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PED-EM-L  February 2012

PED-EM-L February 2012

Subject:

Re: question about strep

From:

james reingold <[log in to unmask]>

Reply-To:

james reingold <[log in to unmask]>

Date:

Wed, 22 Feb 2012 12:23:00 -0700

Content-Type:

text/plain

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text/plain (138 lines)

Perhaps this does vary by community. Despite what I would consider gross overuse of the rapid strep, we see few positive tests in our ED.
JamesMesa, AZ

> Date: Wed, 22 Feb 2012 10:15:02 -0500
> From: [log in to unmask]
> Subject: Re: question about strep
> To: [log in to unmask]
>
> I'm not so sure any more whether the old paradigms hold true for many of the illnesses we are used to seeing. After all, we now see Cholelithiasis and even a couple cases of diverticulitis every year in teenagers so my thinking is that all bets are off, pretty much, for a lot of things.
> As far as strep goes out here in the Midwest, I regularly test many patients (adults and children) for strep and get a LOT of positives in ALL age groups because it seems pretty endemic in our area. What I'm not seeing so far (knock on wood) is much of the sequelae. Where I am, when someone tests positive they get treated. Few if any patients care to understand why they would test positive and not receive antibiotics, so it's again to mollify the evil Press Gainey monster, and not really for much else except their peace of mind and perhaps some level of symptomatic relief. The community has spoken, perhaps to their detriment. Still, I think it begs the question whether the underlying situation is (perhaps now) different than our classical understanding of the disease would suggest.
> DLooney, MD
>
> *****************************************************
> Shape your musical landscape! Add some funky violin jazz to your vibe!
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>
> > Date: Tue, 21 Feb 2012 18:12:22 -0800
> > From: [log in to unmask]
> > Subject: Re: question about strep
> > To: [log in to unmask]
> >
> > Rick,
> > I do not culture children less than 2 or older than 15. These are the age limits that I have found as being reasonable cut offs when screening for strep. As you mentioned, rheumatic fever is very uncommon outside this range and since Abx have no impact on the duration of strep throat, there is no reason.
> > As to your case, I think that your care and testing was completely appropriate. I would never have checked it and agree that it is not the cause of the fevers in this patient and that a viral illness, in an adequately vaccinated child, is the most likely cause.
> > As one of my favorite attendings used to say in my residency about unnecessary testing...."The problem with picking your nose, is that you need to know what to do with the booger when it comes out!!"
> > Mike Falk, MD
> > New York, NY
> >
> >
> > --- On Mon, 2/20/12, rick place <[log in to unmask]> wrote:
> >
> > From: rick place <[log in to unmask]>
> > Subject: Re: question about strep
> > To: [log in to unmask]
> > Date: Monday, February 20, 2012, 4:51 PM
> >
> > Marty beat me to this posting. I was going to ask the group about this.
> >
> > Last week I received a call from a local pediatric group (a decent one).
> > They wanted me to QI a case. We had seen an 8 month old with a fever of 105
> > and some diarrhea and dehydration and provided IVFs. But we didn't do any
> > testing and therefore "missed" the fact that the child had strep.
> >
> > I really have no idea how to respond to this other than to say that I
> > believe strep was not the cause and that nothing was "missed". But I think
> > that this only results in a he said - she said discussion where the
> > community physicians and ED physicians each think that the other is wrong.
> >
> > Does anyone believe that strep can cause high fevers in infants less than a
> > year of age? Who should be swabbed?
> >
> > (I am not questioning the treatment of a positive strep swab. I think that
> > once you do the test and get a positive, you are stuck).
> >
> > Thanks
> >
> > Rick Place
> >
> > On Mon, Feb 20, 2012 at 3:18 PM, Marty Herman <[log in to unmask]> wrote:
> >
> > > SO for years I have been puzzled why folks swab for strep in kids less
> > > than 2. When I read the Red Book it says testing for Strep in kids 2-3 is
> > > marginally indicated. They say typically 3 and up. According to what I have
> > > been told Rheumatic Fever doesn't occur in kids < 2, and is rare anyway and
> > > so if the reason we swab for strep is to prevent RF by early intervention,
> > > then why waste the money in kids < 2?If it's to limit the symptoms, avoid
> > > spreading contagion especially to daycare classmates, and or to allow
> > > parents to return to work sooner, why don't we screen for other causes of
> > > treatable bacterial infections like Eikenella, or arcanybacterium or
> > > mycoplasma? Studies done looking at the treatment with Penicillin and
> > > cephalosporins excluded kids under 3 ( Pediatric Annals May 1998 . the
> > > entire issue is dedicated to Group A Strep Infections. ). SO how do we know
> > > that treating kids <2 is actually worthwhile? SO do you see patients who
> > > have been diagnosed with "Strep" pharyngitis that are < 2? Do you swab and
> > > treat kids < 2 if positive?
> > >
> > > Marty
> > > Martin Herman, M.D.
> > >
> > > Pediatric Emergency Medicine
> > > Sacred Heart Children's Hospital
> > > FSU @ Sacred Heart, Division of Pediatrics
> > > 5153 N. 9th Ave, 6th Floor Nemours Bldg
> > > Pensacola, FL 32504
> > > Ph: 850 416 7658(office)
> > > Ph: 901 219 9202 ( cell)
> > > Fx: 850 416 7677
> > > Email: [log in to unmask]
> > >
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> >
> >
> >
> > --
> > Rick Place, MD
> > Department of Emergency Medicine
> > Inova Fairfax Hospital for Children
> > 3300 Gallows Road
> > Falls Church, VA 22042
> >
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