If you’re looking to bring your clinical game to the next level, look no further than this next episode where we’ll discuss three huge areas of medical overuse. By the end of the episode, you’ll know pneumonia, cellulitis, blood cultures, and more than you’d ever expect about constipation. We welcome Drs. Leonard Feldman and Carrie Herzke back to the podcast, both TWDFNR authors, to explore and educate us on these topics. Listen along here, and follow us @TheCribsiders on #MedTwitter!
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Blood cultures are often useful in severe infections because they can identify an organism that is driving the illness, allowing the provider to tailor antibiotic therapy towards the pathogenic organism. In fully vaccinated children (particularly HiB vaccination), only 3 of 100 children will grow out an organism, which is oftentimes a contaminant that will not help with your therapy. Overarchingly, 3% of blood cultures drawn in children result in a contaminant.
Dr. Herzke lays out some instances in which blood cultures may be more beneficial than harmful:
Dr. Herzke’s bonus Things We Do For Good Reason: Treatment with high-dose ampicillin. It has better coverage and penetration for S pneumo than ceftriaxone!
If most CAP in toddlers is caused by viruses, should I obtain a RVP?
In a study of pediatric gastroenterologists, 70% would obtain an x-ray to evaluate for stool burden. Yet, the diagnosis of constipation remains clinical delineated by the history (think Rome IV criteria) and physical examination. Alternatively, the x-ray can be misleading with patients having a “moderate stool burden” who have regular, Bristol 4 stools. Indeed, a study in 2010 evaluated different clinical scores and their ability to differentiate between constipation and non-retentive fecal incontinence, and they found that the x-rays did not aid in the diagnosis, which suggested that patients may be undergoing unnecessary radiation.
Dr. Feldman’s expert opinion: There is currently no evidence that performing a digital rectal examination in patients suspected to have constipation helps in the diagnosis, so you should feel comfortable not making it a routine part of your examination.
While constipation is a clinical diagnosis, there may be concerning items on your differential (even if less likely), such as small bowel obstruction, where it may be appropriate to obtain an x-ray. Be sure to do so!
Dr. Herzke lays out her approach to diagnosing and managing cellulitis as follows:
The original studies that examined cellulitis and showed a significant portion of Staph infections were based on wound cultures, meaning that they included predominantly patients with purulent cellulitis. Thus, purulent cellulitis is predominantly caused by MRSA and MSSA; on the other hand, non-purulent cellulitis is predominantly caused by Strep species that are oftentimes not included in the spectrum of activity of oral antibiotics that treat MRSA.
For the treatment of non-purulent cellulitis in the immunocompetent patient, the recommendations state that a cephalosporin is appropriate, specifically cefazolin (IV) or cephalexin (PO). For cephalexin, you can utilize the TID dosing rather than the QID dosing. Sufficient therapy is 5 days rather than the 10 days that is sometimes prescribed.
For the treatment of purulent cellulitis, you can utilize TMP-SMX, doxycycline, and clindamycin, though with clindamycin one must check the susceptibilities for MRSA since it is highly resistant in some patient populations. Dr. Herzke’s expert opinion is that she does not double-cover for Strep in these patients since the pathogenic organism is typically Staph.
Cellulitis is typically a localized infection that does not result in bacteremia. Thus, the rate of positive blood cultures is approximately 0.4 to 2.9% in immunocompetent children. Thus, you oftentimes do not identify a pathogenic organism, and there are additional costs. For each contaminated blood culture (3% of all cultures in children), it costs the hospital approximately $8,000 to $11,000 that does not even account for the typical increased length of stay associated with empirically treating a bacteremia. One hospital based study demonstrated that reducing blood culture contamination by one percent saves $50,000 per month.
Listeners will explain three clinical scenarios of low-value care and be able to more effectively manage these scenarios in the future.
After listening to this episode listeners will…
Dr. Feldman and Herzke report no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Lee N, Herzke C, Feldman L, Chui C, Berk J. “Things We Do For No Reason in Pediatrics”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ 3/17/2021
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This podcast is excellent and very informative! I work as a primary care pediatric nurse practitioner and am continuing onward for my pediatric acute care certification so everything I hear applies in one place or the other. Thank you for a wonderful CE podcast that is far from being dry or boring! Of note, on VCU the quiz for CE that accompanies episode 21 contains a trio of questions that do not apply to any of the topics discussed and may be mixed up with another episode.