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Thanks for the responses...
Rick...
Thank you as well....
My thoughts here...
 
5 Weeks of age...what are the chances of listeria, as you mentioned, so the 
 need for a higher dose of Amp?
 
No maternal lesions, no maternal herpes by history, no vesicular  lesions 
and the pt. being 5 weeks of age... and no bloody tap, (I  PREFACE THIS NEXT 
STATEMENT BY STATING THAT I WOULD NOT BASE MY DECISION ON  GIVING/NOT GIVING 
ACYCLOVIR ON THESE POINTS ALONE)...what are the real chances  of occult 
herpes encephalitis here...
 
The dose of Cefotaxime is meningitic dosing at 50mg/kg...no? 
 
I am doing soul searching here...as I have an extremely low threshold of  
making errors in the side of caution and surprised that this has not come up  
earlier...I was trained by Dr. Soglin, my mentor and idol...and he may be  
reading this...any thoughts?
 
I have practiced if you have a tap/and/or clinical picture that is  
suspicious for bacterial meningitis than give the higher dose, if not give 50  and 
50...
 
 
-Todd Z
 
 
In a message dated 8/7/2009 8:30:35 P.M. Central Daylight Time,  
[log in to unmask] writes:

Todd,  


I appreciate your point that you want to practice good clinical medicine.  
That is to be applauded. But we all recognize that even superior clinical  
skills are limited in terms of sensitivity and specificity.


So the facts of the case. You have (essentially) neonatal fever and a CSF  
with a clear finding that defines meningitis. The literature is equally 
clear  that we cannot with confidence call this viral (otherwise you would have  
simply discharged the patient).


So I think that your PICU colleague is simply asking....why NOT start  your 
ampicillin at 100mg/kg.


As for the acyclovir, I find that any interesting question. I must agree  
that it is probably unecessary and that this is a judgment call. But while we 
 are discussing this: isn't the chance that this child has occult herpes 
greater than the  chance that the child has occult listeria?


So one may ask, why give Ampicillin at all?


Rick


Rick Place, MD
Pediatric Medical Director
Department of Emergency  Medicine
Inova Fairfax Hospital for Children
3300 Gallows Road
Falls  Church, VA 22042

On Fri, Aug 7, 2009 at 11:21 AM, <[log in to unmask] 
(mailto:[log in to unmask]) > wrote:

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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