Penicillin for Pneumonia

Penicillin for Pneumonia

Infectious diseases are commonly considered when dealing with pediatric patients.  We have covered topics in this realm numerous times (I believe that this would be the 64th Morsel in the ID category).  One of the more prevalent considerations is pediatric pneumonia.

Previously, we have discussed the issues that surround making the diagnosis of pneumonia.  We have also touched on some complications and interesting pediatric findings.  Additionally, we covered the basic recommended therapies.  While the recommendations are for narrow spectrum antibiotics as 1st line (penicillin), many of us still see a lot of broad spectrum antibiotics being used, particularly for those who we admit to the hospital. While it may be fun to say “Cef-Kill-it-All,” is that the right answer for community acquired pneumonia in children?

 Community Acquired Pneumonia Basics

  • We see a lot of it – accounts for >500,000 ED visits annually!
  • Accounts for ~7% of pediatric admissions.
  • Streptococcus pneumoniae is the most common bacterial cause of community acquired pneumonia in kids.
    • Narrow spectrum beta-lactam antibiotics are still very effective against S. pneumoniae.
    • A significant amount of patients (even after published recommendations) continue to receive unnecessary broad spectrum antibiotics as initial therapy!

 

Penicillin Works Great!

  • Several recent studies (see references) support the fact that narrow spectrum antibiotics for community acquired pneumonia is an effective 1st line option.
    • Penicillin/Ampicillin/Amoxicillin treat uncomplicated community acquired pneumonia as effectively as broad spectrum agents.
    • Broad spectrum antibiotics also work, but increase risk for developing resistant organisms! (Oh, Darwin!)
  • S. pneumoniae is the primary target.
    • Narrow spectrum penicillins provide appropriate coverage for this bug!
    • S. pneumoniae can become resistant to penicillin; however, this is generally a more important consideration for CNS infections (not pneumonia).
  • This is true even for those that you are admitting to the hospital!
    • The adage “Go Big or Go Home,” does not apply to the selection of 1st line antibiotics for community acquired pneumonia!
    • Even if your patient is not going home… you still don’t need to use the “big gun.”
    • If they are not responding within 48 hours, then the decision to change therapies can be made.

     

The Therapeutic Recommendations

  • In 2011, the Pediatric Infectious Diseases Society and the Infectious Disease Society of America published guidelines for management of community acquired pneumonia.
  • OutPatient
    • Pre-School Age and Fully Immunized
      • 1st Line Therapy – Penicillin or Amoxicillin.
      • Honestly, the majority are viral pathogens.
    • School Age and Fully Immunized
      • 1st line therapy = Penicillin or Amoxicillin.
      • Consider Atypical Pathogens
  • InPatient
    • Fully Immunized Infants – School Aged Kids
      • If local epidemiologic data does not show high level of penicillin resistance, then
        • Ampicillin or Penicillin G
      • If local epidemiologic data shows high level of penicillin resistance, then
        • 3rd Generation Cephalosporin (ceftriaxone or cefotaxime)
      • Consider Macrolide for Atypical Pathogens
    • Not Fully Immunized or with Life-Threatening Infections (ex, Empyema)
      • 3rd Generation Cephalosporin (ceftriaxone or cefotaxime)
      • Vancomycin has not been shown to be more effective for empiric therapy in North America.
      • Vancomycin or Clindamycin should be consider if infection is consistent with S. aureus.

       

     

Moral of the Morsel

Obviously, selection of antibiotics for patients needs to be tailored to the specific individual patient (are they immunocompromised, do they have prior history of resistant organisms, are they not vaccinated, etc); however, the decision to admit the patient does not then mandate that the patient receive broad spectrum antibiotics.  Good old fashion penicillins are appropriate initial selections for the patient with uncomplicated community acquired pneumonia – whether admitted or discharged.

