Not in a clinically well child with those CSF values. As far as acyclovir, again, these children are not well appearing and the CSF can be rather bloody. LFTs are usually elevated in young infants with systemic herpes as well.
Some may not start antibiotics or even admit a child greater than 28-days with this scenario and reliable parents. SB
Scott A. Barron, MD, FAAP
Children's Emergency Center
Mercy Medical Center
Des Moines, IA 50314
> Date: Fri, 7 Aug 2009 11:21:18 -0400
> From: [log in to unmask]
> Subject: question
> To: [log in to unmask]
> 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 -
> CXR -
> 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 asked
> 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 response
> 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....
> -Todd Z
> Dr. Todd Zimmerman
> Medical Director, Pediatric Emergency Medicine
> St. Alexius Medical Center/Alexian Brothers Medical Center
> Midwest Emergency Associates
> CMO, PIRRGA
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