Pediatricians

[docB]

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I've noticed for several years that pediatricians always seem to want to order lots of stuff extra when I call them about their patients. I'm talking about stuff they wouldn't order when seeing the patient themselves. For example I just gave a peds a courtesy call to say that I'm discharging a 2 year old on some amox for a pharyngitis and he askes what the white count is. After I explained that I didn't stick the kid for a non-toxic presentation and a "fever" of 100.0 he said "Well, you really should get a CBC with a diff."

Aside from the fact that this won't change the management of the kid at all I think that these guys just have this attitude that sticking kids in the ED is really easy and quick and that every kid that rolls in needs a full work up. I know that these guys are not referring every pharyngitis and viral syndrome out to the lab for a draw. Why does it need to be done in the ED?

 

[Stitch]

They really considered 100 a fever?? It's not just you though; we get these dumps in our ED as well, but generally I do what I want and tell the PCP why. My personal favorite is "we've been treating his fever for 2 days with antibiotics. Can you rule out a partially treated meningitis?" There's absolutely no reason to get a CBC in the instance you described, and I wouldn't have ordered it either.

Some older pediatricians are convinced that you can identify occult bacteremia by a left shift or increased bands on a CBC. They would want you to give a dose of Rocephin prior to discharge. Most of the studies that looked at bacteremia in children were done prior to the Hib vaccine, and the little data that existed no longer holds much weight. As far as I'm concerned CBCs are way over ordered and not that useful for identifying bacteremia in children. They are either normal and worthless, or worse you find something that you don't know what to do with. Not to mention it's a pain in the ass to stick a kid for a lab that's not useful.

Things I/we do that you may not do in an adult ER:
Full sepsis work up in infants under 6 weeks, including spinal fluid followed by a two day admission on cefotaxime (don't give Rocephin) AND ampicillin. No one has seen Listeria in a long time, but it's still standard to add it.

UA and culture in girls under 2 years with a temp above 39, even if they have an obvious URI. Around 5% of those URIs will have a concomitant UTI.

 

[docB]

Things I/we do that you may not do in an adult ER:
Full sepsis work up in infants under 6 weeks, including spinal fluid followed by a two day admission on cefotaxime (don't give Rocephin) AND ampicillin. No one has seen Listeria in a long time, but it's still standard to add it.

Most of us are still doing the full court press on anything under 3 months. Is it down to 6 weeks now? Are there additional criteria?

 

[Speed Racer]

UA and culture in girls under 2 years with a temp above 39, even if they have an obvious URI. Around 5% of those URIs will have a concomitant UTI.

I have to find the paper, but I was talking to a colleague that referenced a study that said UTI's is waay under diagnosed in young females and can lead to renal sclerosis and HTN later in life. Anyone read this?

 

[Stitch]

Most of us are still doing the full court press on anything under 3 months. Is it down to 6 weeks now? Are there additional criteria?

3 months is probably overkill. 6-8 weeks is where well still doing everything (they might be able to go home if everything is perfect) and people keep trying to push it back. I'd do urine in a well looking 3 month old but no csf unless the kid is unvaccinated or looks bad. 8-12 weeks is grey area but I generally dont pull the trigger on the spinal unless something catches my attention.

You can use the philedelphia criteria. There's a paper on it but I'm out drinking tonight and will try to post it tomorrow.

And yes uti is greatly underdiagnosed. I think urine is always worth checking.

 

[Zanegray]

At our children's ED they do full sepsis workup for infants under 60 days with fever greater than 38.

Same as an above poster for any age greater than that, CBC and UA, possible CXR if indicated for babies older than that and go from there.

I think we still do Rocephin for babies 61-90 days, although cefotaxime and amp for babies younger than that. Any idea why?

 

[docB]

I think we still do Rocephin for babies 61-90 days, although cefotaxime and amp for babies younger than that. Any idea why?

Rocephin can precipitate out in the gallbladder and cause a mild biliary stasis. It also competes with bilirubin for binding sites in the liver and can cause a rise in serum bili. In people over 60 days this isn't a big deal because the hepatic system has enough reserve to deal. In kids under 60 days who are hyperbilirubinemic already from birth it can be a problem. Hence the preference for amp/gent.

I have heard this is really just a theoretical concern like beta blockers with cocaine or morpine and the sphincter of Oddi. Anyone know for sure?

 

[Stitch]

At our children's ED they do full sepsis workup for infants under 60 days with fever greater than 38.

Same as an above poster for any age greater than that, CBC and UA, possible CXR if indicated for babies older than that and go from there.

I think we still do Rocephin for babies 61-90 days, although cefotaxime and amp for babies younger than that. Any idea why?

60 days is a reasonable cutoff. Amp covers listeria which is devastating if missed. You generally shouldn't be using rocephin in this age group due to the risk of hemolysis however this may be institutional dependent. Are you giving to everyone with a fever or only those with abnormal labs? I'd be worried about partially treating something.

