Infectious Disease

Antibiotics for Strep Pharyngitis: The Pediatric Perspective

Around this time last year, a post on R.E.B.E.L. EM discussed the evidence surrounding the risks and benefits of antibiotics in Strep pharyngitis.  The general take-home was that it should not be done.

Since the article did not specifically discuss differences between children and adults, Brendan Fitzpatrick, one of our 4th year residents sent the article to Indi Trehan, who is boarded in both pediatric emergency medicine and infectious disease.  Thankfully, between saving babies in Malawi, writing grants and submitting papers, he crafted this response which he agreed to let us share on the blog:

 

>> Fitzpatrick, Brendan wrote:

Let me know what you think:

http://rebelem.com/patients-strep-throat-need-treated-antibiotics/

Brendan M. Fitzpatrick, MD
PGY-4, Division of Emergency Medicine
Washington University School of Medicine in St. Louis

 

> Trehan, Indi wrote:

Hey man,

I talked about this Strep throat thing with some (admittedly more biased and traditional) folks in ID. You're absolutely right, the incidence of ARF/RHD is going down and there is very little left in rich countries, but I don't think any of us are comfortable yet not treating this.

Some thoughts, going through the article from top to bottom:

Background - 10 million patients treated with antibiotics annually but less than 10% have Strep...

True, but this is 10 million adults and most places don't test them for Strep. One of the outcomes of that study was the re-emphasis on the importance of only testing people with symptoms (Centor score at least 2). In the three big children's hospitals I have worked in, this is standard of care -- we only treat those who have tested positive.

C. diff and allergic reactions

The rate of C. diff is extremely low in children -- for example we use clindamycin like candy. Otherwise healthy ambulatory kids who come in with a sore throat just don't get C. diff from the occasional course of antibiotics.

Yes, allergies are always a risk with antibiotics. Hence an additional reason to limit their usage by only testing and treating appropriately as above.

Argument #1

Agreed, reducing symptoms is uninteresting to most of us.

Argument #2

Agreed, suppurative complications are not why most of us treat.

Argument #3

I think this is probably a place where adult data doesn't apply to kids. The rate of RHD/RF reported in that military study in the 1950s is indeed quite low but that's because that was in military recruits. RHD/RF simply happens at much much lower rates in adults than kids -- it really is a disease that is almost entirely of 5-15 year olds, a few younger and a few older of course, but it doesn't surprise me at all to see only a 1-2% rate among what is probably 17-25 year olds.

But even aside from this fact, these studies from the 50's and 60's are all quite small and given the very low rate of these complications, a meta-analysis is in order in order to be able to have enough power to detect a difference. The Cochrane review on this subject does this meta-analysis for us -- see Analyses 4.1 and 4.2 which found that giving antibiotics reduced ARF -- RR 0.27 (95% CI 0.12-0.60). Giving penicillin specifically was also studied -- RR 0.27 (95% CI 0.14-0.50).

Need to treat 2 million patients in order to prevent a single case of RF...

This number is not exactly right. It is correct in its intention of pointing out that you need to treat a ton of people to prevent one complication, but the denominator is not correct since we really shouldn't be testing or treating adults and we shouldn't be treating those without a positive rapid test or culture. So if you limit the testing and treatment to the high risk population (i.e., children) and then only treat those who have a positive test, this 2 million number falls dramatically.

The point about hygiene as the real cause of the decrease in rates of ARF is exactly correct and I'm glad they are pointing this out. In the same way that polio's eradication in the US is just as much a result of improved hygiene as it is from vaccination, we still need to keep immunizing kids against polio due to the unpredictable risk of it flaring up in an outbreak at any time. (Admittedly, this analogy falls apart when comparing the almost-zero risk of complications due to vaccination when compared to the slightly higher risk of penicillin allergy.)

The thing with Group A Strep is that certain strains are rheumatogenic and far more likely to cause ARF. Which ones these are is quite unpredictable. There also seems to be certain people that are particularly susceptible because of their own genetic predisposition (this comes from twin studies and such). And of course who those people are is unknown with our limited genetic techniques.

