Print

Print


Thanks ALfredo.I am not sure where this discussion is taking us. I guess that is because I do believe that streptococcosis exists, that GAS can cause pharyngitis in young kids but I don't understand why people who look for and thent reat GAS in kids < 2 don't culture for other bacterial pathogens. 
SO if you think GAS is worth looking for and treating, why isn't EIkenella or Acanybacterium, etc. If the rationale for treating is to prevent ARF, then why look for it in kids < 2 or3, since ARF is so rare if not non existent in that age group?  
Marty
Martin Herman, M.D.

Pediatric Emergency Medicine 
Sacred Heart Children's Hospital
FSU @ Sacred Heart, Division of Pediatrics
5153 N. 9th Ave, 6th Floor Nemours Bldg
Pensacola, FL 32504
Ph: 850 416 7658(office)
Ph: 901 219 9202 ( cell)
Fx: 850 416 7677
Email: [log in to unmask]
 
CONFIDENTIALITY NOTICE: 
This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege.



 > Date: Wed, 22 Feb 2012 22:32:29 -0500
> From: [log in to unmask]
> Subject: Re: question about strep
> To: [log in to unmask]
> 
> The GAS was diagnosed by rapid streps of their exudative lesions in both cases.  In our institution if the rapid strep is positive, the throat culture is cancelled.  The abscesses were confirmed by CT of the neck with contrast (the older kid had RPA, the 11 month old had a parapharyngeal abscess, but a deep neck infection nonetheless).  We do not have ENT services at our hospital so they were transferred out to an outside facility and I do not know the follow up for what bug grew out from the abscesses.  Given that GAS is one of the more common organisms responsible for deep neck infections, I usually do a strep test and throat culture as part of the intial w/u on a patient with evidence of an exudative pharyngitis and a deep neck infection, although the final microbiology diagnosis will ultimately be made on what grows out of the abscess.   I had done a literature search at the time and could not find any evidence that indicated that if I had tested and treated the patient on the initial visit, the outcome would have been any different.  Therefore, I have not changed my practice management and do not routinely test kids <2 yo with an exudative pharyngitis and just make sure to give close discharge instructions to the family.  
>  
> 
> > Date: Wed, 22 Feb 2012 18:41:50 -0600
> > From: [log in to unmask]
> > Subject: Re: question about strep
> > To: [log in to unmask]
> > 
> > Well I don't find this any more "practice changing" than other statements. First we all know anecdotal statements when held up to the scrutiny of a RDBCS usually don't hold up. Even a when looking at coin flips, you might have preponderence of heads for several hundred flips. Rare things are just that....SO the fact that someone had two RPAswhile the rest of have had none doesn't change the overall incidence. SO was the pus cultured from these RPAs? or was a strep screen done and it was assumed that the Strep caused the RPA? 
> > Besides are we sure treating for the GAS would prevent the RPA? Aren't SUppurative complications known to occur whether you treat or not?Again I have to ask with all this the rationale for looking for a nd treating the strep infections in thiese young kids is to shorten the illness, reduce contagion or prevent suppurative complications, why don't we go back to doing comprehensive throat cultures to look for Non Group A infections, and other bacterial pathogens? Afterall each of them could go on to suppurate. 
> > Marty
> > Martin Herman, M.D.
> > 
> > Pediatric Emergency Medicine 
> > Sacred Heart Children's Hospital
> > FSU @ Sacred Heart, Division of Pediatrics
> > 5153 N. 9th Ave, 6th Floor Nemours Bldg
> > Pensacola, FL 32504
> > Ph: 850 416 7658(office)
> > Ph: 901 219 9202 ( cell)
> > Fx: 850 416 7677
> > Email: [log in to unmask]
> > 
> > CONFIDENTIALITY NOTICE: 
> > This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege.
> > 
> > 
> > 
> > > Date: Wed, 22 Feb 2012 16:09:44 -0700
> > > From: [log in to unmask]
> > > Subject: Re: question about strep
> > > To: [log in to unmask]
> > > 