 

[Rendar5]

Full sepsis work up in infants under 6 weeks, including spinal fluid followed by a two day admission on cefotaxime (don't give Rocephin) AND ampicillin. No one has seen Listeria in a long time, but it's still standard to add it.

I wasn't aware that Listeria's a rare form of Meningitis. I've seen Listeria before in a newborn, presumed dx from the monocytosis and later confirmed by culture. Perhaps it's more common in the nursery/NICU environment than in the ED environment.

 

[Stitch]

I wasn't aware that Listeria's a rare form of Meningitis. I've seen Listeria before in a newborn, presumed dx from the monocytosis and later confirmed by culture. Perhaps it's more common in the nursery/NICU environment than in the ED environment.

Interesting; I guess that's why we still cover for it!. I did my peds residency at a high volume children's hospital and only ever saw it in the blood once, never in the CSF. Our ID guys said they hadn't seen it in a long time either, but it could just be location. I'd be curious to know if the neos are seeing it a lot.

Here's a summary from the University of Chicago on the Rochester, Philadelphia and Boston criteria for identifying high risk infants. And here's a supporting article from 2005. There was another, which I'm not able to find at the moment for some reason. Some of those criteria use CSF, but the Rochester does not. You basically have the choice above six weeks whether to tap or not.

But basically here's what I do (and my partners pretty much practice the same) for a temp greater than 38 taken rectally.
0-5 weeks: Full work up plus admission with amp and cefotaxime or gent. Slam dunk, no questions.
6-8 weeks: Very low threshold to tap, especially the closer you are to 6 weeks, but not positively necessary. I do tap most of the 6 week olds, but not 7-8. If everything is perfect (including vital signs!) per the above criteria and you can ASSURE follow up within 24 hours, the kid can go home. I usually call their pediatrician and document the call. I do not treat with any antibiotic if I'm sending them home. If they need antibiotics, then they need to stay.
8-12 weeks: generally CBC, blood culture and UA/culture but no tap unless they are not immunized. They can go home with close follow up. Again, I don't send them out with Rocephin or any antibiotics so as not to cloud the picture provided everything looks normal.

In general I don't think it's ever wrong to tap an infant. Anything sounds sketchy in the history or physical and they get the needle.

 

[J-Rad]

I'm discharging a 2 year old on some amox for a pharyngitis and he askes what the white count is. After I explained that I didn't stick the kid for a non-toxic presentation and a "fever" of 100.0 he said "Well, you really should get a CBC with a diff."

"Why the amox [in a non-febrile 2 y.o. with pharyngitis in the first place]?" would be my line of questioning (politely inquired, of course). And, yeah, the CBC really seems like overkill.

 

[Apollyon]

I remember L. monocytogenes from preclinical microbiology as a cause of neonatal meningitis. It was Group B strep at birth, E. coli just after, Listeria for the first 2 months, the HiB (before the vaccine), the meningococcus in teens, and the pneumococcus in adults (but still a factor all the way down the line).

Guess my schooling wasn't that bad!

 

[docB]

"Why the amox [in a non-febrile 2 y.o. with pharyngitis in the first place]?" would be my line of questioning (politely inquired, of course). And, yeah, the CBC really seems like overkill.

Because every peds visit to a suburban ED must end with a script for the pink stuff or a poor Press Ganey and a call to the CEO will result.

 

[Rendar5]

Because every peds visit to a suburban ED must end with a script for the pink stuff or a poor Press Ganey and a call to the CEO will result.

I'm prolly gonna regret mentioning this since I haven't had a chance to read the article yet (only hit the abstract), but apparently an article in this months AEM suggests that failure to meet a patient's preconceived notions of care is not particularly significant in determining patient satisfaction. Kinda the opposite of what I woulda thought.

 

[Seaglass]

The ACEP clinical policy on the workup of febrile children is well researched and helpful. I don't do a mandatory tap after 4 weeks and neither do any of my partners or the peds EM guys. We generally don't do blood work after 4 weeks either unless there is a clinical indication.

 

[Interpolfanclub]

I have to find the paper, but I was talking to a colleague that referenced a study that said UTI's is waay under diagnosed in young females and can lead to renal sclerosis and HTN later in life. Anyone read this?

Sigh, I've heard this too. I think the chances we are missing serious UTI's that cause renal scarring and HTN later are really, really small. Most HTN in America isn't caused by docs missing occult UTI's, it's caused by too many french fries. But if anyone can provide a study showing we're missing these UTI's and destroying kidneys I'm all for it.

 

[Stitch]

Sigh, I've heard this too. I think the chances we are missing serious UTI's that cause renal scarring and HTN later are really, really small. Most HTN in America isn't caused by docs missing occult UTI's, it's caused by too many french fries. But if anyone can provide a study showing we're missing these UTI's and destroying kidneys I'm all for it.