When you put these together, sometimes you get the perfect storm of sporadic or widespread cases of ARF. So some fair number of kids will still get ARF/RHD and then there are also big outbreaks that arise periodically and unpredictably -- the most famous was in Utah in the 80's -- and so keeping the burden of this bacteria low and limiting its spread seem to be a worthwhile public health goal.

But overall, your point is well taken -- this is a disease with declining incidence and morbidity and we are getting close to the point of not needing to treat it in the US, with the caveats that the numbers derived from adults don't necessarily apply to children who have a much higher incidence of rheumatic complications and that those who will suffer these is relatively unpredictable, especially given the problem that kids are not the cleanest in the world and quickly spread bacteria around their house and day care centers and schools. Another small practical problem we have to remember is "standard of care" -- so if you don't test or treat a child with Strep throat who goes on to develop ARF/RHD and the community standard of care -- "what any reasonable practitioner would do" -- still says to test and treat, then you are up a creek when it comes to malpractice. But I do hope that when IDSA looks to update and revise their guideline (as they do every few years), they take a serious look at this changing epidemiology and decide to narrow their recommendations for treatment...

indi

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.
EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  





Oldie But Goodie:

This post isn’t actually that old, but it’s about older patients, so we’re gonna count it. On the heels of Dr. Galante’s lecture from last month, Ken Milne at the Skeptics’ Guide to Emergency Medicine takes on Chris Carpenter’s systematic review of ED tool to predict fall risk ingeriatric patients from this months Annals.
This is a can’t-miss episode, as it is the initial installment of the “Hot Off The Press” series. You can watch in real-time as the FOAMed and published-journal worlds start to merge. Each episode of this series will feature a critical analysis and interview with an author of a paper just published in Annals or CJEM. The audience (i.e., everyone) will have a chance to respond with their own post-publication peer review via social media outlets. The top responses will be featured in a future publication in each journal. Knowledge translation and crowdsourced feedback at the speed of social media!

F(FN)OAMed:

If you’re going to pick one podcast to listen to religiously, that podcast should probably be EM:RAP. This month, be sure to check out the segment on IV contrast myths.
Take-home points: Iodine is not an allergen. Seafood allergy does not increase risk of anaphylaxis to IV contrast any more than any other given allergy, although previous reaction to IV contrast or past history of atopy does increase risk. And most notably – premedication with steroids has not been shown to decrease the number of severe reactions.

The Gunner Files:

1. Check out Scott Weingart’s interview with Dr. John Hinds regarding his approach to the patient with blunt traumatic arrest.
In Dr. Hinds’ shop, before they do anything else they: 1) intubate, 2) perform bilateral finger thoracostamies, 3) place a pelvic binder, 4) reduce any gross long-bone deformities, 5) start uncrossmatched transfusion. Only then do they start a formalized assessment. Really interesting stuff.

2. Similar to the R&R from the Fastlane mentioned above, Ryan Radecki’s EM Lit of Note blog is another excellent version of a curated primary literature review. Here is his critical appraisal summary of a systematic review and meta-analysis comparing trauma “pan scan” with more selective imaging.

3. The most recent installment of the EM BASIC podcast is your panic-free look at what we know about Ebola – screening, clinical signs & symptoms, diagnosis, isolation, and treatment.

4. The ultimate skeptic, Rory Spiegel of EM Nerd, turns his nihilistic eye towards the cash cow of cardiac interventionalists everywhere – PCI. Turns out, there’s not a lot of evidence to support its use outside the realm of emergent intervention for STEMI.

5. In the most recent podcast on Emergency Medicine Cases, an EM sports medicine specialist and an orthopedic surgeon help you to avoid falling prey to the “Commonly Missed (Uncommon) Orthopedic Injuries.” Want to know how not to miss a DRUJ? Lisfranc? Perilunate? Tune in.


Never stop learning,


C. Sam Smith, PGY-3

#FOAMed Digest No. 6: Ain't Nobody Got Time For That

Welcome back, FOAMheads! My apologies for the delay this week. I ended up being a bit busier than I expected, which not coincidentally brings me to the theme for today's entry.

Sometimes you have a lot on your plate and may not be able to set aside a large chunk of time to watch/listen to a 30-minute-plus podcast. But that doesn't mean you don't have time to get your learn on! This time around, we'll highlight some of the best FOAMed sources of short-and-sweet educational pearls. Easily digestible for the highly-distractible mind of the EM trainee.

