POTD. Pediatric Grand Round. Pediatric Fevers

Today’s Pediatric grand rounds was given by Dr. Prashant Mahajan, MH, MPH, MBA. 

• Professor and Vice-chair of the department of Emergency Medicine; Professor of Pediatric Medicine, Division Chief of Pediatric Emergency Medicine, Professor of Pediatrics at the University of Michigan

• For those that don’t know him- He’s really smart and has done a ton of research on febrile infants

• and he's proposing a new model to rule out serious bacterial infections in infants <60 days old. 

TL:DR

• Serious Bacterial Infection (SBI) can be ruled out febrile infants from 29-60 days old with a-

  • Negative UA

  • Absolute Neutrophil Count (ANC) < 4090/μg

  • Procalcitonin < 1.72 ng/m

• This prediction rule has a

  • Sensitivity of 97.7% (95% CI, 91.3-99.6)

  • Negative predictive value of 99.6% (95% CI, 98.4-99.9)

  • Negative likelihood ratio of 0.04 (95% CI, 0.01-0.15)

  • Specificity of 60.0% (95% CI, 56.6-63.3)

• This rule requires further validation, but has promise to substantially decrease the use of lumbar punctures, broad-spectrum antibiotics, and hospitalization for many febrile infants 60 days and younger.

The longer and more detailed approach:

- 8-13% of infants <60 days with  fever have a SBI

• ~5-8% have a UTI

• ~1-2% have bacteremia

• ~0.5% have meningitis

- ~500,000 febrile infants are evaluated by healthcare professionals annually

• Missed SBIs may lead to serious complications

• Febrile infants frequently receive invasive management including lumbar punctures, broad spectrum antibiotics, and hospitalization

• Variation exists in the management of febrile infants <60 days

• 90% of those 28 days or less receive lumbar puncture and admission

• The incidence of SBIs has decreased over time

• We need to balance hospital related complications, costs, and increases in antimicrobial resistance with the consequences of missed SBIs

- Our screening tests to assess for SBIs have holes in them

• Physical Exam

  • Yale Observation Scores (YOS) in infants with SBI’s have similar median scores to those without SBI’s

  • I didn't know the YOS was a thing either. It's a clinical score developed on 6 behavioral domains to predict SBI’s, 

• CBC’s are not sensitive in ruling out bacteremia or meningitis

  • WBC< 5,000 has a sensitivity of 10%, specificity of 91%

  • WBC> 15,000 has a sensitivity of 18%, specificity of 87%

• Several of the commonly used rules for febrile infants (Philadelphia, Rochester, Boston, and Pittsburgh) were not statistically derived and therefore lacked optimal balance between test sensitivity (avoiding missed SBIs) and specificity (preventing overtesting and overtreating patients without SBIs). Additionally, several included data from LP’s an invasive procedure not required in the newly proposed rule (Boston, Phladelphia, Pittsburgh, Milwaukee.

- In this study

• Negative UA alone ruled out an SBI in 97.6% of cases

  • Anyone hear of diapedesis? Consult Hector Vazquez for more info

• Negative UA + ANC <4090 ruled out SBI in 99.2% of cases

• Negative UA + ANC <4090 + PCT <1.71 ruled out SBI in 99.8% of cases

- Further validation in a cohort with more SBI’s is needed before implementation of this new rule.

The conclusion

• Dr. Mahajan recommends using this rule in infants 29-60 days old. He currently recommends pursing your institutions’s standard of care (Full Sepsis Workup) in infants 28 days old or less  

The Article:

https://jamanetwork.com/journals/jamapediatrics/fullarticle/2725042

POTD: 3 Common Anti-Vaxxer Beliefs

“It is better to light a candle than to curse the darkness” - Carl Sagan

In an era where “fake news” threatens the fabric of our society, we as physicians have a duty to educate our patients and fight the insidious creep of disinformation. We often think of anti-vaxxers as granola-eating, compost pile-making eccentrics living off the grid somewhere in Montana, when the truth is that even some amongst own hospital colleagues may espouse these beliefs.

Here, we discuss three common arguments made by anti-vaxxers in supporting their stance and counterarguments based on empirical evidence we may use to challenge them.   

