The Case: A 5wk old ex FT boy presenting with bilateral ear drainage and fussiness without fevers and otherwise normal exam

Here’s how you answered the questions:

Discussion: Ahhh babies. Their peculiar behaviors can be nothing (i.e. seborrheic dermatitis that extends to the external auditory canal with inflammation) or everything (SBI). In this case of a fussy, afebrile infant with bilateral ear drainage, the dilemma to do a full sepsis eval vs nothing/PO abx and send home is real.

Based on the polling questions and lively discussion, attendings and trainees alike were split on whether blood work is needed for this patient. While some are concerned that the otitis externa/potential otitis media represents a bacterial source of infection, others felt that this was unlikely to change overall management. With a normal CBC, the question of full/partial/no sepsis work up remains strong.

With lack of clarity from the labs and ENT exam that still did not fully visualize the TMs, the debate continues. More attendings and trainees were comfortable with PO antibiotics, topical drops, and discharge home. There remained a concern, however, regarding appropriate follow up, and missing subsequent fevers, or other signs/symptoms of SBI. With admission, however, the question of whether or not to treat also remains as if patient does not receive a full sepsis work up prior to ceftriaxone and admission, adding antibiotics can muddy the waters if he goes on to develop fevers or other new symptoms.

It is interesting to note, as Drs. Chapman and Lindgren pointed out, that having an ‘obvious source’ of infection can exclude febrile infants from a sepsis work up, however otitis media is excluded as an ‘obvious source.’ The dilemma remains. Looking at the literature, there is lack of clear evidence for management of infants with otitis <60 days old. Overall, limited available evidence suggests that the risk of IBI in infants younger is not increased by the presence of AOM and the evaluation and treatment should be based on other clinical features (cited below).

Turner D, Leibovitz E, Aran A, Piglansky L, Raiz S, Leiberman A, Dagan R SO. Acute otitis media in infants younger than two months of age: microbiology, clinical presentation and therapeutic approach. Pediatr Infect Dis J. 2002;21(7):669

Nozicka CA, Hanly JG, Beste DJ, Conley SF, Hennes HM. Otitis media in infants aged 0-8 weeks: frequency of associated serious bacterial disease. Pediatr Emerg Care. 1999;15(4):252. 

Denouement: Patient admitted to the hospitalist for continued observation and CTX, while cultures pending. Blood cultures NG at 24 hrs, discharged home on Augmentin and Ciprodex. He had follow up in ENT clinic with full resolution of otitis and normal hearing exam.

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