 

References

Ross RK1, Hersh AL, Kronman MP, Newland JG, Metjian TA, Localio AR, Zaoutis TE, Gerber JS. Impact of infectious diseases society of america/pediatric infectious diseases society guidelines on treatment of community-acquired pneumonia in hospitalized children. Clin Infect Dis. 2014 Mar;58(6):834-8. PMID: 24399088. [PubMed] [Read by QxMD]

Queen MA1, Myers AL, Hall M, Shah SS, Williams DJ, Auger KA, Jerardi KE, Statile AM, Tieder JS. Comparative effectiveness of empiric antibiotics for community-acquired pneumonia. Pediatrics. 2014 Jan;133(1):e23-9. PMID: 24324001. [PubMed] [Read by QxMD]

Iroh Tam PY. Approach to common bacterial infections: community-acquired pneumonia. Pediatr Clin North Am. 2013 Apr;60(2):437-53. PMID: 23481110. [PubMed] [Read by QxMD]

Williams DJ1, Hall M, Shah SS, Parikh K, Tyler A, Neuman MI, Hersh AL, Brogan TV, Blaschke AJ, Grijalva CG. Narrow vs broad-spectrum antimicrobial therapy for children hospitalized with pneumonia. Pediatrics. 2013 Nov;132(5):e1141-8. PMID: 24167170. [PubMed] [Read by QxMD]

Ambroggio L1, Taylor JA, Tabb LP, Newschaffer CJ, Evans AA, Shah SS. Comparative effectiveness of empiric β-lactam monotherapy and β-lactam-macrolide combination therapy in children hospitalized with community-acquired pneumonia. J Pediatr. 2012 Dec;161(6):1097-103. PMID: 22901738. [PubMed] [Read by QxMD]

Esposito S1, Principi N. Unsolved problems in the approach to pediatric community-acquired pneumonia. Curr Opin Infect Dis. 2012 Jun;25(3):286-91. PMID: 22421754. [PubMed] [Read by QxMD]

Bradley JS1, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT, Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. 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. Clin Infect Dis. 2011 Oct;53(7):e25-76. PMID: 21880587. [PubMed] [Read by QxMD]

Bradley JS1, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT, Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Executive summary: 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. Clin Infect Dis. 2011 Oct;53(7):617-30. PMID: 21890766. [PubMed] [Read by QxMD]

Tsarouhas N1, Shaw KN, Hodinka RL, Bell LM. Effectiveness of intramuscular penicillin versus oral amoxicillin in the early treatment of outpatient pediatric pneumonia. Pediatr Emerg Care. 1998 Oct;14(5):338-41. PMID: 9814400. [PubMed] [Read by QxMD]

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Ketamine for Analgesia

Ketamine for analgesia

Last week’s Morsel discussed patellar dislocations and mentioned the use of nitrous oxide to assist with the reduction.  Many of you had great feedback on other pain management options (thank you!).  Obviously, the management of pain is one of our primary objectives and the science and art of it does not lend itself to a simple, single option.  Fortunately, we have many options that can be appropriately tailored to our patients.

Recently, a colleague and friend, Dr. James Homme, delivered a brilliant presentation on Ketamine for Analgesia at the ACEP/AAP Advanced Pediatric Emergency Medicine Assembly and proclaimed “To know ketamine, is to love ketamine.”

We have covered Ketamine’s use for Delayed Sequence Intubation and for the treatment of Hypercyanotic Spells and the team at Don’tForgetTheBubbles.com just covered it’s use for Conscious / Procedural Sedation.  Now, let’s explore the next frontier for Ketamine usage: Analgesia!

 

The Problem with Brief Painful Procedures…

  1. Many of the procedures that we need to perform in the Emergency Department do not require a prolonged time.
    1. Incision and drainage, uncomplicated joint reductions, wound cleansing / debridement, uncomplicated laceration repair are all great examples of procedures that often do not require more than a few minutes of actual procedure time.
  2. The problem with these procedures is that they are still painful and scarey.
  3. This creates a difficult to solve risk : benefit ratio equation.
    1. Risk of full conscious / procedural sedation
    2. Risk of suboptimal pain and anxiety control
    3. Risk of physical restraint
  4. Unfortunately, the equation is often solved in a manner that inadequately controls the child’s discomfort in favor of being expedient.

 

There is No Perfect Rx, But Ketamine is Close…

  • The World Health Organization has characterized Ketamine as a “core medication for basic healthcare systems.”
    • While those of us in Ivory Towers can debate, it is recommended for systems with far fewer resources.
  • The US Defense Health Board called Ketamine “a new alternative to conventional battlefield analgesia” in 2012.
    • Ketamine is ideal for pain management in an austere environment.
      • Safe and effective.
      • Rapid onset.
      • No respiratory depression.
      • Requires little (if any) monitoring.
      • Our EDs are like luxury hotels compared to the austere regions it is being used in.
    • Referred to morphine as “the slipping gold standard.”
  • The world’s literature (see references) notes Ketamine is effective at reducing pain quickly (usually by 5 minutes).

 

Dosage Matters

  • The first publication showing Ketamine as being effective as an analgesic was in 1971.
    • Ketamine used at subdissociative doses worked better than merperidine for reducing pain response.
  • Since then we have become very comfortable with it as a medication for conscious / procedural sedation.
  • It’s association with PCP has likely affected its usage as an analgesic, however.
  • Analgesic Dosages: 0.1 – 0.3 mg/kg IV; 0.5 – 1 mg/kg IM
  • Partial Dissociation: 0.4 – 0.8 mg/kg IV
  • Dissociation Dosages: 1 – 2 mg/kg IV; 2 – 4 mg/kg IM

 

Barriers to Ketamine’s Use

  • Institutional labeling
    • If your hospital has labeled it as a medication to be used for sedation purposes, you will likely met resistance to giving it for analgesia without filling out 1,000 pages of conscious sedation paperwork.
      • Perhaps you can use the references below to change that.
    • Certainly we use other medications for various applications (opioids, benzodiazepines, etc).
  • Myths about head injury
  • Fear of Emergence Reaction
    • This is actually a rare event for the group that receives subdissociative doses of Ketamine.

 

Potential Therapeutic Groups

See reference

  • The awake patient who needs a brief painful procedure (5-10 min).
  • The patient with chronic pain on opioids presenting with intractable pain (ex, Sickle Cell Pain Crisis).
  • The patient in whom pain is associated with emotional distress.
    • Ketamine not only controls pain, but it also makes people seem to be indifferent to it.
    • Ketamine is also being looked at for treatment of depression.

 

So, while you might not be using Ketamine for Analgesia during your next shift for that I+D, maybe in the very near future you will be.

 

References

Nielsen BN1, Friis SM, Rømsing J, Schmiegelow K, Anderson BJ, Ferreirós N, Labocha S, Henneberg SW. Intranasal sufentanil/ketamine analgesia in children. Paediatr Anaesth. 2014 Feb;24(2):170-80. PMID: 24118506. [PubMed] [Read by QxMD]

Ahern TL1, Herring AA, Stone MB, Frazee BW. Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain. Am J Emerg Med. 2013 May;31(5):847-51. PMID: 23602757. [PubMed] [Read by QxMD]

Norambuena C1, Yañez J, Flores V, Puentes P, Carrasco P, Villena R. Oral ketamine and midazolam for pediatric burn patients: a prospective, randomized, double-blind study. J Pediatr Surg. 2013 Mar;48(3):629-34. PMID: 23480923. [PubMed] [Read by QxMD]

Herring AA, Ahern T, Stone MB, Frazee BW. Emerging applications of low-dose ketamine for pain management in the ED. Am J Emerg Med. 2013 Feb;31(2):416-9. PMID: 23159425. [PubMed] [Read by QxMD]
Richards JR1, Rockford RE. Low-dose ketamine analgesia: patient and physician experience in the ED. Am J Emerg Med. 2013 Feb;31(2):390-4. PMID: 23041484. [PubMed] [Read by QxMD]

Niesters M1, Khalili-Mahani N, Martini C, Aarts L, van Gerven J, van Buchem MA, Dahan A, Rombouts S. Effect of subanesthetic ketamine on intrinsic functional brain connectivity: a placebo-controlled functional magnetic resonance imaging study in healthy male volunteers. Anesthesiology. 2012 Oct;117(4):868-77. PMID: 22890117. [PubMed] [Read by QxMD]

Arroyo-Novoa CM1, Figueroa-Ramos MI, Miaskowski C, Padilla G, Paul SM, Rodríguez-Ortiz P, Stotts NA, Puntillo KA. Efficacy of small doses of ketamine with morphine to decrease procedural pain responses during open wound care. Clin J Pain. 2011 Sep;27(7):561-6. PMID: 21436683. [PubMed] [Read by QxMD]