There is no moment like the present -- let's get started!




Three Stars:

1. The Glasgow Coma Scale was first introduced 40 years ago. It's past time we started assessing it properly. "GCS 12" doesn't cut it any more. What are the deficits? How do you score for eye-opening if the patient's eyes are swollen shut from trauma? What does "abnormal flexion" even mean, anyway? Ian Miller at TheNursePath provides us an excellent infographic-style breakdown of the "new" GCS.

2. The EMS 12-Lead blog, edited by EMT-P and prehospital resuscitationist extraordinaire Tom Bouthillet, is an excellent resource of EKG cases. This week's case provides an excellent example of why a resuscitationist must always treat the patient, not the monitor. Review the EKG and develop your interpretation first, then read the conclusion.

3. I don't know that a FOAMed segment has ever been more appropriately titled. "Positively Painful Private Parts" is a four-part series published by Brad Sobolewski on his PEM Blog, focusing on the evaluation of acute testicular and scrotal pain. There is a pediatric focus, not surprising given the nature of the blog, but Dr. Sobolewski does include information on "adult" diagnoses like epididymitis as well. Each part is succinct and high yield.
Part 1: Focused H&P
Part 2: Testicular torsion
Part 3: Pathology of the appendix testis
Part 4: Epididymitis

Oldie But Goodie:

An excellent case from The Blunt Dissection, in which Dr. Chris Partyka lays out everything you need to know when you must intubate a crashing neonate.

F(FN)OAMed:

Via your EMRA membership, you now have access to all of the resources from the EMedHome website. Go to the site and explore for yourself the wealth of resources available -- everything from taped lectures from prior EM conferences, the EMCast podcast hosted by Amal Mattu, weekly clinical and radiology pearls, and other vodcasts and presentations.

This week, check out the clinical pearl describing some of the changes in the new 2014 AHA/ACC guidelines for management of patients with NSTEMI.  Ryan Radecki at EM Lit of Note also published his take on the new guidelines this week; well worth the quick read.

(As always, if you need help getting access to any of these resources, please contact your friendly neighborhood Social Media Committee member.)

The Gunner Files:

1. Reinforce the take-home points from the EM Lyceum piece on DKA management with this bullet-pointed breakdown by Adaira Landry on emDocs.

2. In case you've been off the grid for the past week, ebola is here. Triage and isolation protocols are coming to an ED near you any day now. Luckily for all of us Daniel Cabrera at the Mayo EM Blog published for your review the CDC infographic Algorithm for Evaluation of the Returned Traveler.

3. So the latest installment of the Skeptic's Guide to Emergency Medicine will take you about half an hour to listen to, but it's well worth the time. Drs. Milne and Swaninathan analyze the Ottawa Aggressive Protocol for ED cardioversion and discharge of patients presenting with AFib.
This piece really highlights the interconnectedness of the FOAMed world, as it references back to last week's FOAMCast on AFib (as seen in FOAMed Digest #5), and a recently-published research letter (containing data from the largest-ever study on this topic) in JAMA calling into question the safety of cardioverting AFib patients presenting with >12 hours of symptoms.
This research letter was analyzed in depth by Rob Orman on the latest episode of his ERCast.
We're all in this together, folks.

4. I don't want to think too hard about having a cricket or other insect lodged in my ear canal, but it is probably in our best interest to know what to do if we're presented with it. Mitchell Li at ALiEM has us covered. (Great tip for getting out plastic beads, too!)

5. When you do get a little extra time, don't miss the September installment of the Annals of Emergency Medicine podcast. Covered topics include pigtail catheters for pneumothorax, acute stroke care, age-adjusted D-dimer cutoffs, and the HINTS exam (authored by our very own Dr. Brian Cohn!) You can download the podcast directly here.
(And be sure to check out Cohn's paper!)

