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PED-EM-L  February 2012

PED-EM-L February 2012

Subject:

Re: question about strep

From:

Alfredo Maldonado <[log in to unmask]>

Reply-To:

Alfredo Maldonado <[log in to unmask]>

Date:

Thu, 23 Feb 2012 11:49:42 -0500

Content-Type:

text/plain

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text/plain (266 lines)

Below are most of the articles that I had seen when I did the literature search at the time.  I was limited to jounals that I could access online at the time.  It's been about a year since I did the search, so I don't know if anything new has come out.  I found mainly retrospective chart reviews and case reports.  I did not find any prospective randomized studies that showed that identifying or treating known infections would have altered outcome.  What I got out of these articles was:
 
1) Deep neck infections are uncommon in kids <2 yo, but they happen
2) GAS has been isolated in this age group, but it is not the only bug that causes it.  S. aureus might be more common than GAS in this age group
3) No studies have been done looking at whether testing or treating for strep will make a difference in outcome.
 
Wasn't enough to change my management in these kids and attributed the two cases i saw to chance.  
 
 
Alfredo Maldonado
 
El Paso Children's Hospital
Pediatric Emergency Medicine
 
-  Acta Otolaryngol. 2009 Nov;129(11):1274-9.  Surgical management of retropharyngeal abscesses.
Schuler PJ, Cohnen M, Greve J, Plettenberg C, Chereath J, Bas M, Koll C, Scheckenbach K, Wagenmann M, Schipper J, Hoffmann TK.
 
retrospective chart review over 28 months.  11 patients.  6 of them children.  2 were <2 yo.  No mention of what bacteria grew.  One of the two had a repeat RPA that required drainage again.
 
- Increased incidence of head and neck abscesses in children.

Cabrera CE, Deutsch ES, Eppes S, Lawless S, Cook S, O'Reilly RC, Reilly JS.
Otolaryngol Head Neck Surg. 2007 Feb;136(2):176-81.
 

retrospective chart review from 2000-2003 of facial, orbital/intracranial, neck and intraoral (including PTAs, RPAs and parapharyngeal) abscesses.  38 kids had intral oral abscesses.  9 of these were <2 yo.  Intraoral abscesses were predominantely GAS, but this was not broken down by age.  Looking at all abscesses, kids 0-2 had equal incidence of GAS and Staph species (4, 4).  

 
- Retropharyngeal abscess in children: the emerging role of group A beta hemolytic streptococcus.

Abdel-Haq NM, Harahsheh A, Asmar BL.
South Med J. 2006 Sep;99(9):927-31.
 
11 year retrospective chart review of kids admitted with RPA. 67 kids identified.  Youngest age was 5 months.  36 (54%) were < 4 yo, but no breakdown on how many were <2 yo.  Pus obtained from 41 kids with 101 bacterial isolates from these kids.  Of the total 84 aerobic isolates, 22 were GAS, 24 were Strep viridans.  No breakdown on whether this varied by age.  
 
- Age-, site-, and time-specific differences in pediatric deep neck abscesses.

Coticchia JM, Getnick GS, Yun RD, Arnold JE.
Arch Otolaryngol Head Neck Surg. 2004 Feb;130(2):201-7.
 
10 yr retrosective chart review of kids <19 yo with deep neck abscess.  169 total patients.  33 were <1yo, 75 were 1-4 yo.  Youngest age was 2 months.  Kids <1yo were infected with S. aureus (79%) more than GAS (6%), p<.001.  Kids >1 yo were more commonly affected with strep (29%) than S. aureus (16%), p .07.  In kids <1 yo, location of the abscesses were: retropharyngeal or parapharyngeal 21%, submandibular 36%, ant/post triangles 39%.  
 
- Retropharyngeal abscess in a toxic-appearing infant.

Toback S, Herr S.
Pediatr Emerg Care. 2001 Aug;17(4):255-7. No abstract available. 
 
case report of 8 month old male with fever to 103 for 4 days, diarrhea, emesis and lethargy.  Ended up getting diagnosed with RPA on MRI and grew out GAS and pseudomonas. Pt had nl OP on exam initially and had small NT cervical LNs and nuchal rigidity.  
 
