In Brooklyn, there seems to be a run on febrile children with high WBC (>20,000). I probably would have included a CXR after seeing that WBC count on the intitial visit and the hx of mild abdominal pain. We've picked up some cases of pneumonia, despite a normal lung exam.
Christopher Kelly MD
Brooklyn NY> Date: Wed, 19 Dec 2007 08:24:14 -0800> From: [log in to unmask]> Subject: Re: fever and antibiotics> To: [log in to unmask]> > I saw one of these yesterday. 3 yo with fever for 4 days. only > complaint was mild abd pain. seen 3d b4 and other doc got cbc, chem > 7, and urine. exam was b9. wbc=24k. urine with +trace nitrate and 4 > wbc/hpf. sent home with no abx. came back the day b4 i saw her, and > repeated wbc=12 and got strep screen altho throat exam said normal and > it was + (although also + in oct). started on amox. came back > yesterday and i saw her. extremely adorable and pleasant and playful > active who"kept mom up all not" treating the fever. the temp was > 102.9. all ohter vitals normal. urine now groing staph aureus 25-50k > that is mssa. was a cath spec. repeat urine with 4wbc and +nit. I > switched to keflex and gave shot of rocephin.> > Any critique of me (or others- i would critique others).> > don> On Dec 19, 2007, at 6:29 AM, Peter Auerbach wrote:> > > Not to be facetious, but you are describing the majority of the > > patients I see every day.> > Febrile, "not unwell", started on antibiotics by PCP, continues to > > have fever (despite the antibiotics!), "looks well in the ED" with > > "no focus of infection".> > In a child over the age of two, who has been fully vaccinated and > > appears to be well,> > I would do no tests (a urine only if urinary symptoms, history of > > UTI or suspicion of UTI on the part of the parents)> > and reassure the parents as to the likely viral and self-limited > > nature of the infection.> > (And if they asked me if they should continue the antibiotics, I > > would say that I saw no reason why they should.)> > I would only worry about meningitis (partially-treated or otherwise) > > if the child had acted meningitic at some point> > (e.g. c/o HA, vomiting, neck stiffness, etc.).> > I am curious as to why this case was a cause of concern?> > Did something bad or unusual happen to the child?> > Peter Auerbach> > Inova Fairfax Hospital for Children> > Falls Church, VA> > USA> > P.S. I do worry about "partially-treated meningitis" in very young > > children (e.g. under 3 months) with fever without a source who have > > been on antibiotics already and are getting worse or acting fussy or > > vomiting, or in somewhat older infants (up to a year?) with fever > > who are on antibiotics and have had a seizure, but not in well- > > appearing older children who never had symptoms suggestive of > > meningitis at any point during their illness.> >> >> >> >> Date: Wed, 19 Dec 2007 15:10:44 +1100> From: [log in to unmask]> > >> Subject: fever and antibiotics> To: [log in to unmask]> > > >> A case which has caused concern for us in Australia:> > 2yo girl > >> onset of illness 5 days ago. Initially saw primary care > physician > >> 4 days ago with History of 1 day of fever. Commenced on > oral > >> amoxicillin, was not unwell at that time. Now 4 days after > > >> commencing antibiotics she presents to our ED with ongoing fevers > >> to > 39.5 C. She has remained well but not quite her usual self, > >> and looks > well in the ED, no focus of infection.> > What workup > >> will you do? When do we need to exclude partially > treated > >> meningitis/bacterial illness? What symptoms or signs are > reliable > >> in this setting> > We would appreciate the collective knowledge of > >> the list as the > literature does not seem to help> > Thanks> Ed> > > >> Ed Oakley> Paediatric Emergency Physician> Department of Emergency > >> Medicine> Royal Children's Hospital,> Flemington Rd> Parkville > >> Victoria 3052> Australia> > Tel: +61 3 9345-6592> Fax: +61 3 > >> 9345-5938> email: [log in to unmask]> > > 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:> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> > 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:> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> > Donald Zweig MD> [log in to unmask]> > 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:> http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
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