Ask the Experts - Recurrent Otitis Media in HIV-Infected Children?
I'm a pediatrician responsible for caring for HIV-infected children in a public hospital in Rio de Janeiro. In my practice I have many children receiving dual or triple therapy (depending on their viral load and CD4+ cell counts) who have otitis media with effusion, generally growing Pseudomonas or Staphylococcus in the culture. Some of them have mastoiditis on tympanocentesis (TC) scan. How long should I treat for mastoiditis? Do I have to treat until the TC image disappears? Should I maintain these children on gammaglobulin every 28 days or daily trimethoprim/sulfamethoxazole to try to lessen recurrent otitis? Do you use amoxicillin prophylaxis for recurrent otitis media? Do you think that I should change the antiretroviral regimen if the child is having recurrent otitis media with effusion, even if he has a good immunologic and virologic response?

Otitis media (OM) is a common problem for the HIV-infected infant or child, as it is for the immunocompetent child. In general, the organisms that cause acute otitis media (AOM) are similar in both populations and include Streptococcus pneumoniae, nontypable Haemophilus influenzae,and Moraxella catarrhalis. Staphylococcus aureus appears to occur much more often in the severely immunocompromised HIV-infected child. Respiratory viruses have been identified in 10% to 40% of middle-ear effusions. Pseudomonas species also have been identified, but less frequently.

As in the immunocompetent child, AOM is common in the first year of life, but with increasing age the HIV-infected child has a higher annual incidence of infections than the immunocompetent child. Recurrent and chronic OM are generally caused by the same organisms, but Pseudomonas aeruginosa, S aureus, Proteus, and anaerobes are seen more commonly in chronic OM. In our experience mastoiditis is not a frequent complication with proper evaluation, follow-up, and treatment. Acute mastoiditis is, in general, a consequence of AOM, and thus the organisms present are similar. Chronic mastoiditis results from chronic suppurative OM, and thus treatment and prevention involve optimal therapy for chronic suppurative OM. Organisms include P aeruginosa, enteric gram negatives, and Staphylococcus species.

The pathogenesis of OM is multifactorial and includes upper respiratory infection leading to obstruction of the eustachian tube and resultant fluid collection in the middle ear; recurrent allergic rhinitis also leading to obstruction; abnormal local and systemic immunity; and neutropenia as a result of treatment.

The treatment for AOM is prompt antibiotic treatment, as it is for recurrent AOM, and the current recommendation in the United States is to begin with amoxicillin. For OM that is prolonged or recurrent, broad-spectrum antibiotics (eg, amoxicillin/clavulanate; erythromycin/sulfisoxazole; trimethoprim/sulfamethoxazole; cefuroxime; or azithromycin) may be warranted. We generally do not perform tympanocentesis in routine cases of OM. For chronic OM, I recommend working with an otolaryngologist on the evaluation and follow-up of your patients. Treatment for chronic suppurative otitis media includes topical antimicrobial agents (eg, corticosporin) chosen after cultures are taken with aural canal toilet.

Acute mastoiditis is a serious complication of OM and ideally should be treated in close consultation with an otolaryngologist. Treatment includes intravenous antibiotics along with myringotomy and tympanostomy tube placement. If there is not rapid improvement within the first 48 hours or so, surgical intervention with simple mastoidectomy is indicated. The length of therapy must be individualized, but should comprise a minimum of 7-10 days of intravenous antibiotics followed by oral therapy for a total of 1 month -- again, in close association with an otolaryngologist.

Prevention of OM can include chemoprophylaxis, as you suggest, and myringotomy with tube placement. A child may also need adenoidectomy along with tube placement, and thus early consultation with an otolaryngologist is highly recommended after multiple and recurrent episodes of acute OM or chronic OM. It is recommended that prophylactic antibiotic therapy be used with caution, but this may be the best option in some children who have had at least 3 episodes of OM in a 6-month period. Many patients need prophylaxis against Pneumocystis carinii pneumonia, in which case the use of trimethoprim/sulfamethoxazole would potentially offer dual coverage. Alternatives include amoxicillin and sulfisoxazole.

The efficacy of intravenous immunoglobulin (IVIG) in the prevention of recurrent OM has been controversial. Before the availability of potent antiretroviral therapy, a study demonstrated a decrease in the number of cases of OM in patients treated with IVIG. However, a study by the Pediatric AIDS Clinical Trials Group demonstrated that among zidovudine-treated children, IVIG was only associated with fewer bacterial infections among children who were not receiving trimethoprim/sulfamethoxazole prophylaxis. Although many HIV providers continue to use IVIG in selected cases, there is no convincing evidence that it prevents chronic OM in the HIV-infected child in this age of highly active antiretroviral therapy (HAART). The USPHS/IDSA Prevention of Opportunistic Infections Working Group recommends the use of IVIG in children who have hypogammaglobulinemia, or other manifestations of humoral defects, with inadequate antibody response following immunizations; patients who have recurrent serious bacterial infections despite antibacterial therapy may also be candidates for routine IVIG. In practice, since the advent of HAART, very few children now receive IVIG.

It is also prudent to ensure that the children that you treat have both H influenza and S pneumoniae vaccinations as early as possible in their disease course. Following treatment with HAART and resultant viral suppression and immune reconstitution, you may need to revaccinate. Although immunologic responses to vaccination were variable prior to the HAART era, early studies indicate that many HAART-treated children have adequate responses. Since S pneumoniae is the most important pathogen to cause OM, vaccination may be important in preventing this common problem.

Finally, if a child has adequate virologic and immunologic responses to antiretroviral therapy, with undetectable viremia and a CD4+ cell count that no longer indicates severe immunosuppression, I would not recommend change in antiretroviral therapy purely because of recurrent OM. Consultation with an otolaryngologist and appropriate treatment would be the better course of action.