a 17months old boy was admitted in the pediatrici ward since a few weeks due to burns (II degree, 9%, involving abdomen, genitals, perianal area, lower limbs), having a PICC line and having spent several time in the PICU.
The night on call pediatrician is called for high fever since the afternoon. Blood tests show White Blood Cells 33530/mmc, N 29370/mmc, CRP 85 mg/l, PCT 0.84 mg/ml,. Blood cultures sent.
WHAT WOULD YOU DO?
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The night oncall doctor decides to start Ceftriaxone 100mg/kd.
Do you Agree?
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I disagreed.
The most commonly found Gram-positive bacteria in BWI include Staphylococcus species (spp.), Enterococcus spp., and β-hemolytic group A Streptococci (GAS) [12]. Specifically, vancomycin-resistant Enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) are the pathogens of high concern in patients with severe burns
Among Gram-negative ones, P. aeruginosa are not only the major pathogens that cause respiratory tract infections (HAIs) but are also ubiquitous in invasive burn wounds, owing to their preference for moist environments. Pseudomonas is usually followed, as frequence, by Acinetobacter baumanii, Enterobacter cloacae, Escherichia coli, Serratia marcescens, Klebsiella oxytoca, K. pneumoniae, Stenotrophomonas maltophilia, Salmonella enteritidis, Proteus miribalis.
In this study, Gram-positive bacteria were the most common causative agents of bloodstream infections in patients with burns (54.6%), followed by Gram-negative bacteria (32.9%) and fungi (12.3%). Gram-negative bacteria were the most common causative agent of wound infections (86.7%). Prolonged hospitalization positively correlated with the extent of the burn surface area (P: 0.031), degree of burn (P: 0.001), use of central venous catheter (P: 0.028), and intensive care unit stay (P: 0.044)
The morning I arrived, the children was still feverish. Ceftriaxone was not covering BOTH the two most common pathogens in this scenario, S. aureus (and we have high burden of MRSA in Italy, and this child had a PICC line and had been a lot in PICU) and P. aeroginosas. A very risky choice by the doctors, in case the infection would have further progressed.
To cover them, I started cefepime (a IV gen cephalosporine with coverage for Pseudomonas) and Linezolid (to cover MRSA), as I don’t like vanco a lot (several problems with the line - which I stopped in that case), doses, side effects, etc.
Do you agree?
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In the afternoon, blood culture was positive for MSSA, so I stopped everything and continued with cefazoline, to narrow the spectrum with a first gen cefalosporin with anti MSSA activity.
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