Good Morning! Welcome Applicants! FRIDAY, N OVEMBER, 7 TH 2014

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1 Good Morning! Welcome Applicants! FRIDAY, N OVEMBER, 7 TH 2014

2 Prep Question You are camping with a group of boys at a rural campground in the southeastern Unites States when one of the campers is bitten by a snake. His tent mates kill the snake (see Figure). The victim is crying and guarding his right hand. On examination of the boy s hand, you note several small, erythematous abrasions but no swelling or ecchymosis. Of the following, the MOST appropriate course of action is to: A. Apply a tourniquet above the bite B. Apply ice to the wound C. Incise and suction the wound D. Provide local wound care E. Transport the boy to the hospital for antivenom

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5 Laboratory Findings CBC WBC H/H 13.8/39.9 PLT 141 Differential: Seg 48 Bands 5 Lymphs 20 Monos 25 Basos 1 Metamyelos 1 CMP Glucose: 62; Calcium 9.7 TP/Alb/AST/ALT/TB/AP/MAG: within normal limits

6 Laboratory Findings Urinalysis Specific gravity Nasal Aspirate: negative ph 7.0 Leuk esterase/nitrite: negative WBC 0-2 No blood, ketones, glucose, reducing substances, RBC s, Bacteria CSF Colorless/clear WBC4 RBC 388 Differential: Neutrophils 10 lymphocytes 17 monocytes 53 eosinophils 20 Glucose: Gram stain: no microbes, many RBC s Protein: 54

7 7 - DAY- OLD, EX / 7 W GA MALE WITH FEVER, LETHARGY, AND THROMBOCYTOPENIA R U L E O U T S E P S I S / S E R I O U S B A C T E R I A L I N F E C T I O N Febrile Neonates and Young Infants

8 Tradition dictates Neonates (<28 days old) and young infants (29-90 days of age) gives us few clues that they have serious bacterial infections (SBI). Sepsis Bacteremia Urinary tract infections Meningitis Pneumonia Bacterial gastroenteritis Osteomyelitis/SSTI Septic arthritis So we proceed with aggressive laboratory investigation and often empiric antibiotics Categories <28 days of age days of age 3-36 months of age

9 Just the Facts The incidence of SBI s in neonates (0-28 days) is % of febrile infants Bacterial meningitis is more common in the 1 st month of life than any other time. Early vs. late GBS No current established, widely-accepted guidelines for evaluation and/or treatment of neonates/young infants who have fever without a localizing source. Hib and pneumococcal vaccines introduced less occult bacteremia Antibiotic resistance rising

10 What do we do with febrile neonates??

11 How do we work them up? Thorough History and Physical Exam Fever: What if mom reports fever at home but none documented in ER? = Fever What if patient is heavily swaddled? If low-grade, unswaddle and repeat in 15 min; If high-grade = Fever CBC with differential, BMP/CMP, UA and Urine culture, Blood culture, CSF with studies Laboratories: +/- viral studies (viral panel) +/- stool studies +/- CRP/PCT Imaging: +/- CXR 38 C or F +/- other imaging as dictated by history/clinical suspicion All neonates (<28 days old) should: (1) be admitted to the hospital, (2) have blood, urine, CSF cultures taken, and (3) have empiric antibiotic started regardless of how well-appearing they may be!

12 What bugs are we worried about? Community-acquired infections Group B Strep HSV What s the most common cause of fever? Viral infection! E. Coli Listeria

13 So should we do some antibiotics? Any other medications you would consider? Ampicillin + gentamicin OR Ampicillin + cefotaxime *gentamicin resistance Better CSF penetration? Penicillin-resistant Strep peumo = vancomycn Acyclovir Indications for Acyclovir: Ill-appearing Lethargy/change in mental status Mucocutaneous vesicles consistent with HSV Seizures CSF pleocytosis Elevated liver enzymes If bacterial cultures are negative at hours but patient has no clinical improvement

14 Length of Treatment Depends on the scenario If bactermic/septic/meningitic typically days If afebrile and cultures all remain negative, treat hours at least If persistently febrile, treat longer *Virus is identified = low risk for SBI (3-10%)

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17 What about the older infants?

18 CASE 1 You are seeing a 57-day-old male in the emergency department. Mom reports the patient has been vomiting for the past 12 hours and is becoming more difficult to arouse. She thought he felt warm at home but did not take a temperature. She reports fewer wet diapers today. In the ED, the patient is irritable with an axillary temperature is F, and you note a dry cough. What work-up is indicated? Hospitalize or discharge? CBC with diff, UA, Blood/Urine/CSF cultures, CSF studies, Viral Panel, CXR Hospitalize! Antibiotics or no antibiotics? Antibiotics! If yes, which antibiotics? Ampicillin +/- cefotaxime/ceftriaxone +/- Vancomycin All infants (29-90 days old) who are ill appearing should: (1) be admitted to the hospital, (2) have blood, urine, CSF cultures taken, and (3) have empiric antibiotic started!

19 Bugs? Antibiotics? Group B Strep Ampicillin E. coli Cefotaxime/Ceftriaxone Listeria +/- Vancomycin Herpes Simplex Virus +/- Acyclovir Salmonella Neisseria meningitides Streptococcus pneumonia Haemophalus influenza type B Staphylococcus aureus Most common cause of fever: viral infections! Which bugs are you most worried about?

