Written by Clay Smith
The prevalence of invasive bacterial infection (IBI) was very low among afebrile infants ≤90 days with acute otitis media (AOM). Use caution if you plan to treat with antibiotics and not do a septic workup, especially in 0-28 day olds.
Why does this matter?
Young infants are at greater risk for IBI. In medical school, I was taught that AOM in a young infant requires a full septic workup. But what is the risk of a young afebrile infant developing IBI as a result of AOM?
Is it just an ear infection at that age?
This was a retrospective multicenter study over ten years with 1,637 afebrile infants ≤90 days with otitis media; 6% 0-28 days; 27% 29-56 days; 67% 57-90 days. Of these, 278 (17%) had a blood culture, and 102 (6.2%) had CSF. None had bacteremia or meningitis. In all, one child returned with cervical adenitis, and another had culture negative sepsis but was ill-appearing on the initial visit. Nearly half of neonates 0-28 days did not have a blood culture, and two thirds didn’t have CSF obtained; yet they were treated with antibiotics, and 52% were discharged. The older infants were, the lower the percentage who had any diagnostic workup. This study provides some reassurance that an afebrile infant with otitis media has very low risk of subsequent IBI. It also shows that in real-world practice, a lot of emergency physicians don’t work these children up. I’m not sure I am ready to embrace this just yet. I would definitely not prescribe antibiotics to a child 0-28 days without a full sepsis workup. How I apply this to older infants will be on a case by case basis. The older they get, the more comfortable I would be avoiding a big workup. Also, keep in mind, otitis media is somewhat of a subjective diagnosis. There was no gold standard assessment for AOM. In addition, a minority of children got a diagnostic workup; we don’t know the true prevalence of bacteremia or meningitis. We assume discharged patients did well, but they didn’t follow each child and only considered a lack of return visits to the same facility as evidence the child didn’t have IBI. This leaves a lot of room for error.
I asked co-author Dr. Holly Hanson for her take on this study. She commented, “I think it is important to note that this was an afebrile population and does not apply to the febrile population with AOM. I agree with you in that the group with blood and CSF cultures obtained was small so true prevalence cannot be established with the study. I think the sample size was large enough, however, to given some reassurance in not necessarily working up AOM (especially as kids get older) if kids are otherwise well-appearing, healthy, and have good follow up and return precautions.”
Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media. Pediatrics. 2020 Dec 7;e20201571. doi: 10.1542/peds.2020-1571. Online ahead of print.