- Third branchial cleft anomaly presenting as a retropharyngeal abscess.

Huang RY, Damrose EJ, Alavi S, Maceri DR, Shapiro NL.
Int J Pediatr Otorhinolaryngol. 2000 Aug 31;54(2-3):167-72.
 
case report of a 5 week old with RPA that grew out alpha-hemolytic strep, GAS, group D strep, Klebsiella and Veillonella.  Pt had underlying branchial cleft cyst.
 
- Retropharyngeal abscess: a clinical review.

Goldenberg D, Golz A, Joachims HZ.
J Laryngol Otol. 1997 Jun;111(6):546-50.
 
10 year retrospective chart review of patients of all ages.  Total 19 patients had RPA.  Youngest was 1 year old.  7 cases were <5 yo, 3 between 6 and 16, and the remainder were >16 yo.  No breakdown as to how many there were per age, their presentation or what bacteria caused it.  
 
- Posterior mediastinal abscess caused by invasive group A Streptococcus infection.

Conway JH, Nyquist AC, Goldson E.
Pediatr Infect Dis J. 1996 Jun;15(6):547-9. No abstract available.
 
Case report of a 9 month old female that presented with fever, vomiting, loose stools and had a strep throat contact.  Mild OP erythema, but otherwise nl.  Pt grew out GAS in her blood and continued to be febrile on abx and upon further imaging was found to have post mediastinal abscess likely extending from a RPA that was also seen.  Cultures were neg at that time after being on abx for several days, but strep test was positive.  
 
