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Peds ID Antibiotics Question of the Week

Peds ID Antibiotics Question of the Week is provided by the Harbor-UCLA Pediatric Infectious Diseases Division as part of their Antibiotic Stewardship program. Answer choices are centered around infectious causes and will not address non-infectious causes in the differential diagnosis.

6/19/17 question of the week

It is the middle of flu season, and a 3 year old female is brought in by mom for 3 days of fever, cough, congestion, decreased PO intake, emesis x 2. His exam shows fever, mild tachypnea and tachycardia, but he has good urine output. On exam, he also has diminished breath sounds to bilateral bases, mild subcostal retractions. CXR shows bilateral infiltrates, worse in bases.   The child is being admitted, which anti-infective(s) should be initiated in the ED?

a) Ceftriaxone alone

b) Oseltamivir alone

c) Ampicillin alone

d) Ampicillin and azithromycin

e) Ampicillin and oseltamivir

f) Ampicillin, azithromycin and oseltamivir

g) Ceftriaxone and oseltamivir

h) Ceftriaxone, vancomycin, and oseltamivir

Submit answers to HUCLAstewardship@gmail.com. Check back in a few weeks for answer/discussion.

6/12/17 question of the week

3 year old male with a “spider bite“ x2 days.  Mom states he has been scratching it and noted a small amount of blood yesterday. Today it is more red, swollen and painful.  Denies fever, chills.

Physical exam:  3cm x 4cm erythematous, edematous area to the dorsal aspect of the left arm.  There is a small punctate of dried/crusted blood.  It is mildly indurated, warm and tender to touch, no joint swelling or stiffness.

You should (choose all that apply):

a) Obtain blood cultures

b) Obtain wound cultures from I&D or aspiration

c) Treat with IV dose of clindamycin in ED, followed by oral regimen

d) Admit and start IV antibiotics

e) Send home with Rx for Bactrim or Clindamycin

f) Send home with Rx for Keflex plus Bactrim

g) Send home with Rx for Keflex

Submit answers to HUCLAstewardship@gmail.com. Check back in a few weeks for answer/discussion.

6/5/17 question of the week

It is early January and you are seeing a previously healthy 3yo F who presents with fever, nasal congestion, cough, and decreased PO intake for 4 days.  The child is febrile.  On exam, there are copious, thick yellow nasal secretions and you note inspiratory crackles bilaterally.  Otherwise, exam is unremarkable.
The caregiver reports that there are multiple sick contacts at home with fever, runny nose, cough, and myalgias.  A chest XR demonstrates hazy bilateral infiltrates.

You decide to (choose all that apply):

a) Start amoxicillin/clavulanate

b) Prescribe oseltamivir

c) Administer a dose of ceftriaxone

d) Send Respiratory PCR Panel (Biofire) testing

e) Obtain a urinalysis and urine culture

f) Supportive care with close follow up

Submit answers to HUCLAstewardship@gmail.com. Check back in a few weeks for answer/discussion.

5/29/17 question of the week

3 year old female is brought to the Peds ED by mom.  Mom states “she’s been sick for a month, her symptoms improve a little bit but then come back.”  Her PMD diagnosed her with a viral illness 1 week ago.  She has rhinorrhea, cough, subjective fever 2 weeks ago, and is tolerating PO’s. On exam, the patient has upper airway congestion, moderate nasal discharge, with an otherwise normal exam.  Mom is frustrated and insists on going home with antibiotics so “she can get better!” You would do the following (choose all that apply):

a) Order CBC

b) Blood cultures

c) Tell Mom the patient has sinusitis and treat with Augmentin for 10 days

d) Reassure mom that this is just a virus and recommend supportive care

e) Order a respiratory PCR panel (Biofire) and treat if with oseltamivir if positive for influenza

f) Tell Mom this is probably viral, and give her a delayed prescription for 10 days of amoxicillin in case it is sinusitis

Submit answers to HUCLAstewardship@gmail.com. Check back in a few weeks for answer/discussion.

