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2020 Pediatric Hospital Medicine Advanced Practice Providers Virtual Conference
Presented in part by the AAP SOHM Subcommittee for Advanced Practice ProvidersChair: Leah Rawdon DNP, APRN, CPNPVice Chair: Rebecca Carlson MAN, APRN, CPNPVice Chair: Jodi Lohrey MSN, APRN, CFNP
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Please open and use the Q&A function for any questions or comments you have pertaining to the conference topics. We will address these throughout and at the end
of the presentation.If you have technical difficulties with Webex, please contact Caitlin Schweder via the
chat function or you can email her at cschweder@aap.org
AgendaOctober 30th Central Standard Time
12:00 -12:10: Introductions, discuss goals and objectives for the day
12:10 -1:20: Pediatric Hospital Medicine Top 10: Review and Updates of the Most Frequently Encountered Diagnoses
1:20 -2:30: CBC with differential; interpretation leading to antibiotic therapy considerations.
2:30 -3:00: Ending remarks with an introduction from the Chair of the AAP Section on Hospital Medicine; H.Barrett Fromme, MD, MHPE. We will conclude with APP subcommittee updates.
Goals and Objectives for the Day:● The Conference provides an opportunity for APPs and other related providers to meet
specific learning needs while accommodating the ability to network with others in the field. ● Pediatric Hospital Medicine Top 10
○ Faculty will review current standards of care for the most common diagnoses in PHM, and highlight the most recent updates and changes to national guidelines.
○ They will also discuss recent research related to these diagnoses and changes that may be coming to practice
● CBC with differential and Culture Results○ Faculty will discuss interpretation leading to antibiotic therapy considerations and also review
components and interpretation through didactic education and case studies.○ They will also discuss abnormal results and considerations based on lab work; and also review
culture interpretation, identification of organism, and appropriate antibiotic choice based on lab findings and diagnosis
PEDIATRIC HOSPITAL MEDICINE TOP 10
Presented by: Rebecca Carlson, MAN, APRN, CPNP&
Abigail Burkett Vetter, MSN, APRN, CPNP-AC/PC
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We have no relevant financial relationships to disclose.
Disclosure
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• Review current standards of care for the most common diagnoses in Pediatric Hospital Medicine (PHM).
• Highlight recent updates and changes to national guidelines for the care of hospitalized children with these diagnoses.
• Examine current research and literature and identify changes that may be relevant to practice.
Learning Objectives
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• Reviewed AAP Guidelines and other organizational guidelines when appropriate.
• Consulted the Red Book and Cochrane Reviews when available.
• Reviewed articles from 2018-2020 from journals with the top 5 highest impact factors related to PHM
Our Process
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• Number of Advanced Practice Providers (APPs) are increasing.• 15.3 APPs/100 MDs in 2001• 28.2 APPs/100 MDs in 2016• 53.9 APPs/100 MDs in 2030
• Increasing number of hospital medicine services utilizing APPs
• APPs are filling a variety of rolls within PHM
State of APPs in PHM
33.3% in 2016 41.7% in 2018
Resident Team
Independent Rounding
Complex Care Team
Consult Service
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1 - Bronchiolitis
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• Viral lower respiratory tract infection• Inflammation, edema, necrosis of epithelial cells, increased mucous production• Most common reason for hospitalization
in children <12 months• Estimated $1.73 billion
per year in hospitalizations
Bronchiolitis Fun Facts
Virus Type
RSV Rhinovirus InfluenzaHMV Coronavirus Parainfluenza
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Bronchiolitis 2014 AAP Clinical GuidelinesDefinitely Maybe Definitely Not
Assess for risk factors 3% hypertonic saline Routine labs/radiographs
NG or IV fluids (if poor PO) Measure O2 sats Albuterol *
Racemic epinephrine
Systemic corticosteroids
Chest physiotherapy
Antibiotics *
BRONCHIOLITIS -NEVER HAVE I
EVER…• Given an albuterol neb• Performed bronchial drainage• Ordered steroids• Given hypertonic 3% saline
nebulizer
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3% Saline – Does it help?
Continuous vs. intermittent pulse oximetry and LOS: decrease LOS by 20 hours,
increased readmission from 3.3%-5%
HFNC on the floor?
Coronavirus & Bronchiolitis
Bronchiolitis: What’s New?
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2 -Croup
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Croup
• The most frequent cause of laryngotracheitis is parainfluenza• Standard treatment consists of:
– Decadron 0.6 mg/kg– Nebulized racemic epinephrine
• Cochrane Review 2018– Steroids improved symptoms at 2 hours and lasted at least 24 hours– Children given steroids less likely to have return visits compared to placebo
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Croup
https://www.childrensmn.org/ref erences/cds/croup-guideline-age-3-months-8-y ears.pdf
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Croup – How many racemic epinephrine nebs?
Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment.
