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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 asked 
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 response  
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

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