Outpatient Treatment of Otitis Media in Infants Younger than 2 Months of Age
December 1, 1999 3 minutes read
Outpatient Treatment of Otitis Media in Infants Younger than 2 Months of Age
abstract & commentary
Source: Nozicka CA, et al. Otitis media in infants aged 0-8 weeks: Frequency of associated serious bacterial disease. Pediatr Emerg Care 1999;15:252-254.
The management and diagnostic evaluation of well-appearing, afebrile infants younger than 2 months of age with otitis media (OM) is controversial. Many practitioners will do a full sepsis work-up and tympanocentesis, then admit and treat these infants with intravenous antibiotics pending culture results. Investigators from the Children’s Hospital of Wisconsin recently reported on the frequency of serious bacterial infections (SBI) in well-appearing infants younger than 2 months of age with OM.
This was a prospective case series of infants younger than 2 months of age who were identified by the pediatric emergency physician staff as having OM. Included were well-appearing term infants with an uncomplicated perinatal history and no prior use of antibiotics. Eligible subjects were referred to one of two pediatric otolaryngologists who confirmed the diagnosis using a binocular microscope. Over a 16-month period in 1994-1995, 90 children were identified by the emergency medicine physicians; a convenience sample of 42 of these children were examined by the otolaryngologists. Forty of these 42 infants underwent a full sepsis evaluation and tympanocentesis and were admitted for intravenous antibiotics until culture results were negative at 48 hours.
The mean age of the infants was 4.2 weeks (only 1 infant was < 2 weeks old), and 38% were febrile at the time of enrollment. Bacterial pathogens were isolated from the middle ear fluid (MEF) cultures in 25 of the 40 infants (63%). There were no significant demographic or clinical characteristic differences between the infants with positive or negative MEF cultures. All of the afebrile infants had negative blood, urine, and spinal fluid cultures (upper limit 95% CI 0.11). Two of the 15 febrile infants had positive cultures from sites other than the middle ear fluid (blood and urine); both of these infants had an elevated white blood cell count. The most common MEF bacterial pathogens were Streptococcus pneumoniae (26%) and Moraxella catarrhalis (18%). Four of the infants (8%) had gram-negative coliforms (Escherichia coli and Klebsiella) isolated from the MEF cultures; none of these infants developed SBI or any sequelae related to OM. All 40 infants were discharged to complete a full course of oral antibiotic treatment; none were readmitted for the development of SBI or delayed sequelae of their OM.
Comment by Leonard Friedland, MD
Limitations of this study include the small number of enrolled subjects, only one subject being younger than 2 weeks of age, and the convenience sampling of patients who were referred to the otolaryngologists. However, the results suggest that the isolated finding of OM in an afebrile full-term child who is well-appearing and between 2 and 8 weeks of age may not require a full sepsis work-up nor tympanocentesis, and that these selected infants may be managed safely and effectively with oral antibiotics. Careful patient selection and coordination with the infant’s primary care provider will be mandatory if you choose this management strategy.
When considering the infant younger than 2 months of age who has otitis media, all of the following are correct except:
a. a majority will have associated serious bacterial illness.
b. afebrile, full-term infants who are well-appearing are at low risk for associated serious bacterial illness.
c. febrile infants with otitis media should be managed as you would febrile infants.
d. the most common bacterial pathogen for otitis media is S. pneumoniae.
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