https://w ww.childrensmn.org/references/cds/croup-guideline-age-3-months-8-years.pdf
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• Imaging/Labs/viral testing:– Drooling, tripod, trismus, limited neck ROM, lethargy or agitation
• Repeat Decadron dosing– Once? – Sure– More than once? – Hmmm…
Croup – When to do More
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Brief Resolved Unexplained Event
3 - BRUE
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Never Have I Ever…
• For a child admitted for BRUE• Skipped CPR training for parents • Done a swallow study• Assumed it was GERD• Prescribed GERD medication• Told a parent to chillax
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BRUE Guideline
• AAP 2016
• ALTE = BRUE
• Low risk infants
25
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2016 Low-risk BRUE Guidelines
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ALTE vs BRUEComparison of ALTE criteria to BRUE criteria
78 patients met ALTE criteria
Only 1 met BRUE criteria Most instances did not meet because event was not truly unexpected
Importance of thorough H&P
Use of BRUE criteria decrease admissions
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Higher-risk BRUE
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Post-BRUE
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4 – SSTISkin and Soft Tissue Infections
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IV antibiotic choice for infants
Combination = Staphylococcal coverage plus broad spectrum/neonatal sepsis abx to cover gram negative organisms
More likely to have fever and CSF testing LOS and cost 35-40% higher
Those receiving staphylococcal coverage alone
More likely infection
In infants <60 days of age utilization of combination therapy of IV antibiotics
Increased LOS Increased cost But not necessarily 30 day readmission
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Decolonization*• Those with MRSA colonization are at high risk for SSTI• Decolonization protocols are effective in eradicating colonization• But…
•Do not prevent recolonization or recurrence of MRSA infection
• High Risk for MRSA recurrence:• Personal or family hx of MRSA infection or abscess • Hispanic ethnicity• Fever on admission
• Decolonizing just MRSA pt not inferior to decolonizing every household member
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Tests aren’t needed
Yes No Maybe soHx and exam only for Dx
Blood cultures CBC, CRP, ESR
Use pathway
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Observations and 3-4 doses
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5 - Asthma
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AsthmaTranslating complex care guidelines into routine practice:• NHLBI Expert Panel Guidelines 2007• An International Consensus on Pediatric
Asthma 2012• British Thoracic Society/Scottish
Intercollegiate Guideline Network 2016• Global Strategy for Asthma Management and
Prevention 2017• The National Institute for Health and Care
Excellence asthma guideline consultation 2017• Global Initiative for Asthma (GINA) 2019
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Assessseverity using
a scoring tool
O2 if hypoxic
Give albuterol,
ipratropium & steroids
Consider magnesium,
or pulmonary
consult
Discharge on controller
when indicated
Asthma
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Vaccines: PPSV 23?Discharge criteria: Q4h?
Asthma
GINA 2019 Guidelines
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6 - Gastroenteritis
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Gastroenteritis - JAMA Clinical Guideline 2017Fluid Choice When to Test When to Treat Empirically Additional Therapies
ORS is preferred for mild-moderate dehydration
Fever or signs of sepsis <3 months with suspected bacterial infection
Consider antiemetics if patient >4
Consider NG for ORS Bloody or mucous stool Recent international traveler with fever
Consider probiotics
Isotonic IVF if severe dehydration, altered LOC, or ileus
Severe abdominal pain or tenderness
Ill appearing and suspected Shigella
Zinc
Human milk for infants *Recent travel, current outbreak, or immune compromise
*Avoid if Shiga toxin producing E. Coli
Return to age appropriate diet ASAP
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GastroenteritisProbiotics – Are they doing anything?• Multicenter, double blind, RCT with 886 participants
– 5 days of BID combination probiotic– No significant difference in development of moderate to severe diarrhea in 14 days
• Multicenter, double blind, RCT with 943 participants– 5 days of BID Lactobacillus rhamnosus– No significant difference in duration of diarrhea or vomiting, missed day care days, or rate of household transmission
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7 - Febrile Infant
43
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Clinical Pathways
• Implementation of a clinical pathway resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs
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Febrile InfantFebrile infants without an identifiable source of fever Risk = 7%.
Distinct viral syndrome Low risk <1%
CRP and PCT Improve clinical decision-making
Among infants treated for UTI without CSF testing No cases of delayed meningitis
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Prediction Rule
Low Risk Prediction Rule
• Normal urinalysis• Absolute neutrophil count
≤4090/μL• Serum procalcitonin ≤1.71
ng/mL.• No meningitis was missed
Low Risk
• Normal urinalysis result• Absolute neutrophil count
<5185 cells per μL• A temperature <38.5°C • Fever by history only
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To LP or not to LP
Shared decision-
making with parents
Although ∼0.5% of all febrile infants have
bacterial meningitis, prevalence
among infants classified as low risk by these
algorithms may approach 0%
Poor outcomes• Hx of
prematurity
• Ill appearance
• Bacterial meningitis
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Dipstick UTILow sensitivity
Negative UA + Positive UCx = increased LOS• More likely to be contaminant• Does not follow current recommendations
Positive nitrite test independent risk factor for IBI
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8 - Urinary Tract
Infections
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UTI
Repeated infections can cause renal scarring
1Long term use of prophylactic abx may reduce symptomatic recurrence
2Long-term low-dose use of abx should be reserved for high risk •Young infants•Children with renal abnormalities
3
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Recurrent febrile UTI
Duration of fever prior to treatment
Presence/grade of VUR
Certain gene polymorphisms
• Procalcitonin• MMP-9• TIMP-1• Angiotensinogen• Endothelin – 1/Cr• IL-8• NGAL
Non-invasive biomarkers
Renal Scarring Risk Factors
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Narrow spectrum antibiotics are ok to use while waiting culture results
Typically resistant to 3rd gen cephalosporins
Risk factorsLower rates of
appropriate empiric antibiotic therapy
Higher rate of hospitalization
Higher rate of having undergone VCUG
Higher rate of recurrence in 30 days
Antibiotic Resistance
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Duration of IV Antibiotics
Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics
Did not have more frequent recurrent UTIs or hospital reutilization
Short-course parenteral therapy with early conversion to oral antibiotics
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Renal Bladder Ultrasound
After first febrile UTI in child 2- 24 mo• Not cost effective• Defer until after 2nd febrile UTI
Only 64% accurate
91pts would need to be screened to prevent 1 recurrent UTI
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Concurrent Infection with Positive Viral Illness
If low risk for UTI
Less than 1% chance of having UTI
UTI evaluation not required
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9 – Community Acquired
Pneumonia
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CXR and ABX in CAP
Good news
ABX are being prescribed appropriately, per guidelines
Bad News
More CXRs are obtained than
necessary
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CAP Diagnostics
• US saves time and money• Decreased ED LOS
Lung Ultrasound vs CXR
• Can differentiate between consolidation and atelectasis• Less accurate at lung abscesses d/t user experience
US
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Prediction of severityUse of biomarkers to predict CAP severity• WBC• ANC• CRP• Procalcitonin
Not generally useful
CRP and procalcitonin• Good at identifying
• Empyema requiring chest drainage• Sepsis requiring vasoactive infusions
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CAP and Bacteremia
• No routine blood cultures
Decreasing prevalence of bacteremia in children
• Complicated CAP: empyema, abscess, fistula, or metastatic complications• Requiring ICU care for shock and/or advanced respiratory support• Concern for pathogens other than penicillin sensitive S. pneumonia, immunocompromised, under-
immunized, inadequate response to empirical ampicillin
Get a blood culture from the following:
Procalcitonin elevated in those with bacteremia
Only 2.2% of BCx identify causative organism
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10
PALS IV Fluids
• 2018 AAP Guideline
–“Patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate KCl and dextrose because they significantly decrease the risk of developing hyponatremia.”
