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]> 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 -
> 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
> 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....
> -Todd Z
> Dr. Todd Zimmerman
> Medical Director, Pediatric Emergency Medicine
> St. Alexius Medical Center/Alexian Brothers Medical Center
> Midwest Emergency Associates
> CMO, PIRRGA
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
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