FALSE: Vaccines cause undue harm due to antigenic overload

    ▪    A misconception propagated by Robert W. “Doctor Bob” Sears that holds infants are incapable of responding safely to the “large number” of vaccine antigens given and that antigenic overload results in a “cytokine storm” or “immune cascade” that triggers adverse health events.

    ▪    Not surprisingly, “Dr. Bob” failed to cite any data to support this claim.

Counterarguments:

    ▪    From the moment of their birth, infants encounter numerous microorganisms and their antigens at a level far exceeding the antigen exposure due to vaccines.

    ▪    Numerous studies show that vaccines are safe and efficacious at the routine vaccine schedule with no evidence of an “antigenic overload.”

    ▪    Infants and children today actually receive far less antigenic “exposure today” with routine vaccination than they did in the past. The smallpox vaccine given in the 1900s contained 200 proteins and the whole cell pertussis component of DTwP vaccine given in the US up until the 1990s contained approximately 3,000 proteins. Today, the entire schedule of 15 recommended vaccines from birth to age 5 contains no more than 150 proteins and polysaccharides.

FALSE: Vaccines can result in autoimmune diseases such as T1DM, MS, and GBS.

Counterarguments:

    ▪    A panel of experts of the Institute of Medicine recently reviewed more than 12,000 published reports and failed to find any evidence whatsoever for the development of any of these three autoimmune diseases as a result of vaccines.

    ▪    The diversity of antigens presented during “natural” infection support the counterclaim that infections are more likely than vaccines to result in autoimmune phenomena, such as influenza virus or Campylobacter infection causing GBS.

FALSE: Immunity produced by “natural infection” is safer than vaccine-induced immunity.

Counterarguments:

    ▪    Wild type influenza kills 1 in every 8,300 Americans.  No deaths have been attributed to the flu vaccine.

    ▪    The flu vaccine does not cause myocarditis, PNA, bronchitis, sinusitis, or significant amounts of lost work and school time — but “natural” influenza certainly does.

    ▪    While “natural” measles virus infection does provide lifelong immunity, it also causes death in about 1 out of every 3,000 cases, as well as other non-lethal and disabling complications. The measles vaccine has not been associated with death or disabling complications, despite billions of vaccine doses given.

Harms done by the anti-vaccine movement

    ▪    The anti-vaccine movement has successfully pressured numerous countries to discontinue use of the pertussis vaccine. These countries now have a documented 10- to 100-fold increased in morbidity and mortality from pertussis.

    ▪    Doctor Bob Sear’s alternative vaccination schedule has resulted in under-vaccination and measurable increased rates of measles and pertussis.

    ▪    Europe, Australia, New Zealand, and the Americas are now seeing major outbreaks of measles as a result of Wakefield’s fraudulent study claiming a link between the MMR vaccine and measles.

    ▪    In a Wisconsin survey, 31% of parents who refused vaccination cited “autism” as their reason.

Poland et al (2012) “The clinician’s guide to the anti-vaccinationists’ galaxy.” Human Immunology, Volume 73, Issue 859-866

POTD: How to Treat Cellulitis...and Leishmaniasis

You diagnose a patient with cellulitis and you reach the old, familiar mental roadblock: which antibiotic do I use? Sure, you treated your last cellulitis patient with Keflex, but this patient has a small, mild abscess — do we use a different antibiotic?

UptoDate is tedious, and you’ve called the ED pharmacy 15 billion times today already for other med recommendations. Is there a better way?

B  E  H  O  L  D :  The IDSA Practice Guidelines

https://www.idsociety.org/practiceguidelines#/name_na_str/ASC/0/+/

From treating cellulitis to combat-related infections to leishmaniasis, the IDSA has the most current recommendations for you, the practitioner.

Back to our patient's skin infection. A quick search will yield this handy chart:

Our patient is young, with no comorbidities, and he has a mild, superficial, purulent infection with no systemic symptoms. According to this chart, we could treat with I & D and NO ANTIBIOTICS AT ALL. However, the same patient with a more deep-seated infection, systemic symptoms, or any risk factors would warrant empiric treatment with doxy or bactrim.

IN SUM: The IDSA practice guidelines exist. Use them.