AND (while we're on anecdotes) ... periorbital cellulitis!

I had a toddler recently who dropped his sippy cup onto his left eye 

a small abrasion (which the parents didn't think much of at the time), 

then presented to the ED several days later highly febrile with a very severe 

cellulitis, culture of which (from the abrasion area, which was mildly

purulent) grew Group A Strep.

His examination in the ED also revealed exudative tonsillitis, Quick 

positive (so at the time of admission I strongly suspected Group A

strep as the cause of his periorbital cellulitis).

Peter Auerbach, MD, FAAEM, FAAP

> Date: Thu, 3 Jun 2010 11:26:38 -0500
> From: [log in to unmask]
> Subject: Re: Strep Outcomes--Necrotizing Fasciitis
> To: [log in to unmask]
> Another anecdote, but a serious consideration...Group A Strep can cause Necrotizing Fasciitis.  A real life story of a surgeon contracting Group A Strep from an infected patient with necrotizing fasciitis. (A fellow surgeon got swabbed for pharyngitis symptoms and was positive for the same strain and treated) This surgeon possibly carried it in his nasopharynx and contaminated macerated skin between his toes with the same strain.  He developed toxic shock and necrotizing fasciitis of his leg. Thanks to the wonderful care he received, he survived, leg intact.
> Jill C Obremskey, MD, MMHC
> Director Pediatric Emergency Department Fast Track
> Monroe Caroll Jr Childrens Hospital at Vanderbilt
> Nashville, TN
> [log in to unmask]
> cell:  260-2208
> beeper: 835-8396
> Assistant:  Barbara Crossland 936-3898
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Amy Baxter
> Sent: Thursday, June 03, 2010 9:19 AM
> To: [log in to unmask]
> Subject: Re: Strep--Other Considerations
> OK, I've stayed out of this, in part because I agreed with Kevin Powell's
> comments and didn't want to be redundant, but seriously?  When I start to
> feel streppy because some kid I did a strep test on coughs in my face, I
> am thrilled when the swab they do at employee health comes back positive.
> Thanks to the wonders of post-1943 medicine, I know I'll be feeling better
> in 12 hours and don't need to try to swap my shift the next day, know I
> will be productive again, know I can manage my own contagion.  And of
> course I take antibiotics!
> I do lots of pain drops for viral otitis, and am scrupulously parsimonious
> even when parents of adenoviral children wail and get in my face.  I swab
> children less than three years once or twice a year, I quote the red book,
> and even when they have exudates and a positive family contact if the
> rapid is negative, too bad: no antibiotics for you.  But in the face of a
> positive bacterial contagion, the "high likelihood" of an adverse reaction
> doesn't stop me from gratefully getting treatment myself; bacterial
> illness is what antibiotics are for.  I fight the good fight against
> antibiotics for viral illnesses on a daily basis, but good heavens, if I
> have strep, DELUGE me, and that goes double for the patients who entrust
> their time, health, comfort, and money in me.
> Double penicillin latte for me, please.
> -Amy
> Fergus Thornton <[log in to unmask]> writes:
> >"Primum non nocere"
> >
> >Giving a course of Ab with a high likelihood of an adverse reaction for
> ><24hr sooner relief
> >violates this.  Many of you seem to be looking at this from the
> >perspective of one child (yours!) but multiply this by 10,000/day to get
> >a sense of the unnecessary antibiotics given in the US daily. This is
> >difficult to justify.  I'm sorry your kid has one extra day of a sore
> >throat but really . . . . is it worth deluging the world with more
> >antibiotics?  
> >
> >-----Original Message-----
> >>From: "Chamberlain, Jim" <[log in to unmask]>
> >>Sent: Jun 1, 2010 10:51 PM
> >>To: [log in to unmask]
> >>Subject: Re: Strep--Other Considerations
> >>
> >>I agree with you about shortening the course of disease.
> >>
> >>I disagree that we should lower ourselves so we are practicing at the
> >lowest common denominator. We need to educate our parents (and
> >administrators) about the risks and benefits of medications. Otherwise,
> >we should just put a large vat of amoxicillin in our waiting rooms and
> >let parents decide when they want antibiotics.
> >>
> >>James Chamberlain, MD
> >>Division Chief, Emergency Medicine