BMV is reasonable compared with advanced airway during cardiac arrest in the out of hospital setting
ECPR for pediatric patients with cardiac diagnoses
Comatose after cardiac arrest
TTM 32oC –34oC or to use TTM 36oC to 37.5oC.
PALS IV Fluid Management
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Questions?
CONTACT INFORMATIONRebecca Carlson, MAN, APRN, CPNPChildren’s Minnesota rebecca.carlson@childrensmn.org
Abigail Burkett Vetter, MSN, APRN, CPNP-AC/PCChildren’s MinnesotaNorth Dakota State Universityabigail.burkettvetter@childrensmn.orga.burkettvetter@ndsu.edu
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References1. Auerbach D.I., Staiger, D.O., & Buerhaus, P.I. (2018). Growing ranks of advanced practice clinicians - implications for the
physician workforce. The New England Journal of Medicine. 378, 2358-2360.2. State of hospital medicine report. (2018). Society of Hospital Medicine.
Bronchiolitis1. Ralston, S.L., Lieberthal, A.S., & Meissner, H. C. (2014). Clinical practice guideline: The diagnosis, management, and
prevention of bronchiolitis. Pediatrics, 134(5), e1474-e1502. Retrieved from https://pediatrics.aappublications.org/content/134/5/e1474
2. House, S. A., Gadomski, A. M., & Rawlston, S.L. (2020). Evaluating the placebo status of nebulized normal saline in patients with acute viral bronchiolitis. JAMA Pediatrics, 174(3), 250-259. doi:10.1001/jamapediatrics.2019.5195
3. Harrison, W., Angoulvant, F., House, S., Gajdos, V., & Ralston, S.L. (2018). Hypertonic saline in bronchiolitis and type I error: A trial sequential analysis. Pediatrics, 142(3):e20181144.
4. Mittal, S., et al. (2019). Successful use of quality improvement methodology to reduce inpatient length of stay in bronchiolitisthrough judicious use of intermittent pulse oximetry. Hospital Pediatrics, 9(2) 73-78.
5. Kalburgi, S., & Halley, T. (2020). High Flow Nasal Cannula Use Outside of the ICU Setting. Pediatrics,https://doi.org/10.1542/peds.2019-4083
6. Leyenaar, J.K., & Ralston, S.L. (2020). Widespread Adoption of Lo—Calue Therapy: The Case of Bronchiolitis and High Flow Nasal Cannula. Pediatrics. https://doi.org?10.1542/peds.2020-021188
7. Mansbach, J.M., et al. (2020). Severe Coronavirus Bronchiolitis in the Pre-COVID-19 Era. Pediatrics.https://doi.org/10.154/peds.2020-1267
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ReferencesCroup1. American Academy of Pediatrics. (2020). Parainfluenza Viral Infections. In The Red Book 31st Edition. American Academy of Pediatrics (593-595).
https://redbook.solutions.aap.org/chapter.aspx?sectionId=189640147&bookId=2205&resultClick=1
2. Colin, P.M., Cooper, M.N. (2019). Prednisolone versus dexamethasone for croup: A randomized controlled trial. Pediatrics, 144(3), 1-11.3. Gates, A., Johnson, D.W., Klassen, T.P. (2019). Glucocorticoids for croup in children. JAMA Pediatrics, 173(6), 595-596.4. Gates, A., Gates, M., & Vandermeer, B.. (2020). Glucocorticoids for croup in children. Cochrane Library. https://doi.org/10.1002/14651858.CD001955.pub4
5. Hester, G., Zenker, P., Chawla, S. (2019). Clinical guideline: Croup (age 3 months-8 years). https://www.childrensmn.org/references/cds/croup-guideline-age-3-months-8-years.pdf6. Hester, G., Barnes, T., O’Neill, J., Swanson, G., McGuinn, T., Nickel, A. (2019). Rate of airway intervention at a tertiary children’s hospital 2015-2016. The Journal Of Emergency Medicine, 57(3), 314-321.
7. Asmundsson, A.S., Arms, J., & Kaila, R. (2019). Hospital course of croup after emergency department management. Hospital Pediatrics, 9(5), 326-3328. Weatherly, J., Song, Y., Meister, K., and Berg, M. (2019). The runaway croup train: Off the pathway and into the woods. Hospital Pediatrics, 9(10), 820-823.
9. Tyler, A. et al. (2017). Variation in inpatient croup management and outcomes. Pediatrics, 139 (4), e20163582.
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ReferencesBRUE:
1. Khan, A. et al. (2018). Caregivers’ perceptions and hospital experience after a brief resolved unexplained event: A qualitative study. Hospital Pediatrics, 9(7), 508-515. doi: https://doi.org/10.1542/hpeds.2018-0220
2. Ari, A. et al. (2019). Long-term follow-up of infants after a brief resolved unexplained event-related hospitalization. Pediatric Emergency Care, 35(11), 765 – 768.
