Dr. Platt's case illustrates so many different issues it is hard to know where to begin.
First off, anyone with focal disease or fever >38.0 under the age of 60 days is no longer low-risk according to the Rochester Criteria and in terms of the original case that started this thread, the criteria also mandate that if you treat in this age range, you must tap. Of course, there will always be those kids in any age range who appear to be doing well but turn out to have serious disease afoot, and we can only hope that through good instructions and appropriate follow-up, the disease will be found and treated before there is an adverse outcome. Obviously, we can't do a full septic workup on everyone of any age.
Whether or not Dr. Platt's case falls into that category is an academic point. Through watchful waiting, perhaps even if the pneumonia had been treated with an initial dose of parenteral antibiotic followed by oral antibiotics and close outpatient followup, the child would not have improved as expected and a more detailed workup would have uncovered the presence of the Klebsiella meningitis. While this is an interesting scenario to ponder, it is complicated by the fact that we have standards and protocols for patients in this age range, and deviation from them exposes everyone, physician and patient, to some degree of risk. This risk exists for the physician even if there is no true difference in outcome for the patient. So we are back to the first question I posed in my last post, is this a good reason to do an LP? We have no evidence to support not doing an LP and this complicates both the physician's perception of his responsibility in the case of a bad outcome as well as his vulnerability to malpractice claims.
Practicing according to case reports is also dangerous. Everyone knows a case where a 2 week old was brought in because he was "a little fussy" and had a 37.8 temp...the child looks good but a conservative physician taps him and it's group B strep. Where do these cases go in our decision tree? Hopefully, not very far up, but they should at least serve as cautionary tales to keep us from being too cavalier.
It comes down to the issue that if you follow the protocols for the 7 week old originally presented, you must tap him. If you don't, there is the chance of adverse outcome which will be attributed to your lack of adherence to the protocols whether or not this in fact, could have changed the outcome. Until we have more data about children in this age range with fever and focal disease, all of these issues will have to be weighed every time the question arises.
R. David Smith, MD
Children's Acute Care
Cape Fear Valley Medical Center
Fayetteville, North Carolina
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