Hospitalization or testing may not be needed

Infants with clinician-diagnosed acute otitis media (AOM) who are without fever have a low prevalence of invasive bacterial infections and rarely have adverse events, researchers have found, and suggested that it is reasonable to treat those patients without hospitalizing them and diagnostic testing.

The study, by Son H. McLaren, MD, MS, Department of Emergency Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, and colleagues, was published in Pediatrics.

Acute otitis media is a very common infection in childhood (affecting more than 80% of children before reaching the age of 3). However, recommendations for treating infants (under 3 months) are not available since the current American Academy of Pediatrics (AAP) guideline on the diagnosis and management of AOM does not include infants under 6 months.

Treatment of young infants is further complicated by concerns that AOL in younger infants could be accompanied by invasive bacterial infections (IBIs). “The clinical conundrum of AOM in infants younger than 3 months may be most relevant to those without fever, for whom the appropriate diagnostic evaluation for IBI, if any, is unclear,” McLaren and colleagues pointed out.

In this study, the authors’ objective was to determine the prevalence of IBIs (bacteremia and bacterial meningitis) and adverse events in afebrile infants with AOM. They also wanted to determine patterns of diagnostic testing in these patients.

This was a 33-site cross-sectional study of 1,637 infants 90 days or younger with AOM and without fever. McLaren and his colleagues found:

  • None of 278 infants with blood cultures had bacteremia
  • None of 102 infants with cerebrospinal fluid cultures had bacterial meningitis
  • Two of 645 infants with follow-up at 30 days had adverse events (lymphadenitis and culture-negative sepsis)

The authors noted that the medical history of the infant with culture-negative sepsis — a potentially AOM-related adverse event – suggested the primary cause was likely severe dehydration from underlying milk protein allergy.

Of the patients in the study, 21.7% had one or more diagnostic tests administered for infectious illness and 34% of infants 28 days and younger underwent lumbar puncture. Of 1179 infants with symptoms of upper respiratory tract infection, 4.9% underwent lumbar puncture, and 13.7% had blood cultures obtained. Nine of every 10 infants (90.4%) discharged from the ED was given a prescription for an antibiotic.

McLaren and colleagues also found that older infants (over 28 days) were less likely than younger infants to have blood or cerebrospinal fluid cultures taken.

They suggested that the increased testing in the younger infants was likely due to a lack of data on the risk of IBI in AOM patients, concerns about IBI in younger patients based on data from infants with fever, as well as an unwillingness to prescribe antibiotics without testing.

“Despite the low probability for IBI in this population, more than one-fifth underwent IBI diagnostic testing and were hospitalized,” the authors observed. “With the data from our study, we suggest that given the low rates of IBI and adverse events, outpatient management without IBI testing is reasonable for most afebrile infants with a clinical diagnosis of AOM.”

In a commentary accompanying the study, Joseph Ravera, MD, and M.W. Stevens, MD, MSCE, both of the Larner College of Medicine, University of Vermont, noted that young infants in this study (28 days or younger) were underrepresented (just 6% of the sample) and had a hospitalization rate of nearly 50%.

This underscores the clinical uncertainty pediatric ED providers face in treating these patients “who have the highest risk of occult bacteremia and systemic spread of a focal bacterial infection,” wrote Ravera and Stevens. “Management of infants in this age group after finding a focal bacterial infection continues, for now, to be part of the art of clinical care.”

However, they added, the study does contribute a “robust” data set of afebrile infants between 1 and 3 months of age with an ED diagnosis of AOM that “provides a base of support for carefully designed prospective studies in which researchers aim to determine the best care for AOM in children aged <6 months.”

  1. Infants with acute otitis media who are without fever have a low prevalence of invasive bacterial infections or adverse events.

  2. This study suggests that they may not need diagnostic testing or hospitalization.

Michael Bassett, Contributing Writer, BreakingMED™

None of the authors cited in this article disclosed any relevant relationships.

Cat ID: 138

Topic ID: 85,138,254,138,192,925