3. Duncan, D. R. et al. (2019). The impact of the american academy of pediatrics brief resolved unexplained event guidelines on gastrointestinal testing and prescribing practices. The Journal of Pediatrics, 211, 112-119.
4. Gerber, N. L., Fawcett, K.J., Weber, E. G., Patel, R., Glick, A. F.,Farkas, J. S., & Mojica, M. A. (2020) Brief resolved unexplained event. Pediatric Emergency Care. DOI:10.1097/PEC.0000000000002069
5.. Merritt, J. L. et al. (2019). A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics, 144(2), e20184101. doi: https://doi.org/10.1542/peds.2018-4101
6.. Oglesbee, S. J. et al. (2020). Implementing lower‐risk brief resolved unexplained events guideline reduces admissions in a modeled population” Journal of Evaluation in Clinical Practice, 26, 343–356.
7. Sethi, A., Baxi, K., Cheng, D., Laffey,S., Hartman, N., & Heller, K. (2020). Impact of guidelines regarding brief unexplained events on care of patients in the emergency department. Pediatric Emergency Care, DOI: 10.1097/pec.0000000000002081
8. Soung, J., Ramgopal, S., & Pitetti, R. (2019). Patients with apparent life threatening events meeting criteria for brief resolved unexplained event. Pediatrics, 19(8), 963-968.
9. Tieder, J.S. et al. (2016). Clinical practice guideline: Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: Executive summary.” Pediatrics, 137(5), e20160591. doi: https://doi.org/10.1542/peds.2016-1488
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ReferencesSSTI:1. Begem Lee, D. et al. (2020). Reducing unnecessary testing in uncomplicated skin and soft tissue infections: A quality improvement approach. Hospital Pediatrics, 10(2),129 – 137. doi: https://doi.org/10.1542/hpeds.2019-01792. Girdwood, S.T. et al. (2019). Improving the transition of intravenous to enteral antibiotics in pediatric patients with pneumonia or skin and soft tissue infections. Journal of Hospital Medicine, 15(1), 10-15. doi: 10.12788/jhm.32533. Hogan, P.G., Parrish, K.L., Mork, R.L., Boyle, M.G., Muenks, C.E., Thompson, R.M., Morelli,J.J., Sullivan,M.L., Hunstad, D.A., Bubeck Wardenburg, J., Rzhetsky, A., Gehlert, S.J., Burnham, C.D., & Fritz, S.A. HOME2 Study: Household Versus Personalized Decolonization in Households of Children With Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infection—A Randomized Clinical Trial, Clinical Infectious Diseases https://doi.org/10.1093/cid/ciaa7524. Markham, J. L. et al. (2019). Variation in antibiotic selection and clinical outcomes in infants <60 days hospitalized with skin and soft tissue infections. Hospital Pediatrics, 9(1), 30-38. doi: https://doi.org/10.1542/hpeds.2017-02375. Papastefan, S.T. et al. (2019). Impact of decolonization protocols and recurrence in pediatric MRSA skin and soft-tissue infections. Journal of Surgical Research, 242, 70-77. https://doi.org/10.1016/j.jss.2019.04.0406. Yusuf, S. et al. (2019). Managing skin and soft tissue infections in the emergency department observation unit. Pediatric Emergency Care, 35(3), 204-208. doi: 10.1097/PEC.0000000000000975
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ReferencesAsthma1. Nkoy, F. L., Wilkins, V.L., & Fassl, B. A. (2019). Contextual factors influencing implementation of evidence-based care
for children hospitalized with asthma. Hospital Pediatrics, 9(12), 949-957.2. Tesse, R. et al. (2018). Treating pediatric asthma according to guidelines. Frontiers in Pediatrics, 6,
234. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115494/3. Seattle Children’s. (2018) Asthma v7.0. https://www.seattlechildrens.org/pdf/asthma-pathway.pdf4. Connecticut Children’s Medical Center. (2019). Clinical pathway: Inpatient asthma.
https://www.connecticutchildrens.org/wp-content/uploads/2019/12/Asthma-Inpatient-Algorithm.pdf5. Kenyon, C. et al. (2018). Inpatient asthma pathway. Children’s Hospital of Philadelphia.https://www.chop.edu/clinical-
pathway/asthma-inpatient-care-clinical-pathway6. Lo, H.Y. (2018). Discharging asthma patients on 3-hour β-agonist treatments: A quality pmprovement Project. Hospital
Pediatrics, 8(12),733-739.7. Simmon, J.M., Biagini Myers, J.M., & Martin L.J. (2018). Ohio pediatric asthma repository: Opportunities to revise care
practices to decrease time to physiologic readiness for discharge. Hospital Pediatrics, 8(6), 305-313.8. Castro-Rodriguez, J.A., Abarca, K., Forno, E. (2020). Asthma and the risk of invasive pneumococcal disease.