- There were also a few case reports about neonates presenting with RPA that grew out Group B strep and S. Pneumo
 > Date: Wed, 22 Feb 2012 22:32:29 -0500
> From: [log in to unmask]
> Subject: Re: question about strep
> To: [log in to unmask]
> 
> The GAS was diagnosed by rapid streps of their exudative lesions in both cases. In our institution if the rapid strep is positive, the throat culture is cancelled. The abscesses were confirmed by CT of the neck with contrast (the older kid had RPA, the 11 month old had a parapharyngeal abscess, but a deep neck infection nonetheless). We do not have ENT services at our hospital so they were transferred out to an outside facility and I do not know the follow up for what bug grew out from the abscesses. Given that GAS is one of the more common organisms responsible for deep neck infections, I usually do a strep test and throat culture as part of the intial w/u on a patient with evidence of an exudative pharyngitis and a deep neck infection, although the final microbiology diagnosis will ultimately be made on what grows out of the abscess. I had done a literature search at the time and could not find any evidence that indicated that if I had tested and treated the patient on the initial visit, the outcome would have been any different. Therefore, I have not changed my practice management and do not routinely test kids <2 yo with an exudative pharyngitis and just make sure to give close discharge instructions to the family. 
> 
> 
> > Date: Wed, 22 Feb 2012 18:41:50 -0600
> > From: [log in to unmask]
> > Subject: Re: question about strep
> > To: [log in to unmask]
> > 
> > Well I don't find this any more "practice changing" than other statements. First we all know anecdotal statements when held up to the scrutiny of a RDBCS usually don't hold up. Even a when looking at coin flips, you might have preponderence of heads for several hundred flips. Rare things are just that....SO the fact that someone had two RPAswhile the rest of have had none doesn't change the overall incidence. SO was the pus cultured from these RPAs? or was a strep screen done and it was assumed that the Strep caused the RPA? 
> > Besides are we sure treating for the GAS would prevent the RPA? Aren't SUppurative complications known to occur whether you treat or not?Again I have to ask with all this the rationale for looking for a nd treating the strep infections in thiese young kids is to shorten the illness, reduce contagion or prevent suppurative complications, why don't we go back to doing comprehensive throat cultures to look for Non Group A infections, and other bacterial pathogens? Afterall each of them could go on to suppurate. 
> > 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]
> > 
> > CONFIDENTIALITY NOTICE: 
> > This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege.
> > 
> > 
> > 
> > > Date: Wed, 22 Feb 2012 16:09:44 -0700
> > > From: [log in to unmask]
> > > Subject: Re: question about strep
> > > To: [log in to unmask]
> > > 
> > > Agreed, I found that post to be pretty concerning since I pretty much don't have strep in my differential dx at that age.
> > > James
> > > 
> > > > Date: Wed, 22 Feb 2012 13:00:43 -0800
> > > > From: [log in to unmask]
> > > > Subject: Re: question about strep
> > > > To: [log in to unmask]
> > > > 
> > > > Great. I hate it when someone says something that has the potential to change the very basics of my practice of medicine. I tell residents that when a good doctor says : "I've never seen such and such" you have to take it with a grain of salt: he/she just might not have been working that day. But when a good doctor says: "I have seen such and such" you have to incorporate this fact into your fund of knowledge. So Alfredo saw two kids <2 years of age with (+) strep tests who later came down with RPAs. I can't just dismiss such information out of hand, no matter how much I'd like to. ASO titers and carrier states aside, I'll think twice about dismissing (+) strep tests in 2 year olds out of hand. Thanks a lot, Alfredo. Really. I love being 60 years old and just now finding out I have been wrong for these last 30+ years.
> > > > 
> > > > NM
> > > > 
> > > > From: Alfredo Maldonado <[log in to unmask]>
> > > > To: [log in to unmask] 
> > > > Sent: Tuesday, February 21, 2012 10:28 PM
> > > > Subject: Re: question about strep
> > > > 
> > > > I was also trained not to test for strep in kids <2 yo and teach that to our residents. In the past year I have seen two kids <2 yo (one was 11 months old) that I saw for fever and found them to have exudates who I did not test initially and treated supportively. They came back 2-3 days later with retropharyngeal abscesses caused by GAS. I know RPAs are usually polymicrobial and that they are most common in the 2-4 yo age group, but it did make me pause to consider if there is any value in testing for strep in the <2 yo age group. I haven't started testing in this age group, but make it a point to have a detailed conversation with the parents of any child <2 yo with an exudative pharyngitis about the signs/symptoms of deep neck infections. 
> > > > 
> > > > Alfredo Maldonado 
> > > > 
> > > > El Paso Children's Hospital
> > > > Pediatric Emergency Medicine
> > > > 
> > > > Sent from my iPhone
> > > > 
> > > > On Feb 21, 2012, at 11:00 PM, "Michael Falk" <[log in to unmask]> wrote:
> > > > 
> > > > > 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]
> > > > >> 
> > > > >> CONFIDENTIALITY NOTICE:
> > > > >> This email message and any accompanying data or files is confidential and
> > > > >> may contain privileged information intended only for the named
> > > > >> recipient(s). If you are not the intended recipient(s), you are hereby
> > > > >> notified that the dissemination, distribution, and or copying of this
> > > > >> message is strictly prohibited. If you receive this message in error, or
> > > > >> are not the named recipient(s), please notify the sender at the email
> > > > >> address above, delete this email from your computer, and destroy any copies
> > > > >> in any form immediately. Receipt by anyone other than the named
> > > > >> recipient(s) is not a waiver of any attorney-client, work product, or other
> > > > >> applicable privilege.
> > > > >> 
> > > > >> 
> > > > >> 
> > > > >> 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://listserv.brown.edu/ped-em-l.html
> > > > >> 
> > > > > 
> > > > > 
> > > > > 
> > > > > -- 
> > > > > Rick Place, MD
> > > > > Department of Emergency Medicine
> > > > > Inova Fairfax Hospital for Children
> > > > > 3300 Gallows Road
> > > > > Falls Church, VA 22042
> > > > > 
> > > > > 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://listserv.brown.edu/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://listserv.brown.edu/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://listserv.brown.edu/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://listserv.brown.edu/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://listserv.brown.edu/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://listserv.brown.edu/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://listserv.brown.edu/ped-em-l.html
 		 	   		  
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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