Recalcitrant acute otitis media (AOM), including 2 well-defined and sometimes related entities (persistent AOM and recurrent AOM), is a common pediatric problem. Episodes of AOM in children with either persistent or recurrent AOM were shown to be associated with recovery of middle ear fluid bacterial pathogens (particularly Streptococcus pneumoniae) with higher resistance to antibiotics compared with children with AOM not recently treated with antibiotics. The relationships between nasopharyngeal carriage of Streptococcus pneumoniae and persistence of middle ear fluid pathogens despite clinical improvement or cure and subsequent recurrence are discussed in depth. The findings emphasize the importance of bacteriologic eradication in the prevention of recurrent AOM episodes.