Hot Seat #200: Tip-Toeing Around the Tap
Posted on: November 28, 2022, by : Walter Palmer
By Dr. Timothy Carr, Children’s National Medical Center
You receive a call about a 2 ½-month-old girl presenting to an outside hospital for 2 days of fever, cough, nasal congestion. Tmax at home 39.5 C. Patient has been feeding, voiding, stooling normally. No respiratory support needed. Patient with no medical problems. No regular scheduled medications. No surgeries. Patient born at 38 GA via spontaneous vaginal delivery with negative serologies per mom. No herpetic lesions at time of birth. Negative Group B Strep. Patient had normal newborn nursery course and has been growing and developing normally from that time. Patient has had 2-month vaccinations thus far. No medication allergies.
Patient initially febrile to 39.4 C with associated tachycardia which normalized after defervescence. On current exam per provider, patient afebrile with normal heart rate, blood pressure and respiratory rate. Well appearing with normal HEENT, heart, lung, abdominal, and peripheral vascular exam. The only notable finding is mild nasal congestion and intermittent cough. Feeding well without distress and has had several wet diapers since being in the emergency department.
The provider you’re speaking with recently read an article about the new PECARN criteria and asks you whether this child is appropriate.
Based on or despite your recommendations, the outside hospital obtains CBC, procalcitonin, urinalysis, urine culture and blood culture.
CBC: 13>12/35<275 (ANC 1.2K)
Procalcitonin: 0.3
Urinalysis (catheterized): 25 WBC, +LE, +nitrites
Patient was given first dose of PO cephalexin and sent home to follow up with a scheduled PCP appointment the following day.
[Fast-Forward One Day]
The following day, the same provider calls you saying the patient is back in their ED after a positive blood culture with gram negative rods growing after 18 hours on culture medium. The urine culture is positive for E. coli, sensitive to prescribed cephalexin. The patient still looks well and is feeding well. Parents have been taking the temperature regularly and max temperature is 38.1 C at home and is overall down trending. Patient is afebrile in the ED with normal vital signs. Urinalysis shows 10 WBC (down from 25 WBC), still positive for LE and nitrites. CBC, Procalcitonin are similar from yesterday. The provider is asking whether a lumbar puncture is indicated for this child.
Interesting clinical question! It is reassuring that the fever curve seems to be downtrending and infant is well appearing. You must assume this is E. Coli bacteremia so an outpatient disposition does not seem appropriate. I’m not sure how to use the procal to guide my decision making as the PECARN rule is for infants <60 days. I would recommend repeating the blood culture, LP and admit for IV antibiotics. Another option would be to discuss this case with the hospitalist who can offer a great inpatient perspective. I look forward to the discussion!
What makes this interesting is that the child is clinically improving at home on PO antibiotics, although I don’t know if I’d call 18 hours enough time to determine a decisive trend in the fever curve. I’m surprised the labs (especially the procal) didn’t look worse initially. Kudos to that lab on having sensitivities so quickly! I would be inclined to admit this patient for parenteral antibiotics because of their age, admitting to myself that the key reasons for admission are for observation of clinical improvement and awaiting sensitivities; two boxes which are sort of already checked. The age just gets me. This might be a case where the correct answer depends on things like family vigilance/health literacy, close outpatient follow-up, PMD comfort, proximity of the patient to a hospital, etc.