Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media

Abstract

OBJECTIVES: To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM). METHODS: We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect. RESULTS: Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%–1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%–3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%–1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained. CONCLUSION: Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Disparities and implicit bias in the management of low-risk febrile infants: a mixed methods study protocol

“…The retrospective nature of this study design introduces additional limitations, including information and selection bias in provider documentation. In order to address this, we will use variable definitions that have been previously established and used in prior Pediatric Emergency Medicine Collaborative Research Committee studies of young infants 3 54. There is the possibility of missed adverse outcomes if patients present to a different facility after discharge.…”

“…There is the possibility of missed adverse outcomes if patients present to a different facility after discharge. To attempt to capture these, we will review the first provider note to occur more than 72 hours after the index ED visit for documentation of any possible adverse outcomes that occurred after discharge and are not otherwise captured within the primary hospital system 54…”

“…To attempt to capture these, we will review the first provider note to occur more than 72 hours after the index ED visit for documentation of any possible adverse outcomes that occurred after discharge and are not otherwise captured within the primary hospital system. 54 The qualitative portion of this study will rely on recruitment of an appropriately sized sample of minority parents of febrile infants. If we encounter difficulty recruiting an appropriately sized sample, we will expand our recruitment to include the UF Pediatric ED, Jacksonville.…”

Otologic Examination Findings In Afebrile Young Infants Clinically Diagnosed With Acute Otitis Media

“…Trained site investigators and research coordinators abstracted the following otologic findings and coded them as present, absent or not documented: (1) TM opacity, (2) TM erythema, (3) bulging TM, (4) TM dullness, (5) visualization of perforated TM, (6) decreased TM mobility on insufflation, (7) otorrhea and (8) decreased visualization of middle ear structures. The findings of TM dullness, TM opacity and decreased visualization of middle ear structures were each considered evidence of a middle ear effusion.…”

“…2,4,5 It is unclear what examination findings clinicians use to diagnose AOM in young infants, if they vary from criteria established for older infants and children, and how these differences may impact their care. In our previously published study of afebrile infants ≤90 days with clinically diagnosed AOM, 6 we briefly summarized the documented ear examination findings without assessing combinations of findings or whether examination findings differed across age subgroups. The primary aim of this study was to describe in detail the otologic examination findings documented by pediatric emergency medicine clinicians to diagnose AOM in afebrile young infants.…”