SGEM#334: In My Life there’s been Earache and Pain I don’t know if it’s IBI again – in an Afebrile Infant with Acute Otitis Media

Date: June 11th, 2021 Guest Skeptic: Dr. Dennis Ren is a paediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021 Case: You are working with a medical student at the emergency department when a 2-month-old boy is brought in by his parents for fussiness. They note that he has had upper respiratory symptoms for the past few days and fussier than usual. He has still continued to feed well and make wet diapers. He has not had any fever. Yesterday, they noticed that he seemed to be pulling at his right ear. On exam, he is afebrile, active, and alert. He cries and moves vigorously when you look into his ear. You see a bulging, red tympanic membrane. His left tympanic membrane is clear. The rest of his exam is unremarkable. You turn to the medical student and ask her what she would like to do for this patient. She replies that she thinks the patient has an acute otitis media (AOM) but given his age, she is also thinking about the possibility of an invasive bacterial infection (IBI) and would like to obtain some blood for labs and even consider a lumbar puncture for cerebral spinal fluid. How do you reply? Background: Acute Otitis media is the second most diagnosed illness in children and the most common indication for antibiotic prescription [1-2]. We have covered the of AOM twice on the SGEM: SGEM#132: One Balloon for Otitis Media with Effusion with Dr. Richard Lubell SGEM#278: Seen Your Video for Acute Otitis Media Discharge Instructions SGEMHOP with lead author Dr. Naveen Poonai? In 2013, the American Academy of Pediatrics (AAP) updated recommendations for the diagnosis and management of acute otitis media (AOM) for children older than 6 months. Unfortunately, there is limited guidance for patients younger than 6 months. The diagnosis of AOM becomes more complicated by the concern for concurrent invasive bacterial infections (IBI) in infants less than 3 months of age. Previous studies have demonstrated low prevalence of concurrent IBI in infants with AOM, but sample size has been small and included a mix of afebrile and febrile infants [3-4]. Additionally, the microbiology of pathogens causing AOM has shifted after the implementation of the pneumococcal conjugate vaccine with a higher proportion of patients having culture negative AOM [5]. This uncertainty has led to wide practice variation and controversy surrounding diagnostic testing (blood and cerebrospinal fluid testing), antibiotic administration (IV vs oral), and disposition (discharge vs admission) in infants with AOM. Clinical Question: What is the prevalence of invasive bacterial infections and adverse events in afebrile infants ≤ 90 days of age with acute otitis media? Reference: McLaren SH, et al. Invasive bacterial infections in afebrile infants diagnosed with acute otitis media. Pediatrics 2021 Population: Afebrile infants ≤ 90 days of age with clinically diagnosed acute otitis media across 33 pediatric emergency departments (29 USA, 2 Canadian and 2 Spanish EDs) from 2007 to 2017 Excluded: Temperature ≥38°C and <36°C in the ED or within 48 hours, antibiotic use (other than topical) within 48 hours of presentation, concurrent mastoiditis, evidence of focal bacterial infection, transferred to ED with previous diagnostic testing/antibiotics Intervention: Evaluation of invasive bacterial infections in blood or cerebrospinal fluid (CSF) Comparison: None Outcomes: Primary Outcome: Prevalence of IBI (bacterial meningitis and bacteremia) Secondary Outcomes: Variability in diagnostic testing for IBIincluding blood or cerebrospinal fluid (CSF), parenteral antibiotic administration, and hospitalization. Safety Outcome: AOM-associated adverse events Authors’ Conclusions: “Afebrile infants with clinician-diagnosed acute otitis ...