> > > Agreed, I found that post to be pretty concerning since I pretty much don't have strep in my differential dx at that age.
> > > James
> > > 
> > > > Date: Wed, 22 Feb 2012 13:00:43 -0800
> > > > From: [log in to unmask]
> > > > Subject: Re: question about strep
> > > > To: [log in to unmask]
> > > > 
> > > > Great. I hate it when someone says something that has the potential to change the very basics of my practice of medicine. I tell residents that when a good doctor says : "I've never seen such and such" you have to take it with a grain of salt: he/she just might not have been working that day. But when a good doctor says: "I have seen such and such" you have to incorporate this fact into your fund of knowledge. So Alfredo saw two kids <2 years of age with (+) strep tests who later came down with RPAs. I can't just dismiss such information out of hand, no matter how much I'd like to. ASO titers and carrier states aside, I'll think twice about dismissing (+) strep tests in 2 year olds out of hand. Thanks a lot, Alfredo. Really. I love being 60 years old and just now finding out I have been wrong for these last 30+ years.
> > > > 
> > > > NM
> > > > 
> > > > From: Alfredo Maldonado <[log in to unmask]>
> > > > To: [log in to unmask] 
> > > > Sent: Tuesday, February 21, 2012 10:28 PM
> > > > Subject: Re: question about strep
> > > > 
> > > > I was also trained not to test for strep in kids <2 yo and teach that to our residents. In the past year I have seen two kids <2 yo (one was 11 months old) that I saw for fever and found them to have exudates who I did not test initially and treated supportively. They came back 2-3 days later with retropharyngeal abscesses caused by GAS. I know RPAs are usually polymicrobial and that they are most common in the 2-4 yo age group, but it did make me pause to consider if there is any value in testing for strep in the <2 yo age group. I haven't started testing in this age group, but make it a point to have a detailed conversation with the parents of any child <2 yo with an exudative pharyngitis about the signs/symptoms of deep neck infections. 
> > > > 
> > > > Alfredo Maldonado 
> > > > 
> > > > El Paso Children's Hospital
> > > > Pediatric Emergency Medicine
> > > > 
> > > > Sent from my iPhone
> > > > 
> > > > On Feb 21, 2012, at 11:00 PM, "Michael Falk" <[log in to unmask]> wrote:
> > > > 
> > > > > Rick,
> > > > > I do not culture children less than 2 or older than 15. These are the age limits that I have found as being reasonable cut offs when screening for strep. As you mentioned, rheumatic fever is very uncommon outside this range and since Abx have no impact on the duration of strep throat, there is no reason. 
> > > > > As to your case, I think that your care and testing was completely appropriate. I would never have checked it and agree that it is not the cause of the fevers in this patient and that a viral illness, in an adequately vaccinated child, is the most likely cause.
> > > > > As one of my favorite attendings used to say in my residency about unnecessary testing...."The problem with picking your nose, is that you need to know what to do with the booger when it comes out!!"
> > > > > Mike Falk, MD
> > > > > New York, NY
> > > > > 
> > > > > 
> > > > > --- On Mon, 2/20/12, rick place <[log in to unmask]> wrote:
> > > > > 
> > > > > From: rick place <[log in to unmask]>
> > > > > Subject: Re: question about strep
> > > > > To: [log in to unmask]
> > > > > Date: Monday, February 20, 2012, 4:51 PM
> > > > > 
> > > > > Marty beat me to this posting. I was going to ask the group about this.
> > > > > 
> > > > > Last week I received a call from a local pediatric group (a decent one).
> > > > > They wanted me to QI a case. We had seen an 8 month old with a fever of 105
> > > > > and some diarrhea and dehydration and provided IVFs. But we didn't do any
> > > > > testing and therefore "missed" the fact that the child had strep.
> > > > > 
> > > > > I really have no idea how to respond to this other than to say that I
> > > > > believe strep was not the cause and that nothing was "missed". But I think
> > > > > that this only results in a he said - she said discussion where the
> > > > > community physicians and ED physicians each think that the other is wrong.