I'd be reluctant to dismiss a UTI in the younger population. Part of the concern is that a UTI often represents an anatomical abnormality such as VUR which predisposes the kid to future UTIs and then renal scarring. You're right in there's no long term data, but there's plenty to say that we should be looking, and not knowing long term consequences doesn't mean we shouldn't care about an easily diagnosed and treated condition. Maybe not all of them go on to get hypertension, but what percentage would you care about? Here's a literature review on why we should care.

Here's a CHOP study looking at present of UTI in younger febrile children presenting to the ED.
And two articles on finding UTIs in the presence of RSV here and here . Note the in the presence of RSV serious bacterial infection, including meningitis appears to be less likely.
Another review suggesting UA be checked in fever without source.
And yet another review noting that UA is recommended in febrile children under 36 months.
Prevalence of SBI and UTI in febrile childen with non RSV 'clinical' bronchiolitis.
Australian study documenting presence of UTI in febrile children 3-36 months. Estimated around 5%.

So as far as I can tell, UTIs are out there, and we should probably be looking.

 

[WilcoWorld]

This begs the question of how to diagnose a UTI in pre-verbal kids. Since they can't tell you if they have symptoms, you need to go on the UA.

So what are your criteria for treating a kid's urine?

Obviously we'd all treat kid who has LCE, nitrites WBC's and bacteria in the UA, but what about kids with a catheterized sample, no LCE/Nitrite, but with only a few WBC's and some bacteria? I've seen plenty of variation on this one.

 

[docB]

I think the biggest downside of all the searching for utis would be the post cath strictures. If we're using bag UAs then it'd be the overtreatment due to all the contaminated samples.

 

[Seaglass]

This has been studied and I'm sorry I don't have the reference. For the micro it is >5 WBC on the unspun sample or bacteria on a gram stain. For some reason bacteria on the regular micro doesn't count.

 

[Seaglass]

Regarding the risk of complication - I looked up a bunch of studies on Pubmed - even in pediatric patients who self cath many times a day urethral stricture and other complications are extremely rare to the point where, for me at least, it would not be part of the risk-benefit analysis for the patient.

 

[kungfufishing]

This thread reminds me of an encounter a few weeks back. 40 day old, fever, "not right" per mom etc. Had seen pediatrician the day before, had a white count done, sent home and told was fine. I went ahead with a bigger workup due to mom stating the kid was worse and the return visit. In the ED, had a white count and the CSF was abnormal, so I called the pediatrician to admit. The pediatrician goes off the handle, yells (really!) at me saying "You are just trying to justify an unnecessary procedure with abnormal lab values!" Pretty bizarre. I don't think the CSF grew anything, but I'll never forget that one.

 

[Stitch]

Regarding the risk of complication - I looked up a bunch of studies on Pubmed - even in pediatric patients who self cath many times a day urethral stricture and other complications are extremely rare to the point where, for me at least, it would not be part of the risk-benefit analysis for the patient.

I agree. We cath everyone. Bags are worthless unless you're getting a UDS.

The pediatrician goes off the handle, yells (really!) at me saying "You are just trying to justify an unnecessary procedure with abnormal lab values!" Pretty bizarre. I don't think the CSF grew anything, but I'll never forget that one.

Crazy, man. Nice work putting the WBCs in the CSF. I never would have thought of that.

 

[roja]

I've noticed for several years that pediatricians always seem to want to order lots of stuff extra when I call them about their patients. I'm talking about stuff they wouldn't order when seeing the patient themselves. For example I just gave a peds a courtesy call to say that I'm discharging a 2 year old on some amox for a pharyngitis and he askes what the white count is. After I explained that I didn't stick the kid for a non-toxic presentation and a "fever" of 100.0 he said "Well, you really should get a CBC with a diff."

Aside from the fact that this won't change the management of the kid at all I think that these guys just have this attitude that sticking kids in the ED is really easy and quick and that every kid that rolls in needs a full work up. I know that these guys are not referring every pharyngitis and viral syndrome out to the lab for a draw. Why does it need to be done in the ED?

I generally politely explain that I will not be ordering the CBC, that I will give the patients instructions to follow up in their office tomm, where they can SEE the patient and if they still feel the CBC is warranted, they can draw it. Or I just say politely, something along the lines of 'Well, given the history and physical that I have done, I don't feel a CBC is warranted.' and just wait for about 30 seconds. the pause kills most people.

I just generally treat this kind of stuff with as much polite firmness that I can. (I managed not to laugh or loose it when an OB told me I should do a culdocentesis in a nonpregnant female with RLQ pain, wbc, and free fluid in the belly to rule out hemorrhagic cyst vs appy.) I am not a fast food restaurant: for patients or other physicians. (that said, if its reasonable, adn a tag on or something, I will help out)