Letter to the Editor Safety of Empiric Outpatient Treatment of Suspected Tick-Borne Infection in the Pediatric Emergency Department To The Editors: ocky Mountain spotted fever and human ehrlichiosis are common tick-borne infections in the United States and many patients may be treated as outpatients with doxycycline.1–3 However, bacterial meningitis presents with similar symptoms.4 We evaluated whether empiric outpatient treatment for possible tick-borne illness resulted in cases of inadequately treated bacterial meningitis. We performed a review of all patients seen in our tertiary children’s hospital emergency department (PED) from May to August of 2004–2013 who had a diagnosis consistent with possible tick-borne infection. Clinical and laboratory characteristics of all patients who returned to the PED within 2 weeks were collected from the electronic medical record. During the study period, 718 children were seen in the PED during the months of May to August and discharged with an ICD-9 code concerning for possible tick-borne infection. Of this group, 43 (6.0%) returned to the PED within 2 weeks of initial evaluation. Demographic information from both groups is included in Table (Supplemental Digital Content 1, http://links.lww.com/INF/ B930). The average return visit to the PED occurred 3.4 days after initial visit, and 14 (33%) returned the next day. Thirty-seven (86%) presented initially with at least 2 of the 3 classic findings of tick-borne illness (fever, headache and rash), and 27 (63%) were discharged with a prescription for doxycycline, including all patients who were diagnosed with a tick-borne illness by the PED physician. Titers for Ehrlichia and Rocky Mountain spotted fever were collected at the initial visit in 8 (19%) and 7 (16%) patients, respectively, and all titers were ultimately negative. A majority of children had a complete blood count and basic metabolic profile performed at the initial and return visit. Eleven (26%)
R
The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3312-1308 DOI: 10.1097/INF.0000000000000426
1308 | www.pidj.com
had lumbar puncture performed at the initial visit but only 3 patients, all of whom had neck pain, had a lumbar puncture at the return visit and all 3 were subsequently diagnosed with viral meningitis. There were no deaths and no cases of bacterial meningitis among our cohort of children. Sixteen children (37%) were admitted after their return PED visit, although 10 of these children (63%) were discharged the following day. One child was admitted for 16 days and subsequently was found to have anaplastic large cell lymphoma. Excluding this patient, the average length of stay was 1.8 days. Empiric outpatient treatment of children with possible tick-borne illness did not result in any missed diagnoses of meningitis among our patient cohort. These results suggest that empiric outpatient treatment of suspected tick-borne illness in the summer is a viable strategy and support PED providers’ ability to effectively distinguish between serious infection such as bacterial meningitis and those which can be treated on an outpatient basis (viral syndrome, viral meningitis, mild tick-borne illness). Our study results also suggest that there is a tendency for unnecessary testing in this cohort of patients who were initially discharged from the PED and prospective studies are needed to determine whether certain signs or symptoms may be used to identify children with suspected tick-borne illness who may be discharged from the PED without extensive laboratory testing.
Ian D. Kane, MD Donald H. Arnold, MD
Department of Pediatric Emergency Medicine Vanderbilt Children’s Hospital Nashville, TN REFERENCES 1. Woods CR. Rocky Mountain spotted fever in children. Pediatr Clin North Am. 2013;60:455– 470. 2. Marshall GS, Jacobs RF, Schutze GE, et al.; Tick-Borne Infections in Children Study Group. Ehrlichia chaffeensis seroprevalence among children in the southeast and south-central regions of the United States. Arch Pediatr Adolesc Med. 2002;156:166–170. 3. Chapman AS, Bakken JS, Folk SM, et al.; Tickborne Rickettsial Diseases Working Group; CDC. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis–United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep. 2006;55(RR-4):1–27. 4. Curtis S, Stobart K, Vandermeer B, et al. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pedia trics. 2010;126:952–960.