Never stop learning,
Sam Smith, PGY-3

#FOAMed Digest No.5: But This One Goes to 11

Time once again for your mid-week blast of FOAMy goodness from around the interwebs. There’s no particular subject today; instead we’re going to highlight some of the better podcasts/vodcasts that updated this week. Podcasts are great. They break up the monotony of reading (and the monotony of mundane things like laundry, grocery shopping, training for this damn marathon…). For the more distractible among us, they usually come in easily-digestible 20-30 minute morsels. They expose you to different presentation styles, and allow you to match a face and a voice with the big names in FOAMed. Most of them also feature written show notes with references as well, which allows you both to reinforce the things you learned while listening, and also to dig deeper into topics you’re interested in.

Fun for the whole family!

Three Stars:

1. I think FOAMcast, authored by residents and EM social media savants Jeremy Faust and Lauren Westafer, might be the first example of “metaFOAM.” They peruse the FOAM world for interesting recent posts, then integrate that information with relevant material from the most popular EM textbooks (i.e., “Rosenalli”), other relevant blogs/podcasts, primary literature, and even Rosh Review questions. This week they use a post from ALiEM on calcium channel blockers vs beta blockers for A-Fib as a jumping-off point for a discussion on ED management of A-Fib and A-Flutter. There’s links to vodcasts from Scott Weingart and Amal Mattu on narrow-complex tachydysrhythmias, and plenty of cited references from the primary literature (including one from our own Brian Cohn!). It’s good stuff.

2. Speaking of the Godfather of ED EKG, Dr. Mattu has two quick cases for you to ponder. Remember: T-wave inversion does not always mean cardiac ischemia!
Remember: Gotta think tox in a seemingly unprovoked wide complex tachycardia!

3. Steve Carroll at EM Basic provides an excellent analysis of the ED management of asymptomatic hypertension, including references to the relevant ACEP Clinical Policy document and other FOAMed resources.


Oldie But Goodie:

Chris Nickson, creator and administrator of Life in the Fast Lane, gave an excellent talk at the original SMACC conference in March 2013 with the confidence-inspiring title, “All Doctors are Jackasses.” Why are we jackasses? Because we don’t do enough to understand how we think and how we make decisions, and this leads us to make errors. Watch Nickson’s lecture and begin to understand how to remedy this situation.
(EXTRA CREDIT: Links in the show notes to the other SMACC talks in the “Mind of the Resuscitationist” plenary by Weingart, Cliff Reid, and Simon Carley.)

F(FN)OAMed:

By this point you guys all know how awesome EM:RAP is, but this week is particularly relevant because Herbert & Co. just released an “EM:RAP Mini” segment about the newly-published “Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis” trial in the New England Journal. For those of you that aren’t familiar, this was a study in which we participated, and our own Drs. Aubin and Griffey are authors on the paper! An excellent summary of this paper is found on the Emergency Medicine Ireland blog, with a link to download the EM:RAP Mini segment in the show notes.

The Gunner Files:

1. Time to synthesize the knowledge you gained about non-surgical management of pediatric appendicitis at Journal Club last month. Dr. Cohn is back with another excellent EMJClub podcast along with Drs. Trehan and Horst, summarizing the primary literature.

2. EMin5 is back at it with a review of the four types of shock, in a little over four minutes.

3. From the Maryland Critical Care Project, an excellent lecture from Neuro Critical Care and ED intensivist Dr. Wendy Chang describing the ED management of status epilepticus. She covers the gamut from first-line benzos to second-line AEDs and third-line agents for initiation of therapeutic coma.

4. The good people at the All NYC EM blog posted a lecture given during their conference day by the FOAMed superstar Dr. Haney Mallemat. He covers all the basics of ultrasound evaluation of pericardial effusion and tamponade, even ultrasound-guided pericardiocentesis.

5. In case you’re not familiar, US Air Force Pararescuemen, a.k.a. “PJs,” are the ultimate badasses. Just look at it this way: think becoming a SEAL is tough? PJ training has an even higher failure rate. But I digress.
Former PJ and critical care flight retrieval medic Mike Lauria is now in medical school, and is making a bit of a splash in the FOAMed community as an expert on training, thinking, and operating in high-stress environments. Scott Weingart recently interviewed him on EMCrit about the concept of “mental toughness,” how that translates from the combat realm to the ED, and how to incorporate it into physician training. Really interesting stuff.