5/15/17 question of the week

9 year old female with no significant PMH presents with 12 day history of nasal congestion and discharge, cough and intermittent low grade fevers.  Parents feel that her symptoms have not improved.  On exam she has thick, yellow mucus, mild tenderness with palpation over maxillary sinuses.  You should (choose all that apply):

a) Tell mom she has a viral URI

b) Order a Respiratory PCR panel (Biofire), treat if positive for influenza or atypical bacterial pathogens

c) Obtain a CT scan of the sinuses

d) Obtain a plain film of sinuses

e) Treat the with 1gm of ceftriaxone IM

f) Treat with Amox/Clav for 10 days

g) Treat with Amoxicillin for 10 days

For answer and discussion, go here

5/8/17 question of the week

7 y/o boy comes in with mom who reports she has noticed a rash on his knee.  He fell about 2 weeks ago, and the wound did not heal because he picks at the scab.  Prior to his bath mom noticed multiple honey crusted lesions on his legs.

You should (choose all that apply):

a)Prescribe Mupirocin ointment apply to affected area for 5-10 days (or until resolved)

b)Prescribe Keflex as there are multiple lesions

c)Prescribe Clindamycin or Bactrim alone as Staph aureus is more likely the cause

d)No need for treatment as this will likely resolve without problems

e)Culture the wound so that appropriate antibiotics can be selected

For answer and discussion, go here

5/1/17 question of the week

An 18mo M presents with 3 days of URI symptoms, fever, and ear tugging.  On physical exam, you appreciate an erythematous, fluid-filled right tympanic membrane.  The patient has had one prior episode of OM at 9 mos of age, treated by the patient’s pediatrician.

The appropriate first-line antimicrobial therapy is:

a) Azithromycin for 5 days

b) Ceftriaxone single dose IM

c) Amoxicillin low dose for 10 days

d) Amoxicillin high dose for 10 days

e) Amoxicillin/clavulanate high dose for 10 days

f) Amoxicillin/clavulanate low dose for 10 days

For answer and discussion, go here

4/24/17 question of the week

14 y/o presents with sore throat and fevers. Exam with exudative pharyngitis, no lymphadenopathy.  Reports a lot of people sick at school.  Denies any cough, congestion or rhinorrhea.

You should (choose all that apply):

a) Do nothing and treat symptomatically

b) Perform rapid Influenza, if positive treat with Tamiflu

c) This is possibly strep pharyngitis, do a rapid Strep test and treat if positive

d) Centor Criteria suggest high probability, no need to test, treat for strep

e) Send Serology for EBV

f) Send a Monospot

For answer and discussion, go here

4/17/17 question of the week

A 17 year old male comes in with a 5 day history of URI symptoms and reports abdominal pain and fever of 101.4 today.  He was seen by his PMD two days ago and was told he had a virus. He is febrile with crackles in bilateral lower lung fields.  CXR with bilateral infiltrates.

You should (choose all that apply):

a) Order a respiratory PCR panel (Biofire)

b) Treat with Augmentin

c) Treat with Azithromycin

d) Treat with Levofloxacin

e) Treat with Amoxicillin and Azithromycin

f) Order a Pneumococcal urine antigen

For the answer and discussion, go here

4/10/17 question of the week

You are called by lab for a patient with a urine positive for ESBL E. coli, susceptible only to fosfomycin, amikacin and meropenem.  The colony count was 20,000 cfu/mL.  Reviewing the patient’s chart, you discover that the patient is an 22mo F with a history of febrile UTI when she was 12mo and that she presented to the ED 3 days ago with fever and minimal URI symptoms.  A urine dip on a bag specimen at that time demonstrated 2+ leukocyte esterase, positive nitrites.  There was not enough urine for microscopy.

You should:

a) Recommend that the patient return to provide a catheterized specimen for urinalysis

b) Discuss with parent and provide return precautions

c) Call in a prescription for a single dose of fosfomycin to the patient’s pharmacy, and recommend routine follow up with her Pediatrician in 2-3 days

d) Recommend that the patient return for IV antibiotics and admission to preform ultrasound

For the answer and discussion, go here