I am enjoying this thread and would like to chime in with some additional questions & thoughts.
"x-ray shows a clear RLL infiltrate. His sats are above 95 and he is not
tachypneic. His WBC is normal and is c-reactive protein is 5 ."
Don (Zweig), what do you mean by "clear" infiltrate? Was it lobar consolidation or a linear patchy infiltrate? Bilateral or Unilateral? Although they usually cause afebrile pneumonia syndromes, could this have been a chlamydia or pertussis pneumonia? Did you screen for the latter?
Also, as you know, the diagnostic test profile ( i.e. sensitivity and PPV) of a CBC is no different than a CRP in the setting of a febrile infant, with usual cutoffs . I was curious what the details of the CBC were including the ANC and differential?
"I am nearly complete in writing a case report on a 7 week infant with URI and fever to
101, otherwise well, met all "low risk" criteria published, ( rochester,
philadelphia, boston, etc...) and had influenza A rapid test positive. Rec'd
ceftriaxone and sent home. Day 2, CSF grew klebsiella pneumonia."
Shari (Platt), your case has piqued my interest! I would assume that since the infant was low risk by all the criteria, you implied there was no CSF pleiocytosis? Could you kindly share the details of the CBC (including the band to neutrophil ratio), CSF and urine culture?
Your case proves the point that NO risk stratification criteria has 100% sensitivity!! For example, the low risk Rochester criteria have a sensitivity of 92% for detection of SBI in this age group.
Ultimately, as Jim (Wilde) eloquently stated, EBM "discipleship" has limitations, which we often fail to recognize as it applies to an individual patient. It also serves to remind us that the bacterial players in a 7 week old infant include.. gram negatives, GBS, Listeria and H. Flu.
"What would you and others on this list-serve do with a 7 week old with a
runny nose, fever of 102.1, normal pulse ox and respiratory rate, slight
cough (bronchiolitis season) who looks normal except for the congestion?
a. Do you do a CBC?
b. DO you do an LP?
Regarding the LP question - I would not do one."
Mike, I would also NOT perform a spinal tap in the above case, IFF everything about the HNP and screening labs. was "absolutely" benign. I am curious as to what data your esteemed colleague was citing to defend their position as a plaintiff's expert? I am hoping it was the Cabernet talking and not them!!
"I know our practice and the de facto standard of care dictates an LP in this situation but have wondered "why?" on more than one occasion, even knowing the mantra "If I've already given abx, I won't know what I'm treating....." Not the biochemical "why" but the clinical practice "why".
Rob (Norris), I would reiterate what Jim said...."potential meningitic spread is impossible to detect on the basis of history and physical exam alone" in the < 8 week old."
I don't have the references handy but I can help you focus your search over the holidays. Bill Bonadio and Doug Baker have published wonderful prospective data in the early 1990's attempting to define the reliability of a clinical exam in ruling out SBI in general and meningitis in particular. They concluded that in this 28-60 day group, given their developmental immaturity, even in the hands of experienced PEM's, the sensitivity at best was 70-80%. They had attempted to standardize observations utilizing, if you recall, observation scales like "Yale" score, Young Infant Observation Scale etc in those articles. Perhaps, if they are listening, they could elucidate the point better than I could. Hope that helps some.
Finally, Don, I would also perform an LP and admit as Mike (Gerardi) & Alan (Manheimer) stated.
Jay Pershad, MD, FAAP
Division of Pediatric Emergency Medicine
UT College of Medicine
LeBonheur Children's Medical Center
Memphis, TN 38103
Pediatric Emergency Specialists, PC
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is: