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AOM etiology is in a state of flux. Continued reliance on empirically selected antibiotic therapy as the mainstay of AOM management ensures that drug-resistance patterns among AOM pathogens will continue to evolve. The 7-valent pneumococcal conjugate vaccine (PCV7) altered AOM etiology within a few years of its introduction. Haemophilus influenzae has replaced Streptococcus pneumoniae as the predominant AOM pathogen in many regions, and new virulent  S.
pneumoniae serotypes have emerged to fill the
"pneumococcal vacancies" created by
the vaccine. Planned introduction of a higher-valent
pnemococcal vaccine is likely to promote continued etiological
change. Our knowledge and growing understanding of AOM microbiology is in many ways remarkable. So is the fact that in this era of increasing antibiotic resistance, we routinely prescribe antibiotics for nearly all AOM patients, and we do so with no knowledge of whether a bacterial pathogen is present, or whether the pathogen will be susceptible to the drug we have chosen. Combating antibiotic resistance is a straightforward process: reduce consumption levels, and improve drug-selection accuracy. The "watchful waiting" option provides a starting point for reducing antibiotic use among AOM patients. The self-resolving nature of AOM is well documented. Waiting a day or so before progressing to antibiotic therapy allows time for a percentage of AOM episodes to resolve without antibiotics Watchful waiting however is not always the most palatable choice. An AOM episode severe enough to result in an office-visit or trip to the ER can reasonably be expected to manifest itself in the form of an observably distressed patient and a stressed-out parent. "Let's try analgesis for a few days and see how we do..." may not be what the practitioner really wants to say, and is likely not what the parent wants to hear. In the absence of proactive alternatives to antibiotic therapy for AOM, the watchful waiting decision can seem nearly tantamount to choosing between providing or witholding immediate treatment. Primary-care providers seeking an effective, proactive alternative to immediate antibiotics for their AOM patients may wish to consider adding tympanocentesis to their repertoire. As an adjunct to watchful waiting, tympanocentesis eliminates AOM pain and symptoms during the observation period,and enables the practitioner to select precisely targeted antibiotic therapy for patients who remain symptomatic after the observation period. For more severe AOM episodes in which watchful waiting is not considered, tympanocentesis relieves symptoms while eliminating the guesswork in selecting appropriate antibiotic therapy. By contributing to reduced antibiotic consumption and improving the accuracy of antibiotic therapy selected for AOM patients, tympanocentesis can help reduce antibiotic resistance among AOM pathogens.
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