44: Febrile Digest - Gotta CAP 'Em All!

Sara Dong: 00:00:08

Hello, everyone.

Sara Dong: 00:00:09

Welcome to Febrile a cultured podcast about all things infectious disease.

Sara Dong: 00:00:13

My name is Sara Dong.

Sara Dong: 00:00:14

I'm your host and a Med Peds ID fellow.

Sara Dong: 00:00:17

We are back for another Febrile Digest and I have a new friend

Sara Dong: 00:00:20

with me here today, Michael.

Sara Dong: 00:00:22

Can you introduce yourself and say hello?

Michael Cosimini: 00:00:24

Thanks so much for having me here.

Michael Cosimini: 00:00:26

My name is Michael Cosimini.

Michael Cosimini: 00:00:27

I am a pediatrician.

Michael Cosimini: 00:00:29

I am at OSHU right now, and I am a real enthusiast of medical education

Michael Cosimini: 00:00:35

and this podcast in particular.

Sara Dong: 00:00:37

That's very nice.

Sara Dong: 00:00:38

You're an honorary ID person because of all your love for antibiotics.

Michael Cosimini: 00:00:43

I'm, uh, I am a ID Twitter lurker.

Michael Cosimini: 00:00:46

Absolutely.

Sara Dong: 00:00:47

Well, I was going to say if people don't know you, um,

Sara Dong: 00:00:50

run the Empiric game account, which has a lot of jokes, often at the

Sara Dong: 00:00:55

expense of cefdinir, which is fair.

Sara Dong: 00:00:58

Um, so we were going to talk a little bit today about pneumonia in

Sara Dong: 00:01:03

kids, and then hopefully a little bit just about some serious gaming.

Michael Cosimini: 00:01:08

Yeah, absolutely.

Michael Cosimini: 00:01:08

There's been some really good pediatric pneumonia studies that have come out

Michael Cosimini: 00:01:11

in the last year and I'm glad to have had a chance to review them for this.

Sara Dong: 00:01:14

Yeah.

Sara Dong: 00:01:15

We in ID often get this very skewed perspective of pneumonia, and I

Sara Dong: 00:01:20

think it's because we generally are seeing kids that are in the

Sara Dong: 00:01:23

hospital, that have been admitted or have some sort of complication.

Sara Dong: 00:01:26

And so this was a really good exercise for me as well, to think about some of

Sara Dong: 00:01:30

the newer literature that had come out for treating young children with community

Sara Dong: 00:01:34

acquired pneumonia, or I'm going to say CAP because it is easier to say.

Sara Dong: 00:01:37

So we're going to start first by just doing a quick refresher

Sara Dong: 00:01:41

on the microbiology or the etiologies that we see with CAP.

Sara Dong: 00:01:45

What do you think, Michael?

Michael Cosimini: 00:01:46

I think community acquired pneumonia or CAP is a tough

Michael Cosimini: 00:01:49

diagnosis, and I think that there is a lot of variability of what people are

Michael Cosimini: 00:01:54

calling this and how it's diagnosed.

Michael Cosimini: 00:01:56

And I think that's really important when we think about these studies.

Michael Cosimini: 00:01:58

There was an excellent presentation at PAS last week actually, where they were

Michael Cosimini: 00:02:02

showing huge variability in rates of diagnosis of CAP in patients hospitalized

Michael Cosimini: 00:02:07

with lower respiratory tract infections.

Michael Cosimini: 00:02:10

And that feels totally right to me.

Michael Cosimini: 00:02:13

Um, and there's also like not great inter-rater reliability of some of the

Michael Cosimini: 00:02:17

findings that we use to diagnose CAP in an outpatient, like auscultation for

Michael Cosimini: 00:02:22

crackles or for reduced breath sounds.

Michael Cosimini: 00:02:24

You put two different docs in the room and they're going to say different things.

Michael Cosimini: 00:02:27

So this is a hard diagnosis.

Michael Cosimini: 00:02:29

It's not like got a great research definition and it's

Michael Cosimini: 00:02:32

hard to diagnose clinically.

Michael Cosimini: 00:02:33

So I think that's like an important first step to think about when

Michael Cosimini: 00:02:36

we think about these studies.

Michael Cosimini: 00:02:37

The second half of this, which bugs are we dealing with?

Michael Cosimini: 00:02:41

And that's also not perfectly known in kids.

Michael Cosimini: 00:02:43

And I'm sort of excited to be talking to an adult about this.

Michael Cosimini: 00:02:46

Cause like, I think like pediatric pneumonia is not the

Michael Cosimini: 00:02:49

same thing as adult pneumonia.

Michael Cosimini: 00:02:53

And so, and we don't know exactly what's happening, right?

Michael Cosimini: 00:02:55

What we know is like kids that are admitted to the hospital with

Michael Cosimini: 00:02:57

pneumonia often have positive viral tests really, really frequently, but

Michael Cosimini: 00:03:02

like if I go viral test the kids in the grocery store, a lot of them will

Michael Cosimini: 00:03:06

also have positive viral testing.