That Others May Live,

Sam Smith, PGY-3

#FOAMed Digest No. 4: Butter My Biscuit, Baby

Welcome back, to the brand new edition of the WUEMR FOAMed Digest. Get out your Tintinalli’s and strap in, because we’re going back to basics today. It’s all about the bread and butter. The things any PGY-2 setting off to an overnight Saturday shift in the Deuce should have down cold…yet us seniors still screw up on the daily.

FOAMed…ENGAGE!

Three Stars:

1. If my last shift at Children’s is any indication, the season is upon us – pharyngitis in every exam room. Casey Parker over at Broome Docs (a blog authored by EPs & GPs practicing in rural Australia), presents a magnificent summary of the data surrounding rapid strep swabs, antibiotic use for symptom relief, and antibiotic use for preventing secondary complications of strep. As always, be sure to check out the original literature for yourself. And don’t miss Minh Le Cong’s excellent counterpoint in the comments, which is also well-referenced.

2. What’s your record for most C-collars cleared in one shift? (When you hit double-digits, then we can talk.) The best tools in our arsenal for clearing C-spine in low-risk patients remain the Canadian C-spine and NEXUS instruments. But which one should you use? Do you even remember which criteria belong in each rule, or do you find yourself trying to apply the “Canadi-EXUS” criteria, like I do? Luckily for us, Alayna Hawling at BoringEM authored an excellent rundown and comparison – with a pretty flowchart!

3. As much as you want to start the fist-pumping and beer-chugging as soon as you drop that tube past the cords, your work with the intubated patient is not done, my friend! We’ve already touched on our persistently poor rates of achieving adequate analgesia & sedation in the intubated patient. Another part of quality post-intubation care is knowing what to do if your ventilated patient acutely decompensates. Check out Chris Cresswell’s summary of the DOTTS mnemonic over at EM Tutorials.
(EXTRA CREDIT: He also included a link to Scott Weingart’s notes regarding care of the crashing ventilated patient, which are well worth a look.)

Oldie But Goodie:

There’s been some e-mail discussion lately among our attendings regarding the best way to clean lacs prior to closure. Back in February, Ken Milne at the Skeptic’s Guide (along with Eve Purdy, a rockstar med student and creator of the excellent Manu et Corde blog) published a piece dedicated to breaking down the dogma of management of simple lacerations. Tap water vs sterile water, sterile gloves vs clean gloves, to sew or not to sew…it’s all covered here. Plus there’s links to other excellent FOAMed resources regarding wound care dogma.

F(FN)OAMed:

The good folks over at EB Medicine recently published a stem-to-stern guide to UTI diagnosis and management in the ED, all based on best available evidence. A bit lengthier than your average blog post, but incredibly high-yield and well worth your time. It’s a bit difficult for me to place a direct link here, but you can find it simply by logging into your account at EBMedicine, following the link to browse issues of Emergency Medicine Practice, and opening the July 2014 issue on UTI.
(As always, contact your friendly neighborhood Social Media Committee member if you need help obtaining access to EB Medicine resources.)

The Gunner Files:

1. Hard to get through a Deuce shift without breaking out the prochlorperazine at least once. We’ve all seen patients get jittery, agitated, or downright whacky following its use. Does Benadryl help? A PharmD expert at ALiEM has a good lit review of the topic.

2. Short and sweet: some diabetic medications are more likely to cause harmful hypoglycemia after overdose than others. Quick table-based rundown over at ALiEM.

3. It is asthma season, and you may find yourself in the worst-case-asthma-scenario of impending need for intubation. Check out this post from The Kings of County regarding care for the sick asthmatic, including intubation and mechanical ventilation issues.

4. FOAMed is taking the world by storm! Does the UK College of Emergency Medicine launching a dedicated FOAMed site mean it’s officially gone mainstream? Don’t worry – we were all into FOAMed before it was cool. But seriously, check out this vodcast on diagnostics in EM, and not feel quite so much increase in sphincter tone when Carpenter or Cohn pimp you on likelihood ratios or Bayesian analysis.

5. Another classic from the Skeptic’s Guide, this time addressing another oh-so-common ED complaint: renal colic. Fluids? Flomax? Any good evidence for either? In news that will surprise no one, Ken Milne is skeptical.


Never stop learning,

Sam Smith, PGY-3