jump to navigation

Diagnostic sensitivity of ED clinical assessment — Brain Teaser. Do you know the answer? November 26, 2018

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing pediatric bacterial meningitis.


 

Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

Sign up for our email list below to get updates on future blog posts!

10 Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis November 19, 2018

Posted by Andy Jagoda, MD in : Feature Update , add a comment

The presentation of bacterial meningitis can overlap with viral meningitis and other conditions, and emergency clinicians must remain vigilant to avoid delaying treatment for a child with bacterial meningitis. Here are 10 risk management pitfalls to avoid and 3 time- and cost-effective strategies for when you’re managing pediatric patients with bacterial meningitis.

10 Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis

1. “The patient is sleeping. I don’t want to wake her up to perform a neurological examination.”

The neurologic assessment of the young child can be difficult, even under optimal circumstances. If you are performing this evaluation when a child is fearful or when they should be sleeping, it can be even more challenging and requires patience and, frequently, a dedicated period of observation for reassessment. Efforts should also be made to provide distraction to reduce the amount of fear or inhibition caused by the hospital environment to allow the most accurate examination possible. This distraction can be provided by family interaction with the child or by having the child play independently with a toy.

2. “The patient has inflamed tympanic membranes. The fever and irritability are likely due to otitis media. It’s not meningitis.”

Many young children with bacterial meningitis can have concomitant inflammation in other areas on physical examination or diagnostic study. Otitis media and upper respiratory tract infections are common enough conditions that their presence can lead the emergency clinician to “explain away” the child’s more serious symptoms as being due to those pathophysiologic findings. Anchoring on a simpler, less severe diagnosis can result in missing or delaying the correct diagnosis.

3. “The patient likely had a febrile seizure. I can’t get a neurological examination in his postictal state.”

Delay during decision-making can result in harmful diagnostic or therapeutic delay. A high-risk scenario can develop while waiting for a postictal child to awaken from a febrile seizure to perform a thorough neurologic examination and determining the need for a lumbar puncture or empiric antibiotics. The large majority of patients with simple febrile seizure are going to awaken to a baseline neurologic state within 1 to 2 hours after the seizure. Is the patient who is still “sleeping” 2 to 3 hours after a febrile seizure postictal, or is the patient progressing to a state of unresponsiveness? Patients who behave in this manner after a complex febrile seizure can be particularly concerning, and a lower threshold of lumbar puncture should be considered.

4. “This patient’s neck stiffness or meningismus is likely due to pharyngitis or ‘flu-like’ symptoms.”

Pharyngitis and other viral illnesses can also give a clinical presentation of neck stiffness. Meningismus is not specific to meningitis. Emergency clinicians can be inundated with patients presenting with neck stiffness during the winter months, and it is important to be vigilant for any other clues that seem disproportionate to a normal viral illness.

5. “The patient has a normal WBC count, so I don’t need to be worried about meningitis.”

In isolation, the absence of leukocytosis or leukopenia is an inadequate tool by which to make clinical management decisions. The peripheral blood absolute neutrophil count can be used in combination with other elements of the bacterial meningitis score to guide initial decision-making while awaiting results of CSF culture.

6. “The patient likely has viral meningitis, so we don’t need to get a lumbar puncture.”

The notion that emergency clinicians can distinguish the difference between viral and bacterial meningitis based on the history and physical examination is not supported by the available evidence. The clinical overlap of these conditions is substantial, particularly early in the course of illness. Diagnosis should not be made based on the history and physical examination alone.

7. “I did not consider group B Strep in my differential for this perinatal infant.”

GBS infection must be considered in any febrile infant in the first 2 months of life, even after maternal treatment of colonization.

8. “We need to wait for a CT scan and lumbar puncture before we can give antibiotics, as they can cause sterilization of CSF.”

When caring for a patient with a presumptive diagnosis of bacterial meningitis, do not delay administration of appropriate antibiotics for the completion of a CT scan or lumbar puncture or for the results of these studies. Although antibiotics may obscure the ultimate bacteriologic diagnosis, this is a small clinical price to pay to prevent further bacterial proliferation and inflammation within the CNS.

9. “We don’t need to consider tuberculosis or fungal meningitis.”

Meningitis due to atypical pathogens such as Mycobacterium tuberculosis can be notoriously insidious and indolent in presentation. Consider these pathogens, particularly in patients with immunodeficiency, patients traveling from high-risk parts of the world, or, in the case of tuberculosis, those with prolonged contact with an infected individual.

10. “My patient has a positive urinalysis. This is clearly just a UTI. I don’t need to consider any other diagnoses.”

While concomitant UTIs are rare, they do occur. In a recent study involving 1737 infants aged 29 to 60 days, concomitant UTI with bacterial meningitis occurred 0.2% of the time, and was more prevalent in infants aged 0 to 28 days.90

3 Time- And Cost-Effective Strategies For Pediatric Patients With Bacterial Meningitis

Reference:

90. Thomson J, Cruz AT, Nigrovic LE, et al. Concomitant bacterial meningitis in infants with urinary tract infection. Pediatr Infect Dis J. 2017;36(9):908-910. (Retrospective study; 1737 infants)

Sign up for our email list to get updates on future blog posts!

Which empiric antibiotics to use? — Pediatric Bacterial Meningitis Conclusion November 14, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far
Case Recap:
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
.
Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
.
Case Conclusion:
The 4-month-old boy with a history of cough, pallor, fever, and decreased feeding was placed in a warmer on a cardiorespiratory monitor with continuous pulse oximetry. His heart rate and respiratory rate rose and his degree of responsiveness declined. You decided the patient needed a lumbar puncture, knowing that vital sign abnormalities and subtle neurologic changes can be the first signs of bacterial meningitis in this age group. After obtaining consent from the mother, CSF was obtained on the first attempt, and was visibly purulent. The CSF WBC count was 2257 with 85% polys. The CBC showed a peripheral WBC of 9.9, Hb of 9, and platelets of 329,000. A CSF Gram stain revealed gram-positive cocci in pairs and occasional chains. You immediately suspected pneumococcal meningitis and initiated IV dexamethasone 0.15 mg/kg and IV cefotaxime 100 mg/kg and admitted the patient to the PICU. The CSF grew S pneumoniae that was sensitive to cefotaxime. Over the next 24 hours, the patient developed respiratory failure and progressive cerebral edema, the complication that you feared most. Over the next several days, his cerebral edema was unresponsive to therapy and the child died on the seventh day of hospitalization due to this complication.
.
Sign up for our email list below to get updates on future blog posts!
.

Which empiric antibiotics to use? — Pediatric Bacterial Meningitis November 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 8comments
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
.
Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
.
Sign up for our email list below and come back on Nov 13th to see if you got it right!
.

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 12-16-2018
© EB Medicine