The Cost of a Culture and Doctoring at a Distance

[摘要] A term infant at a community hospital was noted to be apneic with thick meconium at birth. She required intubation for respiratory distress and had an initial axillary temperature of 38.27°C (100.9°F). Blood culture was drawn, umbilical catheter was placed, and ampicillin and gentamicin were started for presumed sepsis. The C-reactive protein (CRP) level at birth was 12.3 mg/L and rose to 30.8 mg/L on day of life (DOL) 2. Cerebrospinal fluid (CSF) was drawn, but the fluid had too many red blood cells for a reliable white blood cell count. The CSF was sent for culture, which remained negative. The NICU team trended CRP levels, and on DOL 3, the CRP fell to 20 mg/L. The neonate continued to do well clinically and on DOL 3 was transitioned to room air. On DOL 7, she was ready for discharge, but the care team decided to obtain another CRP before discontinuation of antibiotics. It was then 88 mg/L. Because of the elevated CRP, peripheral blood and CSF cultures were again obtained while the infant remained on antibiotics administered via umbilical catheter. The blood culture grew Klebsiella pneumoniae that was sensitive to gentamicin. The CSF culture was negative. The NICU team wanted to treat the infection appropriately and called the infectious diseases service at the regional referral hospital for advice on antibiotic choice. The infectious diseases team suggested that either ciprofloxacin or a carbapenem would be appropriate given the resistance pattern. Still, the infectious diseases team thought that bacteremia in an infant who was otherwise clinically ready for discharge was surprising. They suggested consideration of an endovascular source and an ultrasound of the umbilical vein given the concurrent presence of an umbilical line and the growth of a gentamicin-susceptible organism during gentamicin therapy. The radiology department at the community hospital was reportedly unable to obtain neonatal endovascular ultrasound, and therefore the NICU team requested that the infant be transferred to the regional children’s hospital. The infant was switched to intravenous ciprofloxacin, and the umbilical line was removed before transfer.

[学科分类] 儿科学

[关键词] Campylobacter;proljev;dob