A recently approved pneumococcal vaccine (Prevenar or PCV7) could potentially prevent over a million cases of ear infections each year as well as serious infections, such as pneumonia, in American children. The vaccine is now recommended for all children up to age two and certain high-risk children up to age five, such as those at risk for meningitis or widespread infection. It should be noted that protection is not 100%, but the vaccine is still effective in many children. Protection lasts for over six years in most people. In one study, a similar vaccine under investigation protected not only children in day care from serious respiratory infections, but their younger unvaccinated siblings had fewer infections as well.

Experimental Agents

Interfering Bacteria.

Researchers have observed that the noses and throats of children who are prone to ear infections harbor smaller numbers of the "friendly" bacteria that help prevent overproduction of the harmful bacteria, than children without frequent infection. An interesting study in Sweden employed a nasal spray containing harmless bacteria called alpha-streptococcal, which are normally found in the throat and competes for space with harmful bacteria. In the study, the bacteria helped to protect against recurrent otitis media in susceptible children. This is very promising because it could significantly reduce antibiotic use; more research is warranted.

Antiviral Agents.

In one study, when the anti-viral drug, zanamivir (Relenza), was administered in the nasal passages of adults with influenza, middle-ear abnormalities were reduced from 73% to 32%. This drug is available for children greater than seven years old for treatment of influenza, but no research has determined it value for preventing or treating otitis media in children.

Xylitol.

Studies are reporting that children who chew gum or swallow a syrup containing xylitol, a sugar alcohol, experience significantly fewer ear infections. Chewing gum was more effective than the syrup. Xylitol is produced naturally in birch, strawberries, and raspberries. It has properties that fight Streptococcal pneumonia bacteria. Although in one study, xylitol did not reduce bacteria in the nose and throat, it did prevent ear infection. Some health providers report that even children one and a half years old can learn to chew and not swallow gum. The gum is not widely available in the US, however, and studies have not tested children between six and 18 months, the highest-risk age group for otitis media. This is an area for further research.

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