Persson J. Wherefore ketamine? Curr Opin Anaesthesiol. 2010 Aug;23(4):455-60. PMID: 20531172. [PubMed] [Read by QxMD]

Zempsky WT1, Loiselle KA, Corsi JM, Hagstrom JN. Use of low-dose ketamine infusion for pediatric patients with sickle cell disease-related pain: a case series. Clin J Pain. 2010 Feb;26(2):163-7. PMID: 20090444. [PubMed] [Read by QxMD]

Black IH1, McManus J. Pain management in current combat operations. Prehosp Emerg Care. 2009 Apr-Jun;13(2):223-7. PMID: 19291561. [PubMed] [Read by QxMD]

Svenson JE1, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007 Oct;25(8):977-80. PMID: 17920984. [PubMed] [Read by QxMD]

Kronenberg RH. Ketamine as an analgesic: parenteral, oral, rectal, subcutaneous, transdermal and intranasal administration. J Pain Palliat Care Pharmacother. 2002;16(3):27-35. PMID: 14640353. [PubMed] [Read by QxMD]

Sadove MS, Shulman M, Hatano S, Fevold N. Analgesic effects of ketamine administered in subdissociative doses. Anesth Analg. 1971 May-Jun;50(3):452-7. PMID: 5103784. [PubMed] [Read by QxMD]

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Patellar Dislocation

Patellar Dislocation

We all like to feel like we can heal with our hands.  For this reason, simple reductions are sometimes welcome complaints in your ED that is filled with copious rhinorrhea and voluminous emesis.  We have discussed feeling like Mr. Miyagi during reductions of Nursemaid Elbows.  Another reduction that can make you feel similarly is the Patellar Dislocation, but before you bow as you exit the exam room, make sure that you aren’t being too cavalier.

Patellar Dislocation Basics

  • Acute patellar dislocation is a common knee injury.
  • Most often occurs in teenagers.
  • Most frequently associated with sports or physical activities.
  • Often seen when the femur rotates internally, the tibia rotates externally, and the foot is fixed.

Some Important Anatomy

  • The Medial Patellofemoral Ligament (MPFL)
    • Thin transverse band that extends from the femur to the medial aspect of the patella.
    • The MPFL is the primary ligamentous restraint for the patella.
      • It provides 50-60% of the restraining force.
    • The MPFL is ruptured in 94-100% of patients with acute patellar dislocation.
    • Repeat dislocation is dependent upon the MPFL injury rather than other predisposing factors (some listed below):
      • Lateral patellar tilt
      • Patella alta (abnormally high patella)
      • Trochlear dysplasia
      • Increased Q angle
      • Genu Valgum
      • Vastus Medialis Muscle hypoplasia
      • Increased femoral anteversion
      • Congenital conditions that lead to ligament laxity

Reduction of Patellar Dislocation

  1. Flex the Hip to relax the Quads.
  2. Apply medial pressure to the lateral edge of the dislocated patella.
  3. While continuing to apply medial pressure, extend the knee.
  • See friend and colleague,
    Panni AS, Vasso M, Cerciello S. Acute patellar dislocation. What to do? Knee Surg Sports Traumatol Arthrosc. 2013 Feb;21(2):275-8. PMID: 23242381. [PubMed] [Read by QxMD]

    Krause EA1, Lin CW, Ortega HW, Reid SR. Pediatric lateral patellar dislocation: is there a role for plain radiography in the emergency department? J Emerg Med. 2013 Jun;44(6):1126-31. PMID: 23357381. [PubMed] [Read by QxMD]

    Seeley M1, Bowman KF, Walsh C, Sabb BJ, Vanderhave KL. Magnetic resonance imaging of acute patellar dislocation in children: patterns of injury and risk factors for recurrence. J Pediatr Orthop. 2012 Mar;32(2):145-55. PMID: 22327448. [PubMed] [Read by QxMD]

    Sillanpää PJ1, Mattila VM, Mäenpää H, Kiuru M, Visuri T, Pihlajamäki H. Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. A prospective randomized study. J Bone Joint Surg Am. 2009 Feb;91(2):263-73. PMID: 19181969. [PubMed] [Read by QxMD]

    Stefancin JJ1, Parker RD. First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat Res. 2007 Feb;455:93-101. PMID: 17279039. [PubMed] [Read by QxMD]

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