Six-week-old with Eye Drainage

A six-week-old infant was brought to the emergency department (ED) for evaluation of eye drainage. The mother stated her newborn developed mild right eye crusting several days before the visit. She used an “antibiotic drop” left over from an older son’s previous conjunctivitis diagnosis, and the crusting seemed to improve. However, the afternoon of presentation, she noticed redness near the corner of the eye and decided to have him evaluated.  She denied congestion or any other respiratory symptoms. There had been no fever, and the infant continued to feed well. The mother had received good prenatal care, was GBS negative, and had no prior history of HSV, GC, or chlamydia. Due to unexpected events, the infant was born at home and had not received erythromycin ointment to the eyes following birth.  In the ED, the infant was afebrile and nontoxic. He had a 1cm area of periorbital erythema and mild edema, inferior and medial to the right eye. His Wispr digital otoscopic exam is shown.

Which of the following is the most appropriate management for this infant?

A. Prescribe a 10-day course of oral amoxacillin/clavulante  (Augmentin) and discharge.
B. Administer intramuscular ceftriaxone, discharge with follow-up in 48 hours.
C. Perform limited sepsis evaluation with blood analysis. Admit for parenteral antibiotics.
D. Perform full sepsis evaluation with blood, urine, and CSF analysis. Admit for parenteral antibiotics.

This young infant has a left acute otitis media (AOM) as evidenced by the severely bulging tympanic membrane (TM), resulting in the classic “angry donut” sign. His clinical findings are also consistent with early dacryocystitis, an infection of the nasolacrimal duct. Despite seeming innocuous, either one of these infections should prompt the clinician to consider a broad approach and conservative management when found in the very young child.

Considering just the infant’s AOM, the level of evaluation is not well established. Traditionally, a full sepsis work-up and admission has been recommended when managing this condition in infants.  Early studies showed a significant rate of associated illnesses in infants with AOM, including mastoiditis, bacteremia, and meningitis. These findings, combined with the inherent challenges in confidently diagnosing AOM in neonates (see next week’s case discussion), make a conservative full septic work-up a reasonable approach.  However, vaccine administration and more recent investigations have painted a reassuring picture for outcomes of infants with AOM.  Sakran et. Al. and Sommerfleck et. Al. both found AOM to be a localized infection in their study populations.  While these findings provide some evidence for a less invasive approach to management, it is practical to exercise caution in the very young neonate or those with other infectious signs and symptoms of infection. In these instances, institutional approaches to the febrile infant should guide work-up.

The infant in this case was afebrile upon evaluation and very well-appearing--the mother reported she “felt a little foolish” bringing him to the ED. Despite this, the clinicians elected to obtain blood work, administer IV ceftriaxone, and admit to the Pediatric Hospitalist service. While admitted, the child spiked a fever to 101.4^oF.  His WBC and procalcitonin were elevated, but his blood culture remained negative, and he continued to do well throughout his stay. Ophthalmology was consulted for his dacryocystitis, which improved with the antibiotics, and agreed with the management plan.  He was subsequently discharged on oral Augmentin. 

Thank you to Dr. Greg DeMuri at UW Health Pediatric Infectious Disease for his valuable contributions to this case.

References:

Sakran W, Makary H, Colodner R, Ashkenazi D, Rakover Y, Halevy R, Koren A. Acute otitis media in infants less than three months of age: clinical presentation, etiology, and concomitant diseases. Int J Pediatr Otorhinolaryngol. 2006 Apr;70(4):613-7. doi: 10.1016/j.ijporl.2005.08.003. Epub 2005 Sep 9. PMID: 16154644.

Sommerfleck P, González Macchi ME, Pellegrini S, Bernáldez P, Reijtman V, Hernández C, Lopardo H. Acute otitis media in infants younger than three months not vaccinated against Streptococcus pneumoniae. Int J Pediatr Otorhinolaryngol. 2013 Jun;77(6):976-80. doi: 10.1016/j.ijporl.2013.03.024. Epub 2013 Apr 17. PMID: 23601926.