I see by the responses to my "CBC & BCx -- I don't think it is worth it" has
generated the usual round of controversy. Let me just address an issue that
Jay Fisher brought up. Jay stated that existing data "strongly
suggest (as well as one can in this business), that parenteral
antibiotics will abort a case of meningitis and perhaps even prevent a
death (from pneumococcal meningitis or occult meningococcemia- see
Dashefsky et al J Peds 1983) for every two or three thousand kids
evaluated and treated in this manner."
1. I'm not certain that the use of parenteral antibiotics will abort a case
of meningitis...and besides what does that mean? I assume you mean that the
antibiotics will prevent some (or most) of the sequelae of meningitis. If
that's the case, I agree. The question is a relative one then -- that is,
where in the course of the disease does the antibiotic prevent the sequelae.
Theoretically the earlier the better...but how early and do we know if the
delay of a few hours really makes a difference?
2. The theory of treating a child with suspected OB with empiric antibioics
is to prevent the development of menigitis NOT to abort meningitis. Or are we
now saying that we are not treating suspected OB but suspected meningitis.
Wow, where would we draw the line then?
3. I am not convinced that the data is so clean or applicable to today's
conditions. Most of the data published was collected during times of HIB
infection. Take out all those HIB cases and then redo the calculations and
you will find that the data are not convincing.
4. To say that this is an area where we can truely make a difference is
encouraging but questionable. The difference you suggest is in the prevention
of sequelae. The difference I suggest is 1000s of unneccessary venipunctures,
making 1000s of parents overly concerned and fever phobic, 100s of
unneccassary hospitalizations based on results which were contaminents, hours
of additional waiting time (and resultant morbidity of those kids), 1000s of
unneccesary IM shots!!! IS it worth it -- I don't think the data is
convincing enough for that routine!!
5. Think about it, every kid with Roseola gets a CBC & BCx on day 1 (after
all, roseola presents as high fever with no source). Follow through what
occassionally happens. On day 2 of roseola, the blood cx report is gram neg
cocci. He is called to the ED where he is still febrile. Gets a sepsis w/u
including LP, IM cetriaxone and admission. On day 3 he is still febrile, on
day 4 he is afebrile but has a rash (allergic to pen & cef for the rest of his
life). The blood cx eventually is reported as contaminant. I can assure you
that the scenario is much more common than one which prevents meningitis.
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