Pediatrics, 145(1),1-11.9. Reddel, H., Boulet, L.P., & Levy, M. (2019). Asthma prevention and management for adults and children older
than five years. Global Initiative for Asthma. https://ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main-Pocket-Guide-wms.pdf
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ReferencesGastroenteritis1. Parker, M. W., & Unaka, N. (2018). Diagnosis and management of infectious diarrhea. JAMA Pediatrics. 172(8), 775-776.2. Dhingra, U., et al. (2020). Lower Dose Zinc for Childhood Diarrhea – A Randomized, Multicenter Trial. New England Journal of
Medicine, 383(13), 1231-1241.3. Freedman, S.B., et al. (2018). Multicenter trial of a combination probiotic for children with gastroenteritis. New England Journal of
Medicine, 379(21), 2015-2026.4. Schnadower, D., Tarr, P.I., & Casper, T.C. (2018). Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in
children. New England Journal of Medicine, 379, 2002-2014.Febrile Infant1. Aronson, P. L., et al. (2019). Physicians’ and nurses’ perspectives on the decision to perform lumbar punctures on febrile infants ≤8 Weeks Old. Hospital Pediatrics, 9(6), 405-414. doi: https://doi.org/10.1542/hpeds.2019-00022. Aronson, P. L., et al. (2019). A prediction model to identify febrile infants ≤60 days at low risk of invasive bacterial infection for the Febrile Young Infant Research Collaborative, Pediatrics, (144)1, e20183604; doi: https://doi.org/10.1542/peds.2018-36043. Kasmire, K. E. et al. (2019). Reducing invasive care for low-risk febrile infants through implementation of a clinical pathway. Pediatrics, 134(3).4. Kupperman, N. et al., (2019). Prediction models for febrile infants: Time for a unified field theory. Pediatrics, 144(1), e20191375. doi: https://doi.org/10.1542/peds.2019-1375
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ReferencesFebrile Infant - Continued5. Kupperman, N. et al. (2019). A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections for the Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Journal of the American Medical Association Pediatrics, 173(4), 342-351. doi:10.1001/jamapediatrics.2018.55016. Lendner, I. et al. (2019). Urine dipstick low sensitivity for UTI diagnosis in febrile infants. Infectious Diseases, 51(10), 764-771. doi: 10.1080/23744235.2019.16523397. Markham, J. L. et al. (2019). Variation in antibiotic selection and clinical outcomes in infants <60 days hospitalized with skin and soft tissue infections. Hospital Pediatrics, 9(1), 30-38. doi: https://doi.org/10.1542/hpeds.2017-02378. Pruitt, C. M. et al. (2019). Factors associated with adverse outcomes among febrile young infants with invasive bacterial infection on behalf of the Febrile Young Infant Research Collaborative. Journal of Pediatrics, 204, 177-82.9. Schroeder, A. R. et al. (2019). Negative urinalyses in febrile infants age 7 to 60 days treated for urinary tract infection. Journal of Hospital Medicine, 14(2),101-104.10. Stol, K. et al. (2019).Biomarkers for infection in children: Current clinical practice and future perspectives. The Pediatric Infectious Disease Journal, 38, (65), S7 – S13. doi: 10.1097/INF.000000000000231811. Velasco, R, et al on behalf of the Group of Study of Febrile Infant of the Spanish Pediatric Emergency Research Group. (2020). A positive nitrite test was an independent risk factor for invasive bacterial infections in infants under 90 days of age with fever without source. Acta Paediatr, 00, 1– 8. https://doi.org/10.1111/apa.1523012. Wang, M. E. et al. (2019). Testing for meningitis in febrile well-appearing young infants with a positive urinalysis.Pediatrics, 144(3), e20183979. doi: https://doi.org/10.1542/peds.2018-3979
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ReferencesUTI
1. Desai, S. et al. (2019). Parenteral antibiotic therapy duration in young infants with bacteremic urinary tract infections on behalf of the Febrile Young Infant Research Collaborative, Pediatrics, 144(3), e20183844. doi: https://doi.org/10.1542/peds.2018-3844
2. Gaither, T. W. et al. (2020). Cost-effectiveness of screening ultrasound after a first, febrile urinary tract infection in children age 2-24 aonths, The Journal of Pediatrics, 216, 73-81.
3. Kang, K. T. et al. (2019). Third-generation cephalosporin-resistant urinary tract infections in children presenting to thepaediatric emergency department. Paediatrics & Child Health, 25(3), 166-172. https://doi.org/10.1093/pch/pxy175
4. Kosmeria, C. et al.(2019). An update on renal scarring after urinary tract infection in children: What are the risk factors?. Journal of Pediatric Urology, 15(6), 598-603.
5. Mattoo, T. K. & Asmar, B.I. (2020). Annotations on emerging concerns about antibiotic-resistant urinary tract infection. Pediatrics, 145(2), e20193512; DOI: https://doi.org/10.1542/peds.2019-3512
6. Schlechter Salinas, A. K. et al. (2019). Testing for urinary tract infection in the influenza/respiratory syncytial virus–positive febrile infant aged 2 to 12 months. Pediatric Emergency Care, 25(10), 666-670. doi: 10.1097/PEC.0000000000001073
7. Wang, M. E. et al. (2020). Clinical response to discordant therapy in third-generation cephalosporin-resistant UTIs. Pediatrics, 145(2), e20191608. doi: https://doi.org/10.1542/peds.2019-1608
8. Williams, G. & Craig, J.C. (2019). Long‐term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Systematic Review – Intervention. https://doi.org/10.1002/14651858.CD001534.pub4
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ReferencesCAP1. Bradley, J. S. et al. (2011). The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases: IDSA Guidelines, Oxford University Press on behalf of the Infectious Diseases Society of America. DOI: 10.1093/cid/cir531Emergency2. Fritz, C.Q. et al. (2019). Prevalence, Risk Factors, and Outcomes of Bacteremic Pneumonia in Children, Pediatrics, 144
(1) e20183090; DOI: https://doi.org/10.1542/peds.2018-30903. Florin, T.A. et al (2020). Biomarkers and Disease Severity in Children With Community-Acquired Pneumonia,
Pediatrics,145(6). DOI: 10.1542/peds.2019-37284. Harel‐Sterling, M., Diallo, M., Santhirakumaran, S., Maxim, T., & Tessaro, M. (2018). Emergency Department Resource Use in Pediatric Pneumonia: Point‐of‐ Care Lung Ultrasonography versus Chest Radiography, Journal of Ultrasound Medicine, 38(2). https://doi.org/10.1002/jum.147034. Johnson, D. P. et al. (2020). Things We Do For No Reason: Routine Blood Culture Acquisition for Children Hospitalized
with Community-Acquired Pneumonia. Journal of Hospital Medicine, 15(2), 107-110.4. McLaren, et al. (2019). Guideline Adherence in Diagnostic Testing and Treatment of Community-Acquired Pneumonia in Children. Pediatric Emergency Care. doi: 10.1097/pec.00000000000017457. Yan, C. (2019). Lung ultrasound vs. chest X-ray in children with suspected pneumonia confirmed by chest computed tomography: A retrospective cohort study. Experimental and Therapeutic Medicine, 19(2). https://doi.org/10.3892/etm.2019.8333
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PALS1. Duff, J.P. et al. (2019). American Heart Association Focused Update on Pediatric Advanced Life
Support. Circulation, 140, e904–e914. doi: 10.1161/CIR.0000000000000731IV Fluid Management1. Feld, L. G., et al. (2018). Clinical practice guideline: Maintenance intravenous fluids in children.