20 CASE 2 You are seeing a 74-day-old male in the emergency department. The patient s mother thought he felt warm at home but did not take a temperature. However, her mother (the infant s grandmother) insisted she bring him to the ED for evaluation. She reports he is in his usual state of health. She denies lethargy, runny nose, cough, difficult with feeds, emesis, rash, and diarrhea In the ED, the patient with an axillary temperature is F. He smiles back at you and reaches for toys that you dangle in front of him. What work-up is indicated?

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22 CASE 2 You are seeing a 74-day-old male in the emergency department. The patient s mother thought he felt warm at home but did not take a temperature. However, her mother (the infant s grandmother) insisted she bring him to the ED for evaluation. She reports he is in his usual state of health. She denies lethargy, runny nose, cough, difficult with feeds, emesis, rash, and diarrhea In the ED, the patient with an axillary temperature is F. He smiles back at you and reaches for toys that you dangle in front of him. What work-up is indicated? CBC with diff, UA, Blood/Urine cultures, +/- CSF studies and culture* Hospitalize or discharge? Consider discharge IF ALL LABS REASSURING! Follow-up in 24 hours!!! Antibiotics or no antibiotics? +/- Antibiotics!* If yes, which antibiotics? Ceftriaxone If this patient tested positive for RSV, would it change your management plan? May do close outpatient follow-up without antibiotics

23 Infants days of age

24 Case 3 You are seeing a 7-month-old male in the emergency department. The patient s mother thought he felt warm at home and reports an axillary temperature of F. She brings him to the ED for evaluation because of the fever. The patient has not had lethargy, runny nose, cough, difficult with feeds, emesis, rash, or diarrhea In the ED, the patient with an axillary temperature is 98.9 F. He sits unsupported and smiles back at you as you examine him. What work-up is indicated?

25 3-36 Month Old Infants Risk Factors for Occult bacteremia Temperature 39 C WBC count 15,000/µL Elevated absolute neutrophil count or band count Elevated erythrocyte sedimentation rate Elevated CRP C-reactive protein Immunization Status*

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27 Case 3 You are seeing a 7-month-old male in the emergency department. The patient s mother thought he felt warm at home and reports an axillary temperature of F. She bring him to the ED for evaluation because of the fever. The patient has not had lethargy, runny nose, cough, difficult with feeds, emesis, rash, or diarrhea In the ED, the patient with an axillary temperature is 98.9 F. He sits unsupported and smiles back at you as you examine him. What work-up is indicated? Any other history needed? Hospitalize or discharge? Antibiotics or no antibiotics? CBC with diff*, CRP/ESR*, UA*, Urine cultures* Immunizations Status Consider discharge IF ALL LABS REASSURING! Follow-up in 24 hours!!! No antibiotics

28 Bugs? Antibiotics? E. coli Ceftriaxone Listeria +/- Vancomycin Salmonella Neisseria meningitides Streptococcus pneumonia Haemophalus influenza type B Staphylococcus aureus Most common cause of fever: viral infections! Which bugs are we most worried about?

29 Case 4 You are seeing a 7-month-old male in the emergency department. The patient s mother thought he felt warm at home and reports an axillary temperature of 103 F. She bring him to the ED for evaluation because of the fever. The patient has not had lethargy, runny nose, cough, difficult with feeds, emesis, rash, or diarrhea In the ED, the patient with an axillary temperature is F. He sits unsupported and smiles back at you as you examine him. Does the increase in temperature change your management plan? Yes! If Yes, why? Threshold to search for occult bacteremia 39 C (102.2 F) How would you treat this patient? CBC with diff, Blood culture and EITHER -Empiric antibiotics (Ceftriaxone) -Outpatient observation *Urine studies

30 Bugs? Antibiotics? E. coli Ceftriaxone Listeria +/- Vancomycin Salmonella Neisseria meningitides Streptococcus pneumonia Haemophalus influenza type B Staphylococcus aureus Most common cause of fever: viral infections! Which bug(s) are you most worried about?

31 What if a culture comes back positive?!? Depends on the age, clinical situation If CSF is positive treat (inpatient) If urine culture is positive treat (inpatient or outpatient) Proceed with work-up for VUR accordingly If blood culture is positive repeat it! Assess organism (is this a contaminant) AND assess patient proceed accordingly Strep pneumonia in older infants (>3 months) can potentially be treated outpatient It even spontaneously resolves in 30-40% of patients!

32 Summary Lesson 1: Babies are TRICKY! But don t let em scare ya! Any TOXIC-appearing child 0-36 months with temperature >38 C needs a full, rule-out sepsis work-up AND antibiotics. <28 day-old, REGARDLESS OF APPEARANCE admit, full workup, antibiotics Any TOXIC-appearing child 0-36 months with temperature >38 C needs a full, rule-out sepsis work-up AND antibiotics days old If ill-appearing admit, full work-up, antibiotics If well-appearing may consider outpatient close follow-up +/- antibiotics If prescribing empiric antibiotics, gather cultures first! 3-36 month old Threshold for occult bacteremia source search/empiric antibiotics: Temp of 39 C/ WBC 15,000 Immunizations must be considered May consider outpatient follow-up if low-grade temp and normal CBC May consider outpatient (or inpatient) antibiotic treatment (after blood cultures) if clinically stable!

33 CSF HSV1/HSV PCR: Negative CSF culture: No growth Blood culture: No growth Urine culture: No growth Ultimately Discharged to home with diagnosis of viral syndrome

34 Have a great day! Noon conference: Intern Lecture Series Introduction to EBM

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