Thanks for the responses...
Thank you as well....
My thoughts here...
5 Weeks of age...what are the chances of listeria, as you mentioned, so the
need for a higher dose of Amp?
No maternal lesions, no maternal herpes by history, no vesicular lesions
and the pt. being 5 weeks of age... and no bloody tap, (I PREFACE THIS NEXT
STATEMENT BY STATING THAT I WOULD NOT BASE MY DECISION ON GIVING/NOT GIVING
ACYCLOVIR ON THESE POINTS ALONE)...what are the real chances of occult
herpes encephalitis here...
The dose of Cefotaxime is meningitic dosing at 50mg/kg...no?
I am doing soul searching here...as I have an extremely low threshold of
making errors in the side of caution and surprised that this has not come up
earlier...I was trained by Dr. Soglin, my mentor and idol...and he may be
reading this...any thoughts?
I have practiced if you have a tap/and/or clinical picture that is
suspicious for bacterial meningitis than give the higher dose, if not give 50 and
In a message dated 8/7/2009 8:30:35 P.M. Central Daylight Time,
[log in to unmask] writes:
I appreciate your point that you want to practice good clinical medicine.
That is to be applauded. But we all recognize that even superior clinical
skills are limited in terms of sensitivity and specificity.
So the facts of the case. You have (essentially) neonatal fever and a CSF
with a clear finding that defines meningitis. The literature is equally
clear that we cannot with confidence call this viral (otherwise you would have
simply discharged the patient).
So I think that your PICU colleague is simply asking....why NOT start your
ampicillin at 100mg/kg.
As for the acyclovir, I find that any interesting question. I must agree
that it is probably unecessary and that this is a judgment call. But while we
are discussing this: isn't the chance that this child has occult herpes
greater than the chance that the child has occult listeria?
So one may ask, why give Ampicillin at all?
Rick Place, MD
Pediatric Medical Director
Department of Emergency Medicine
Inova Fairfax Hospital for Children
3300 Gallows Road
Falls Church, VA 22042
On Fri, Aug 7, 2009 at 11:21 AM, <[log in to unmask]
(mailto:[log in to unmask]) > wrote:
Ok...I am trying to summarize this as briefly as possible...
I had a 5 week old, nl birth hx, no maternal herpes/lesions, feeding well,
temp at home 101.6 Axillary, no fever in ER.
Pt. looked well, NL exam except classic viral exanthem.
I did a "complete sepsis w/u":
WBC 18 nl diff, lytes nl, UA nl, serum glucose from lytes 75
CSF 64 WBC's, 2 RBC's, CSF Glucose 38, CSF protein 78, CSF gram stain -
I ordered 50mg/kg of ampicillin and 50 mg kg of cefotaxime and called for
admission. The peds hospitalist, a great guy, asked if I would mind to
increase my amp dose to 100mg/kg and to add on acyclovir.
I complied, not the biggest deal in the world.
To me, this was 64 WBC's, NL gram stain, with obvious viral exanthem,,
clinically I was thinking this was most likely a viral meningitis.
Turns out the CSF Enteroviral PCR was +.
The PICU attending, kindly asked me why I did not give 100mg/kg of Amp
right away, rather than 50mg/kg that I originally ordered. And this was
in a very non confrontational manner.
My answer was, as above, classic viral exanthem, 64 WBC's, nl CSF gram
stain, and this appeared to be a viral meningitis. PICU attending's
was, basically, that he felt that if there is ANY abnormality on the tap we
should start with the higher amp dose in the ER.
I am a believer of making errors in the side of caution (to a degree, of
course), and I have been thinking about this for the past 2 hours now....
To my Peds ER colleagues....do you give 100mg/kg of amp with any, and I
mean ANY abnormality to the CSF, whatsoever.....
Thanks for considering this....
Dr. Todd Zimmerman
Medical Director, Pediatric Emergency Medicine
St. Alexius Medical Center/Alexian Brothers Medical Center
Midwest Emergency Associates
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