Pediatrics, 142(6), e20183083. doi: 10.1542/peds.2018-3083.
References
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Interpretation of CBC with differential and Culture Results leading to antibiotic therapy considerations
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Presented By:
Elizabeth Byler MSN, APRN, CPNP
Jackie Pressman MSN, APRN, CPNP
Leah Rawdon DNP, APRN, CPNP
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Disclosures
No conflicts of interest noted for this presentation
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Objectives:
• Review components and interpretation through didactic education and case studies.
• Discuss abnormal results and considerations based on lab work.
• Review culture interpretation, identification of organism and appropriate antibiotic choice based on lab findings and diagnosis.
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Breaking Down a CBC
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Why is a CBC so Important?
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CBC Includes:
• Red Blood Cells (RBC)
• White Blood Cells (WBC)
• Platelets
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RBC• Components:
– HGB (Hemoglobin)
– HCT (Hematocrit)
– MCV (Mean Cell Volume)
(Doig & Zhang, 2017)
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RBC Cont. • MCH (Mean Cell Hemoglobin)
• MCHC (Mean Cell Hemoglobin Concentration)
• RDW (Red Cell Distribution Width)
(Doig & Zhang, 2017)
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RBC Terminology and Interpretation
• Hemoglobin Low: Anemia
• If total RBCs are High: Polycythemia
(Doig & Zhang, 2017)
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WBC Components
•Basophils •Eosinophils •Monocyte •Neutrophils
• Bands• Segs
•Lymphocyte(Calihan, 2021)
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WBC Terminology and Interpretation
• Low: Leukopenia:– Causes: Viral suppression,
Medications, or Cancer (Doig & Thompson, 2017)
(Calihan, 2021)
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WBC Terminology and Interpretation Cont.
• High: Leukocytosis:– Causes:
1.Infection 2.Cancer 3.Steroids4.Stress/Post-op
(Doig & Thompson, 2017) (Celkan, 2020)
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WBC Terminology and Interpretation Cont.
• Increase: neutrophilia, lymphocytosis, monocytosis, eosinophilia, basophilia
• Decrease: neutropenia and lymphopenia. Monocytopenia, eosinopenia, and basopenia are not typically noted since the lower limits of the normal reference intervals are so low
(Doig & Thompson, 2017) (Celkan, 2020)
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Left Shift
(Honda et al, Thompson, 2016)
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Left Shift Cont.
(Honda et al, Thompson, 2016)
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Platelet Terminology and Interpretation
• Low: Thrombocytopenia – Causes: Bone marrow issues, Drug induced,
chemo, viral suppression, TTP, HUS, Cancer • High: Thrombocytosis (concerns for increased
risk for clotting) – Causes: Leukemia, inflammatory disease, acute
blood loss, IBD, Kawasaki, RA, Bacterial Disease
(Celkan, 2020), (Calihan, 2021)
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Mean Platelet Volume
• MPV– Low: Average size of platelets are small. Can
indicate there is a condition affecting the production of platelets from bone marrow.
– High: High number of larger platelets. Younger ones. Can be due to bone marrow producing and releasing platelets rapidly.
(Calihan, 2021)
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Pancytopenia
• All Three Cell Lines are low
• General originates from the bone marrow.
(Celkan, 2020)
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IDENTIFYING THE BUG! BACTERIAL INFECTIONS
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When treating bacterial infections:
● Choose the antibiotic with the narrowest spectrum that covers the pathogen
● Collect cultures prior to starting antibiotics ● If immunocompromised or critically ill, treat
broad for 1-3 days until pathogen is identified
● Always reassess your antibiotic choice and narrow when possible!
