You see a 51-day-old infant in the ED brought in for “fussiness” and ear tugging. She’s afebrile but has a red, bulging tympanic membrane. Do we still need to work her up? Or can you just treat the ear infection and move on?
Acute otitis media (AOM) is a common diagnosis in infants, but it can become a clinical red herring. The temptation is to anchor on the ear and skip the rest of the fever workup. But how safe is that—especially in infants under 2 months? This study looked at the risk of invasive bacterial infection (IBI = bacterial meningitis or bacteremia) in afebrile infants with acute otitis media.
The Evidence:
Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media. Pediatrics. 2021 Jan;147(1):e20201571. doi: 10.1542/peds.2020-1571. Epub 2020 Dec 7. PMID: 33288730.
1637 afebrile infants ≤90 days of age with clinically diagnosed AOM:
- 0 cases of bacteremia
- 0 cases of bacterial meningitis
- 2 adverse events
- Lymphadenitis 20 days after discharge from the hospital
- Child with culture-negative sepsis that likely was actually severe milk protein allergy
It has to be noted that since the presence of otitis media was not verified by another clinician, there likely was an overestimation of good outcomes AKA some children diagnosed with AOM in the study who did not actually have a true infection.
Final Thought
In well-appearing, afebrile infants with a convincing diagnosis of acute otitis media, the evidence from this study is reassuring: invasive bacterial infection is exceedingly rare. For these patients, it’s likely safe to treat the ear infection with antibiotics and forgo a further bacterial workup.
🧠 To consider: What if the infant develops a fever after starting antibiotics?
This remains a tricky clinical gray zone. Is it progression of the primary infection? A new, unrelated illness? Or a partially treated IBI or UTI? While there’s no clear guideline, these scenarios often warrant re-evaluation and a lower threshold for further testing—especially in infants <60 days.
Dr. Joshua Belfer, MD, is a Pediatric Emergency Medicine physician at the Children’s Hospital of Philadelphia, and is the Founder and Editor-in-Chief of HipPEMcrates. He can be reached at HipPEMcrates@gmail.com.