Sepsis and Meningitis Caused by Pasteurella Multocida and Echovirus 9 in a Neonate To The Editors:
W
e present a 22-day-old previously healthy female who came to the hospital with fever (maximum 38.6°C) of 24 hours evolution without any other symptoms. She was born at term by vaginal delivery. A vaginal smear for Streptococcus group B was negative at 35 weeks of gestation. On admission to the emergency room the patient had rectal temperature of 39.4°C with a normal heart rate and blood pressure. The physical examination was normal and she was in good condition. The blood count gave a 8310 leukocytes/mm3, with no left shift, a C-reactive protein value of 41 mg/L (maximum 161 mg/L) and procalcitonin of 2.4 ng/mL (maximum 14 ng/mL). Blood biochemistry and urinalysis were normal. Cerebrospinal fluid (CSF) analysis, sampled after 2 doses of antibiotics, showed a leukocyte count of 5.920 cells/mm3, 95% neutrophils, proteins at 161 mg/dL and glucose of 40 mg/dL (110 mg/dL in blood). Empiric antibiotic therapy was initiated with ampicillin and cefotaxime. A Gram-negative coccobacillus, susceptible to cefotaxime, was isolated in blood culture 48 hours after admission. Ampicillin was discontinued and cefotaxime (200 mg/kg/d) maintained for 14 days. The urine and CSF cultures were negative for bacterial studies. A pediatric bottle of blood culture was incubated in the Bact/Alert 3D system (BioMérieux SA, Marcy-l´Etoile, France) and after 48 hours incubation Gram-negative coccobacilli were observed by Gram stain. The API NE strips (BioMérieux) identified the isolate as Pas teurella multocida with a probability rate of 96% and the strain was sent to the Reference Laboratory for further characterization. Isolates were sensitive to penicillin and ceftriaxone. Definitive characterization of the isolate was performed in the Taxonomy Laboratory (National Microbiology Reference Centre), with the commercial BIOLOG GN2 panel (BIOLOG Inc, Hayward, CA, with 95 carbon sources). A similarity of 100% (T = 0.920) with P. multocida was found. The result was confirmed by sequencing of a 16sRNA fragment of 1429 bp.1 For virological investigation, 200 microl
The authors declare no conflict of interest. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3312-1308 DOI: 10.1097/INF.0000000000000504
The Pediatric Infectious Disease Journal • Volume 33, Number 12, December 2014
R
The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3312-1308 DOI: 10.1097/INF.0000000000000426
1308 | www.pidj.com
had lumbar puncture performed at the initial visit but only 3 patients, all of whom had neck pain, had a lumbar puncture at the return visit and all 3 were subsequently diagnosed with viral meningitis. There were no deaths and no cases of bacterial meningitis among our cohort of children. Sixteen children (37%) were admitted after their return PED visit, although 10 of these children (63%) were discharged the following day. One child was admitted for 16 days and subsequently was found to have anaplastic large cell lymphoma. Excluding this patient, the average length of stay was 1.8 days. Empiric outpatient treatment of children with possible tick-borne illness did not result in any missed diagnoses of meningitis among our patient cohort. These results suggest that empiric outpatient treatment of suspected tick-borne illness in the summer is a viable strategy and support PED providers’ ability to effectively distinguish between serious infection such as bacterial meningitis and those which can be treated on an outpatient basis (viral syndrome, viral meningitis, mild tick-borne illness). Our study results also suggest that there is a tendency for unnecessary testing in this cohort of patients who were initially discharged from the PED and prospective studies are needed to determine whether certain signs or symptoms may be used to identify children with suspected tick-borne illness who may be discharged from the PED without extensive laboratory testing.
Ian D. Kane, MD Donald H. Arnold, MD
Department of Pediatric Emergency Medicine Vanderbilt Children’s Hospital Nashville, TN REFERENCES 1. Woods CR. Rocky Mountain spotted fever in children. Pediatr Clin North Am. 2013;60:455– 470. 2. Marshall GS, Jacobs RF, Schutze GE, et al.; Tick-Borne Infections in Children Study Group. Ehrlichia chaffeensis seroprevalence among children in the southeast and south-central regions of the United States. Arch Pediatr Adolesc Med. 2002;156:166–170. 3. Chapman AS, Bakken JS, Folk SM, et al.; Tickborne Rickettsial Diseases Working Group; CDC. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis–United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep. 2006;55(RR-4):1–27. 4. Curtis S, Stobart K, Vandermeer B, et al. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pedia trics. 2010;126:952–960.
Sepsis and Meningitis Caused by Pasteurella Multocida and Echovirus 9 in a Neonate To The Editors:
W
e present a 22-day-old previously healthy female who came to the hospital with fever (maximum 38.6°C) of 24 hours evolution without any other symptoms. She was born at term by vaginal delivery. A vaginal smear for Streptococcus group B was negative at 35 weeks of gestation. On admission to the emergency room the patient had rectal temperature of 39.4°C with a normal heart rate and blood pressure. The physical examination was normal and she was in good condition. The blood count gave a 8310 leukocytes/mm3, with no left shift, a C-reactive protein value of 41 mg/L (maximum 161 mg/L) and procalcitonin of 2.4 ng/mL (maximum 14 ng/mL). Blood biochemistry and urinalysis were normal. Cerebrospinal fluid (CSF) analysis, sampled after 2 doses of antibiotics, showed a leukocyte count of 5.920 cells/mm3, 95% neutrophils, proteins at 161 mg/dL and glucose of 40 mg/dL (110 mg/dL in blood). Empiric antibiotic therapy was initiated with ampicillin and cefotaxime. A Gram-negative coccobacillus, susceptible to cefotaxime, was isolated in blood culture 48 hours after admission. Ampicillin was discontinued and cefotaxime (200 mg/kg/d) maintained for 14 days. The urine and CSF cultures were negative for bacterial studies. A pediatric bottle of blood culture was incubated in the Bact/Alert 3D system (BioMérieux SA, Marcy-l´Etoile, France) and after 48 hours incubation Gram-negative coccobacilli were observed by Gram stain. The API NE strips (BioMérieux) identified the isolate as Pas teurella multocida with a probability rate of 96% and the strain was sent to the Reference Laboratory for further characterization. Isolates were sensitive to penicillin and ceftriaxone. Definitive characterization of the isolate was performed in the Taxonomy Laboratory (National Microbiology Reference Centre), with the commercial BIOLOG GN2 panel (BIOLOG Inc, Hayward, CA, with 95 carbon sources). A similarity of 100% (T = 0.920) with P. multocida was found. The result was confirmed by sequencing of a 16sRNA fragment of 1429 bp.1 For virological investigation, 200 microl
The authors declare no conflict of interest. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3312-1308 DOI: 10.1097/INF.0000000000000504
The Pediatric Infectious Disease Journal • Volume 33, Number 12, December 2014