(Schleiss, 2016)
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Bacterial Vs. Viral Infection Hints
• “Left shift” on CBC (high band neutrophils- immature cells)
• High inflammatory markers: CRP, ESR, Procalcitonin
• PCR-based diagnostic panels • Fever height
(Schleiss, 2016)
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Bacteria Shorthand● Streptococcus pneumoniae- “pneumococcus”● Haemophilus influenza- “H. Flu”● MSSA- methicillin-sensitive staph aureus● MRSA- methicillin-resistant staph aureus● VRE- vancomycin-resistant enterococcus
(Gilbert, 2018)
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Interpreting Culture Results
• Gram stain: positive versus negative• Preliminary or presumptive bacteria
identification• Sterile versus nonsterile culture sites• What cultures DON’T tell you:
– Presence of infection vs colonization vs contamination
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Interpreting Culture Sensitivities
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Gram Staining 4 categories:1. Gram + cocci
-Clusters: staphylococcus-Chains: enterococcus or streptococcus
2. Gram + rods (very uncommon!): -Clostridium
3. Gram – rods: -E. Coli, Klebsiella, Enterobacter,
pseudomonas4. Gram - cocci:
-Neisseria, Moraxella(Burnham & Storch, 2016)
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Some bacteria do not fall into a category, because of variable shape: coccobacilli
○ Gram + coccobacilli: listeria○ Gram - coccobacilli: H. Flu,
Bordetella, legionella
(Burnham & Storch, 2016)
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Bacteria Classification
Classified by:● Bacteria Morphology: cocci, rod/bacilli,
coccobacilli● Gram Stain: positive, negative, or variable● Antibiotic Resistance: MSSA vs. MRSA● Oxygen Requirement: Aerobic or Anaerobic
(Strong, 2013) (Upinder, 2018)
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Hints from Preliminary Report● Gram + Cocci in clusters: Staphylococcus● Gram + Cocci in pairs and chains:
Streptococcus or Enterococcus● Gram + diplococci: Streptococcus
pneumoniae● Gram - coccobacilli: H. flu● Gram - rods, lactose fermenting: E. coli,
Klebsiella, Enterobacter
(Burnham & Storch, 2016)
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Sites of Infection by Bacteria Type ● Gram + cocci
○ Skin, soft tissue, heart, lung, bone, joint, hardware, central lines
● Gram - rods○ Lung (CAP, HAP, VAP), abdominal organs, GU
system● Anaerobes
○ Lung abscess, oral cavity, abdominal organs● Atypicals
○ Lung (CAP)
(Burnham & Storch, 2016) (Strong, 2013)
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Lungs:CAP >1 month: S. pneumo, H. flu, Mycoplasma, ChlamydiaAspiration PNA/Lung abscess: Anaerobes, Klebsiella, S. aureus, Streptococci
Musculoskeletal:Osteo: S. aureus, Group A StrepSeptic Arthritis: S. aureus, Streptococci, N. Gonorrhea
Skin:Cellulitis: Staph Aureus, GABHS
GU:UTI/Pyelonephritis: E. coli, Proteus, Klebsiella, enterococcus, EnterobacterGenital: N. gonorrhea, Chlamydia, Enteric GNR
GI:Bacterial Gastro: E. coli, Shigella, Salmonella, CampylobacterColitis: C. difficile
ENT:Otitis media- S. pneumo, H. flu, MoraxellaSinusitis- S. pneumo, H. flu, Moraxella
Meningitis: <1 month- Group B Strep, Listeria, GNR>1 month- Strep. Pneumonia, N. Meningitidis, HIB
(Schleiss, 2013)
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Antibiotic Therapy Considerations
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Beta-Lactams
○ Penicillin○ Cephalosporins (5 generations) ○ Carbapenems
(Calihan, 2021)
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Penicillins
● Examples: Penicillin, Ampicillin, Amoxicillin
)
Gram + Gram -Strep, Staph, listeria E.coli, H. Influenzae,
Neisseria
(Calihan, 2021)
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Penicillins
Can be combined with Beta-Lactamase Inhibitor to give broader spectrum of coverage against beta-lactamase producing organisms
○ Amoxicillin/Clavulanate (Augmentin) ○ Ampicillin/Sulbactam (Unasyn)○ Piperacillin/Tazobactam (Zosyn)
(Calihan, 2021)
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Penicillin Resistance
• S. Pneumoniae have intermediate to high resistance to penicillin antibiotics.
• High Dose (80-90 mg/kg/day) amoxicillin helps overcome this resistance
(Calihan, 2021)
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Cephalosporins
● 5 generations. Treats a wide range of infections.
● Gram-negative coverage improves with each generation.
● Does not cover LAME (Listeria, Atypicals, MRSA and Enterococci)
(Calihan, 2021)
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First Generation
• Examples: (Cefazolin,Cephalexin)
Gram + Gram –Most Streptococci and staphylococci
proteus mirabilisE coliKlebsiella
(Calihan, 2021)
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Second Generation
• Example: Cefuroxime
Gram + Gram -
Same as 1st Generation Same as 1st generation plusH. influenza, Enterobacter aerogenes, Neisseria species, and Serratia marcescens
(Calihan, 2021)
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Third Generation
• Example: Ceftriaxone, Cefotaxime
Gram + Gram -S. Pnumoniae (majority) S. pyogenes, Viridansstreptococcus
E.coli, H. Influenzae, Klebsiella, M. catarrhalis, Proteus, Neisseria
(Calihan, 2021)
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Fourth Generation
• Example: Cefepime
Gram + Gram -Same as third generation plus MSSA
Same as third generation plus Pseudomonas aeruginosa.
(Calihan, 2021)
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Fifth Generation
• Example: Ceftaroline
Gram + Gram -Same as third generation plus MRSA
Enteric gm negative rods
(Calihan, 2021)
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Carbapenem
• Example: Meropenem, Imipenem
Gram + Gram -MSSA, S pneumonia, S. pyogens, S. agalactiae, Enterococcus
Pseudomonas, Acinetobacter, Serratia, Klebsiella, E. coli
(Calihan, 2021)
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Vancomycin
Gm + Gm-Streptococci, staphylococciEnterococci
(Calihan, 2021)
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Macrolides
● Example: Erythromycin, Azithromycin
AtypicalsMycoplasma, Chlamydia, H. Flu,
and Legionella
(Calihan, 2021)
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Anaerobic Coverage
● Example: Clindamycin
Gm + Gm -Staphylococcus aureusStreptococcus pneumoniaStaphylococcus eidermis
(Calihan, 2021)
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Anaerobic Coverage
● Example: Metronidazole
Gm + Gm -Clostridium Bacterioides
FusobacteriumH Pylori
(Calihan, 2021)
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Case
K.D is a 2 year old with no significant past medical history brought to the ED for fever and poor po intake.
Per mother, patient developed a fever 4 days prior to admission. 2 days prior to admission, she was noted to have decreased PO intake and decreased wet diapers. On day of admission, she started vomiting and was unable to hold fluids down. Mother then brought to the ED for further evaluation.
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In the ED, K.D was febrile to 39.5 C, tachycardic to 170 bpm, stable room air, no respiratory symptoms, minimal interest in PO, 2 wet diapers in last 12 hours.
Lab work obtained: CBC, BMP, CRP and UA with Culture.
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• Urine Culture Pending • UA:
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You are the hospital medicine provider seeing the patient on arrival to the floor.
What antibiotic do you start?
