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Dr. Oakley
This patient you describe is one that would be handled differently at various institutions, and even amongst providers at those institutions. Even within my hospital, a well staffed Level I pediatric trauma center, I know some who would choose to watch and wait, some who would get some combo of ua, cbc, respective cultures, and a cxr if the wbc count is >20,000. I would likely check a ua and urine culture due to her age, gender and duration of fever without a source (although, you are right...it's likely viral which is why the antibiotics seem not to be helping). A 2 year old may or may not complain of uti symptoms. We are currently revisiting these issues (ages 3-36 mos with fever >39, no focus) in our dept as the blood cultures for occult bacteremia workups are returning more contaminants than pathogens these days in otherwise healthy, well appearing, febrile immunized kids. Given the recent articles published regarding rates of true pathogenic bacteremia in the post hib/post pneumococcal vaccine era in this cohort, I would expect to see more studies and an eventual revisitation of guidelines regarding evaluation of fever without a source in this group. I agree with Dr. Reingold that we do NOT have definitive, evidence based answers for this yet. I presume your question points at the more difficult question of how a child on antibiotics can be appropriately assessed for meningeal signs? Although I was taught that once on antibiotics, all clinical bets are off with meningitis, the 2 partially treated kids I've seen were ill-appearing (and with normal cbc's). This is difficult, however I agree that if the illness did not begin with symptoms of meningitis and the child has not had a seizure, there is no need to worry about it now. 
Alison McCrone, MD> Date: Wed, 19 Dec 2007 16:14:46 -0800> From: [log in to unmask]> Subject: Re: fever and antibiotics> To: [log in to unmask]> > I would suggest that a point to consider in many of these discussions is that some of the participants may not be trained in pediatrics. Very frequently I find that my non-pediatric trained colleagues tend to rely more heavily on tests than their exam of the patient. > > Indeed, the decision to test or not to test may often be more important than to treat or not to treat. In an otherwise healthy, immunized child over the age, oh, say 3 months, I wonder at the clinical utility or added information obtained in a CBC in an otherwise healthy to minimally ill appearing child. I suppose a normal value might be comforting to the doctor... Back in 2001 Pediatrics discussed the use of arbitrary CBC cutoffs in the 3-36 month age range, concluding that increasing use of pneumococcal vaccination would invalidate their use. Recently, the Emerg Med Australia published a retrospective review looking to for correlations to bacteremia (recognizing bacteremia does not necessarily equate to clinical illness) - and came back with neutrophils as having the highest odds predictive ability, and pneumococcus as the predominant organism. The study certainly has limits - Perhaps my more learned colleagues on the list serve could discuss> more recent studies regarding the clinical utility of CBC in this age range? > > If we do not have any clear evidence correlating CBC with the need to give antibiotics, again in the setting of the 3-36 minimally or even moderately ill appearing child with normal vital signs, I wonder at the rationale used in obtaining one. I suspect that it may frequently be used like a d-dimer: if it's normal the doc is reassured?> > I recall an article back in 2004 in JAMA about the clinical acumen of pediatricians - I looked up again to make sure I quote it correctly:> "In this study, relying on current clinical guidelines would not have improved care but would have resulted in more hospitalizations and laboratory testing."> > > Respectfully> > Matthew Cote, MD> > > ----- Original Message ----> From: james reingold <[log in to unmask]>> To: [log in to unmask]> Sent: Wednesday, December 19, 2007 1:58:26 PM> Subject: Re: fever and antibiotics> > I disagree. This is still the most common issue in the ER and there is still both plenty of controversy in management as well as variation among providers. Consider if the pt returned to the ER the next day in septic shock and died. I can assure you there would be plenty of debate about the assessment and treatment. I personally agree with relying on the exam in older (>6 mos if immunized) infants and children, but this issue if far from settled either in the literature or in practice.> > Respectfully,> James Reingold, M.D.> Date: Wed, 19 Dec 2007 15:46:56 -0500> From: [log in to unmask]> Subject: Re: fever and antibiotics> To: [log in to unmask]> > I personally cannot believe the amount of traffic an unexplained fever in a > child on an antibiotic(rightly or wrongly) can generate. I thought this > was for new issues in pediatrics, and having finished my residency in 1974, and > practising Emergency Medicine for 27 years I can assure you that rhis child > is not unique in any way, shape or form. What were you taught in your > training? I was taught to look at the child, GET A FEELING FOR WHETHER HE/SHE IS > SICK, AND EITHER DO FURTHUR WORKUP OR NOT DEPENDING ON YOUR CLINICAL > IMPRESSION. Has this changed? I think not, and these types of questions waste our > time!! Gene Saltzberg MD> > > > **************************************See AOL's top rated recipes > (http://food.aol.com/top-rated-recipes?NCID=aoltop00030000000004)> > 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://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> _________________________________________________________________> Share life as it happens with the new Windows Live.> http://www.windowslive.com/share.html?ocid=TXT_TAGHM_Wave2_sharelife_122007> 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://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html> > > ____________________________________________________________________________________> Looking for last minute shopping deals? > Find them fast with Yahoo! Search. http://tools.search.yahoo.com/newsearch/category.php?category=shopping> > 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://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
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The URL for the PED-EM-L Web Page is:
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