Patient is a 16-year-old transferred to UMMC with Crohn’s Disease. The workup showed multiple intra-abdominal abscesses but  standard drainage was not yielding desired results. Consultation with Interventional Radiology led to drainage using tPA. The clinical question was what is the evidence for using adjuvant therapy, such as tPA,  for treating refractory intra-abdominal/intrapelvic abscesses.

The search for evidence began by backtracking from an article in Radiology provided by the Chief Resident: “Complex Abdominal and Pelvic Abscesses: Efficacy of Adjunctive Tissue-Type Plasminogen Activator for Drainage.” By retrieving it in Medline it was useful to see what subject headings had been assigned to aid in tracking down other related articles. The following search strategy was used:

1     Abdominal Abscess/dt, th [Drug Therapy, Therapy] (467)

2     Drainage/mt, td [Methods, Trends] (7769)

3     Crohn Disease/ (25802)

4     1 and 2 and 3 (4)

5     2 and 3 (43)

Incorporating Crohn’s Disease specifically in the search did not really retrieve any other on target articles. So,

Plan B:

One very useful search strategy is to look at who may have cited the article we have in hand. Usually this will lead to newer articles expanding on the work of the original article which is just what we are seeking. Medline (Ovid) and PubMed both offer links to citing articles. This technique led to finding several articles discussing the efficacy of using fibrinolytic agents, all concluding that it is beneficial and safe, including this randomized trial:

Randomized Prospective Comparison of Alteplase versus Saline Solution for the Percutaneous Treatment of Loculated Abdominopelvic Abscesses

Note: Multiple further searches using different combinations of terms did not yield any other recent articles that addressed adjuvant therapy in a Crohn’s patient.

Case presented was an 18-month-old with failed outpatient management of cervical lymphadenitis. Treatment options include antibiotic therapy and/or surgical drainage. Good discussion of management can be found in Long’s Principles & Practice of Pediatric Infectious Diseases in MDConsult.

 Here is the search performed  in Ovid Medline:

1     Lymphadenitis/dt, su, th [Drug Therapy, Surgery, Therapy] (627)

2     Drainage/ (30222)

3     Anti-Bacterial Agents/tu [Therapeutic Use] (82576)

4     1 and (2 or 3) (130)

5     limit 4 to “all child (0 to 18 years)” (87)

6     limit 5 to english language (67)

7     cervical.m_titl. (61301)

8     6 and 7 (17)

Here are two relevant articles: 

Dulin MF. Kennard TP. Leach L. Williams R
 Carolinas Medical Center, Eastland Department of Family Medicine, Charlotte, North Carolina, USA.
Management of cervical lymphadenitis in children. [Review] [10 refs]
American Family Physician. 78(9):1097-8, 2008 Nov 1.

Peters TR. Edwards KM.
Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
Cervical lymphadenopathy and adenitis. [Review]�
Pediatrics in Review. 21(12):399-405, 2000 Dec.

The case presented was a 2-week old infant with fever and possible omphalitis. The questions raised during the discussion focused on finding evidence-based management information for sepsis in a neonate. The first attempts to find guidelines at http://guideline.gov did not yield any on-target results. The e-books linked from the HS/HSL website led to more useful information. I searched on “pediatric*” as a word in title  (the * searches for singular and plural) to see what books were available and selected Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed. Searching there for ‘sepsis’ retrieved a chapter on bacterial infections in the neonate with great information. This book is part of MD Consult (linked from the HS/HSL database list) a one-stop website that includes e-books, journals, patient handouts and more. It is another good starting point for background information on a particular disease or topic.

Case presented was an 18-year-old female that had recently given birth (January) presenting with abdominal pain, nausea, vomiting, diarrhea, backache. Laboratory findings pointed to pyelonephritis but also showed hypokalemia. In trying to relate that finding to the infection, a search was done in Medline.

Database: Ovid MEDLINE(R) 1950 to Present with Daily Update Search Strategy:

——————————————————————————–

1     Pyelonephritis/ (12397)

2     Hypokalemia/ (6459)

3     1 and 2 (37)

4     limit 3 to english language (14)

Of the 14 articles retrieved one discussed this finding in very young infants  who were in very poor health and dehydrated. The only other relevant article was from 1963, from the Annals of Internal Medicine entitled “The relationship of chronic pyelonephritis to chronic potassium deficiency.”  A follow-up search in PubMed (pyelonephritis and (hypokalemia or potassium)) retrieved an even older case report article from 1956,  from the British Medical Journal entitled “Potassium-losing pyelonephritis.” Their conclusion: “Thus we postulate that only a renal lesion could explain the clinical and laboratory findings in this case. This lesion may either have been present before the attacks of pyelonephritis or could possibly have developed as a result of it.” By the magic of citing forward this led to a 1969 article that followed up on the topic.

A quick look into some of our e-Textbooks did not offer too much help, but a discussion in Harrison’s Principles of Internal Medicine  did address the question of continued fever in the patient:

“The manifestations of acute pyelonephritis usually respond to appropriate therapy within 48-72 h. However, despite the absence of symptoms, bacteriuria or pyuria may persist. In severe pyelonephritis, fever subsides more slowly and may not disappear for several days, even after appropriate antibiotic treatment has been instituted. Persistence of fever or of symptoms and signs beyond 72 h suggests the need for urologic imaging.”

Finally, the discussion of the possibility of this patient having retained placenta causing an infection led to the question of how long post partum should this be considered a concern.  This was a bit elusive, but a search of the National Guideline Clearinghouse, an excellent web site for evidence-based clinical guidelines, turned up this somewhat related statement in a guideline on postpartum hemorrhage:

A 2-month old presented with fever, upper respiratory symptoms and poor feeding. The discussion pointed out the importance of considering a more serious bacterial infection occuring along with a viral infection. To investigate what the current guidelines and considerations are the following general search was performed in Ovid Medline:

1     exp Infant/ (801916)

2     Respiratory Syncytial Virus Infections/ (3449)

3     Bacterial Infections/ (52698)

4     1 and 2 and 3 (26)

I used Infant (exploded to include infant, newborn) as a subject term. You could also combine RSV and bacterial infections and then use the age limit of all infant to restrict your results. In this case, the same 26 articles would be retrieved, but occasionally it may be useful to do the search both ways to be sure you do not miss anything. The human side of indexing can create discrepancies, and this is one way to double-check your strategy.

The results proved interesting, in that there seems to be some varying opinions on how to manage these infants. This 2004 article, Risk of  serious bacterial infection in young febrile infants with respiratory syncytial virus infections in Pediatrics by Levine et.al. concludes that “febrile infants who are < or =60 days of age and have RSV infections are at significantly lower risk of SBI than febrile infants without RSV infection. Nevertheless, the rate of SBIs, particularly as a result of UTI, remains appreciable in febrile RSV-positive infants.”

Also raised in the discussion was the possibility of hyperbilirubinemia occuring in newborns taking ceftriaxone. I retrieved only one  useful article (this time in PubMed, searching ceftriaxone and infants and hyperbilirubinema. Only the abstract for this article is available.

Safety of ceftriaxone sodium at extremes of age

Conclusion: “Ceftriaxone should be avoided or significantly minimized in neonates (especially those treated concomitantly with intravenous calcium solutions and those with hyperbilirubinemia).”

Lastly, the question arose of guidelines for treatment of UTI in infants. A search of the National Guideline Clearinghouse (www.guideline.gov) retrieved Evidence-based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode from Cinncinati Children’s Hospital.