> >>Children's National Medical Center
> >>111 Michigan Avenue, NW
> >>Washington, DC 20010
> >> 
> >>202.476.3253 (O)
> >>202.476.3573 (F)
> >>202.476.5433 (Emergency Access)
> >>
> >>-----Original Message-----
> >>From: Pediatric Emergency Medicine Discussion List
> >[mailto:[log in to unmask]] On Behalf Of Dave Smith
> >>Sent: Tuesday, June 01, 2010 4:29 PM
> >>To: [log in to unmask]
> >>Subject: Strep--Other Considerations
> >>
> >>I want to play devil's advocate for a moment on another set of
> >perspectives:
> >>
> >>1.  What is the impact of not treating in terms of outcomes not
> >considered by studies?
> >>
> >>What I mean by this is that it is all well and good to pound the table
> >and hold up the studies and say, "Best practice says I don't need to
> >test/treat your 2 year old son, Mrs. Smith," but then, how often does
> >Mrs. Smith go to the urgent care down the road where they invariably see
> >a febrile toddler, order blood, urine and a chest xray, and give
> >Rocephin?  Even if she goes to her PMD the next day and they simply do a
> >strep and treat (which I think most PMD's would do despite our urgings to
> >the contrary), she's now incurred another visit to another medical
> >provider, increasing overall costs in the process.  In the former
> >case, the child undergoes a while slew of tests and a treatment we could
> >have prevented.  As I like to say, Evidence-Based Medicine is the
> >beginning of wisdom, not the entirity of it.  We also have to practice
> >"realistic medicine" ."  Over-adherence to dogma may lead to
> >parents seeking other outlets that end up doing far worse
> >> than a script for PenVK.  Writing that script in some (many?) cases
> >would thus be better practice than what the child ended up with even
> >though it may not have been "best practice."
> >>
> >>2.  We live in a world of Press-Gainey
> >>
> >>If your hospital administrators are like ours, they don't really care
> >about the best-practice guidelines...just the satisfaction scores.  When
> >surveys come back giving the doctor a series of 1's because they doctor
> >"didn't do anything about my child's strep throat and I had to go to an
> >urgent care" they want to know what we are doing to improve our scores. 
> >Telling them that strep only gets better a day earlier with treatment and
> >the child wasn't in an age range for rheumatic fever so it didn't matter
> >isn't something they care about.  That's how one ends up with language
> >added to one's contract tying incentives and penalties to Press-Gainey
> >performance.
> >>
> >>3.  What's a day worth to a parent/child?
> >>
> >>When your child is sick, would you like him to be better a day
> >earlier?  As a parent of four, I would have to say my answer is yes. 
> >Most parents I see would say yes as well.  That extra day could be two
> >extra days in some cases and we have no way of knowing for
> >could also be zero, but few parents would see that as an issue if there
> >is a good chance the illness could be one or two days shorter.  For
> >parents who are working, sometimes in positions where taking more sick
> >days could mean not advancing or at the very least, being seen as
> >unreliable because they are always out with "kid issues," that extra day
> >might mean a lot.  So when we say, "It's not worthwhile because they
> >only get better a day earlier at best," we are making a value judgement
> >about the worth of a day of wellness and the value of the parents' time.
> >>
> >>As I said, just playing devil's advocate.  I tend to agree in principle
> >with what others have written in this thread.  But we must always
> >remember that there are times when we still may be doing better care,
> >given the balance of all the issues at hand, when we give a little ground
> >on "best care."
> >>
> >>
> >>Dave Smith, MD
> >>
> >>
> >>      
> >>
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> >
> >
> >Fergus Thornton
> >read my blog @
> >
> >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:
> >       
> Amy Baxter MD
> Pediatric Emergency Medicine Associates
> 404 371-1190
> 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:
> 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:
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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