> > > > > 
> > > > > Does anyone believe that strep can cause high fevers in infants less than a
> > > > > year of age? Who should be swabbed?
> > > > > 
> > > > > (I am not questioning the treatment of a positive strep swab. I think that
> > > > > once you do the test and get a positive, you are stuck).
> > > > > 
> > > > > Thanks
> > > > > 
> > > > > Rick Place
> > > > > 
> > > > > On Mon, Feb 20, 2012 at 3:18 PM, Marty Herman <[log in to unmask]> wrote:
> > > > > 
> > > > >> SO for years I have been puzzled why folks swab for strep in kids less
> > > > >> than 2. When I read the Red Book it says testing for Strep in kids 2-3 is
> > > > >> marginally indicated. They say typically 3 and up. According to what I have
> > > > >> been told Rheumatic Fever doesn't occur in kids < 2, and is rare anyway and
> > > > >> so if the reason we swab for strep is to prevent RF by early intervention,
> > > > >> then why waste the money in kids < 2?If it's to limit the symptoms, avoid
> > > > >> spreading contagion especially to daycare classmates, and or to allow
> > > > >> parents to return to work sooner, why don't we screen for other causes of
> > > > >> treatable bacterial infections like Eikenella, or arcanybacterium or
> > > > >> mycoplasma? Studies done looking at the treatment with Penicillin and
> > > > >> cephalosporins excluded kids under 3 ( Pediatric Annals May 1998 . the
> > > > >> entire issue is dedicated to Group A Strep Infections. ). SO how do we know
> > > > >> that treating kids <2 is actually worthwhile? SO do you see patients who
> > > > >> have been diagnosed with "Strep" pharyngitis that are < 2? Do you swab and
> > > > >> treat kids < 2 if positive?
> > > > >> 
> > > > >> Marty
> > > > >> Martin Herman, M.D.
> > > > >> 
> > > > >> Pediatric Emergency Medicine
> > > > >> Sacred Heart Children's Hospital
> > > > >> FSU @ Sacred Heart, Division of Pediatrics
> > > > >> 5153 N. 9th Ave, 6th Floor Nemours Bldg
> > > > >> Pensacola, FL 32504
> > > > >> Ph: 850 416 7658(office)
> > > > >> Ph: 901 219 9202 ( cell)
> > > > >> Fx: 850 416 7677
> > > > >> Email: [log in to unmask]
> > > > >> 
> > > > >> CONFIDENTIALITY NOTICE:
> > > > >> This email message and any accompanying data or files is confidential and
> > > > >> may contain privileged information intended only for the named
> > > > >> recipient(s). If you are not the intended recipient(s), you are hereby
> > > > >> notified that the dissemination, distribution, and or copying of this
> > > > >> message is strictly prohibited. If you receive this message in error, or
> > > > >> are not the named recipient(s), please notify the sender at the email
> > > > >> address above, delete this email from your computer, and destroy any copies
> > > > >> in any form immediately. Receipt by anyone other than the named
> > > > >> recipient(s) is not a waiver of any attorney-client, work product, or other
> > > > >> applicable privilege.
> > > > >> 
> > > > >> 
> > > > >> 
> > > > >> 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://listserv.brown.edu/ped-em-l.html
> > > > >> 
> > > > > 
> > > > > 
> > > > > 
> > > > > -- 
> > > > > Rick Place, MD
> > > > > Department of Emergency Medicine
> > > > > Inova Fairfax Hospital for Children
> > > > > 3300 Gallows Road
> > > > > Falls Church, VA 22042
> > > > > 
> > > > > 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://listserv.brown.edu/ped-em-l.html
> > > > > 
> > > > > 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://listserv.brown.edu/ped-em-l.html
> > > > 
> > > > 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://listserv.brown.edu/ped-em-l.html
> > > > 
> > > > 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://listserv.brown.edu/ped-em-l.html
> > > 
> > > 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://listserv.brown.edu/ped-em-l.html
> > 
> > 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://listserv.brown.edu/ped-em-l.html
>  		 	   		  
> 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://listserv.brown.edu/ped-em-l.html
 		 	   		  
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://listserv.brown.edu/ped-em-l.html