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Lungs:CAP >1 month: S. pneumo, H. flu, Mycoplasma, ChlamydiaAspiration PNA/Lung abscess: Anaerobes, Klebsiella, S. aureus, Streptococci
Musculoskeletal:Osteo: S. aureus, Group A StrepSeptic Arthritis: S. aureus, Streptococci, N. Gonorrhea
Skin:Cellulitis: Staph Aureus, GABHS
GU:UTI/Pyelonephritis: E. coli, Proteus, Klebsiella, enterococcus, EnterobacterGenital: N. gonorrhea, Chlamydia, Enteric GNR
GI:Bacterial Gastro: E. coli, Shigella, Salmonella, CampylobacterColitis: C. difficile
ENT:Otitis media- S. pneumo, H. flu, MoraxellaSinusitis- S. pneumo, H. flu, Moraxella
Meningitis: <1 month- Group B Strep, Listeria, GNR>1 month- Strep. Pneumonia, N. Meningitidis, HIB
(Schleiss, 2013)
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Third Generation
• Example: Ceftriaxone, Cefotaxime
Gram + Gram -S. Pnumoniae (majority) S. pyogenes, Viridansstreptococcus
E.coli, H. Influenzae, Klebsiella, M. catarrhalis, Proteus, Neisseria
(Calihan, 2021)
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In the next 24 hours, gram stain results: gram negative rod and patient’s fever
curve improving. What to do with current antibiotic
therapy?
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24 hours later, Urine culture results: >100,000 CFU E. Coli. Sensitive to all
cephalosporins, resistant to ampicillin and Bactrim.
Which antibiotic do you narrow coverage to?
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References
Calihan, J. (2021). Hematology. In K. Kleinman, L. McDaniel & M. Molloy, The Harriet Lane Handbook (22nd ed., pp. 328-367). Philadelphia: Elsevier.
Calihan, J. (2021). Hematology. In K. Klembczyk, & S. McAleese, The Harriet Lane Handbook (22nd ed., pp. 408-446). Philadelphia: Elsevier.
Celkan TT. What does a hemogram say to us? Turk Pediatri Ars. 2020 Jun 19;55(2):103-116.
Doig, K., & Thompson, L. (2017). A Methodical Approach to Interpreting the White Blood Cell Parameters of the Complete Blood Count. American Society For Clinical Laboratory Science, 30 (3), 186-193.
Doig, K., & Zhang, B. (2017). A Methodical Approach to Interpreting the Red Blood Cell Parameters of the Complete Blood Count. American Society For Clinical Laboratory Science, 30(3), 173-185.
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Freeman, J., Roberts, S. (2020). Approach to gram stain and culture results in the microbiology laboratory. In: UpToDate. (Accessed on October
01, 2020). Gilbert, D. (2018). Sanford guide to antimicrobial therapy. New York: McGraw
Hill. Honda, T., Uehara, T., Matsumoto, G., Arai, S., & Sugano, M., (2016).
neutrophil left shift and white blood cell count as markers of bacterial infection. Clinica Chimica Acta. 46-53.
Schleiss, M. (2016). Principles of antibacterial therapy. In R. M. Kliegman (Ed.), Nelson textbook of pediatrics 20th edition (1298-1315). Philadelphia, PA: Elsevier.
Strong, E. [Strong Medicine]. (2013, January 5). Eric Strong of Stanford Antibiotic Lecture Series [Video file]. Retrieved from https://www.youtube.com/watch?v=OOGGM6mxjY0
H. Barrett Fromme, MD, MHPE, FAAP , is a Professor of Pediatrics and a pediatric hospitalist at the University of Chicago, Pritzker School of Medicine, where she is the Associate Dean for Faculty Development in Medical Education and Section Chief of Pediatric Hospital Medicine. She is also well known to us as the Chair of theAAP Section on Hospital Medicine.
AAP SOHM Subcommittee for Advanced Practice Providers
ChairLeah Rawdon DNP, APRN, CPNPLrawdon@akronchildrens.org
Vice ChairRebecca Carlson MAN, APRN, CPNPRebecca.carlson@childrensmn.org
Vice ChairJodi Lohrey MSN, APRN, CFNPLohreyj2@ccf.org
AAP SOHM Subcommittee for APPs
The goals of this subcommittee are:
● ·To be a resource for hospitalist APPs● ·To help advance the scope of practice for hospitalist APPs● ·Act as a resource for hospitals looking to add APPs to their hospitalist
services● ·Contribute to research in pediatric hospital medicine● ·Offer mentorship opportunities for new APP hospitalists or new APP
hospitalist programs● ·Utilize the subcommittees’ listserv to provide a structured environment for
communication in sharing best practices
AAP SOHM Subcommittee for APPs Activities:
● Quarterly Microsoft Teams calls● Participate in listserv discussions● Promote educational discussions
○ Twitter account @appjournalclub● Promote research in PHM and the role of APPs● Be on the lookout for a survey specific to APPs coming out in early November
○ Sent out through both listservs● Hopeful for pre -conference at PHM 2021
How you can join:
Go to https://shop.aap.org/aap -membership/ and choose Nurse Practitioner/PA membership
Questions contact: sohm.app@gmail.com
Obtaining continuing education creditClaim Credit:
1. Log on to http://transcript.aap.org with your AAP Username and Password
a. Note: If you are already logged into PediaLink (www.pedialink.org) , click on the Continuing Education tab then the CME Transcript button to access the transcript site and continue to step 2.
2. Next to the activity, click the Claim CME or Claim AAP Credit Only link and enter the total number of credits you are claiming, commensurate with the extent of your participation in the activity
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Non-AAP Members: Please follow the above steps to claim your credits and print a certificate. If you do not have a PediaLink account, you may create one by going to www.pedialink.org, click the link Don’t Know Your Login?, click the link Create an Account, and follow the instructions to setup an account.
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