Michael Cosimini: 00:03:08

Pre pneumococcal vaccine, a huge percentage of kids, you could

Michael Cosimini: 00:03:11

demonstrate pneumococcal infections in.

Michael Cosimini: 00:03:14

Post pneumococcal vaccine, that's not the case anymore, right?

Michael Cosimini: 00:03:17

Like one of the best like that, 2015 Jain, et al.

Michael Cosimini: 00:03:20

epi study where they tried to figure out why hospitalized kids had pneumonia.

Michael Cosimini: 00:03:23

They prove like 5% of them have pneumococcus.

Michael Cosimini: 00:03:26

And so what are we dealing with, right?

Michael Cosimini: 00:03:29

Like what is pneumonia?

Michael Cosimini: 00:03:30

I'm not totally sure, but Strep pneumo is still the most important,

Michael Cosimini: 00:03:33

like quote unquote, typical pathogen.

Michael Cosimini: 00:03:36

After that, it's the gram-positives that every pediatrician needs to love -- Strep,

Michael Cosimini: 00:03:39

um, Staph aureus, and Group A Strep.

Michael Cosimini: 00:03:42

And after those three, it really is rare to have specific individual bugs -- other

Michael Cosimini: 00:03:48

Strep Viridans, Chlamydia pneumoniae, H flu, and maybe other gram negatives.

Michael Cosimini: 00:03:52

But, you know, it's only the really sick kids where you prove what it was.

Michael Cosimini: 00:03:56

And what's actually going on in the alveoli of those other kids.

Michael Cosimini: 00:03:58

I don't know.

Sara Dong: 00:03:59

Yeah.

Sara Dong: 00:04:00

Yeah.

Sara Dong: 00:04:01

And I feel like, I always want to think about Mycoplasma, but it's

Sara Dong: 00:04:04

pretty uncommon in younger kids.

Sara Dong: 00:04:06

So I have this tendency to want to throw it on my list.

Sara Dong: 00:04:09

When in reality, I don't think it's actually that common, especially for

Sara Dong: 00:04:11

the really much, much younger children.

Michael Cosimini: 00:04:14

Yes.

Michael Cosimini: 00:04:15

It very quickly becomes the most common single identified

Michael Cosimini: 00:04:19

bacteria in kids as you get older.

Michael Cosimini: 00:04:21

Like if you NP PCR all these kids, old kids are gonna have Mycoplasma pneumonia.

Michael Cosimini: 00:04:27

But we're not exactly sure.

Michael Cosimini: 00:04:28

We don't typically cover for it.

Michael Cosimini: 00:04:29

We're not sure if coverage helps.

Michael Cosimini: 00:04:31

It's a tough, tough position to be in.

Sara Dong: 00:04:34

Yeah.

Sara Dong: 00:04:35

Well, so we don't always know exactly what we're treating and

Sara Dong: 00:04:38

then the other big question that we're going to focus on today is how

Sara Dong: 00:04:42

long do we treat children for CAP?

Sara Dong: 00:04:45

And so there's some WHO recommendations of three to five days, which is

Sara Dong: 00:04:51

specifically targeted towards low and middle income countries.

Sara Dong: 00:04:53

And I'd say historically for high-income countries, we use

Sara Dong: 00:04:56

somewhere around five to 10 days.

Sara Dong: 00:04:58

And so the first question people always ask is, are there guidelines?

Sara Dong: 00:05:01

Yes, but they're a bit dated now.

Sara Dong: 00:05:04

So there's a 2011 archived, uh, PIDS, so Pediatric ID Society, and

Sara Dong: 00:05:09

IDSA, ID society of America guidance.

Sara Dong: 00:05:11

Um, that at that point had said, yep, 10 days is the best studied, but we probably

Sara Dong: 00:05:15

can do shorter durations for mild cases.

Sara Dong: 00:05:19

And they make a point of having that little caveat of antibiotics probably

Sara Dong: 00:05:23

aren't needed for preschool aged children because they probably have a virus.

Sara Dong: 00:05:26

And separate from that, there's a British Thoracic Society guideline also from 2011

Sara Dong: 00:05:31

that essentially says the same thing.

Sara Dong: 00:05:33

This is kind of our baseline, somewhere in this like ambiguous five to 10 days.

Sara Dong: 00:05:38

And then since honestly, just in these past couple of years, I feel like

Sara Dong: 00:05:42

several of these papers that we're going to talk about, uh, came out.

Sara Dong: 00:05:45

And so, although there's been several randomized trials for, uh, children with

Sara Dong: 00:05:51

non hospitalized pneumonia and low and middle income, we're not really going to

Sara Dong: 00:05:56

talk about those quite as much today, or we're going to focus on what's available

Sara Dong: 00:05:59

to us for uncomplicated pneumonia.

Sara Dong: 00:06:02

And if you look at high-income countries, that's only actually a handful of a couple

Sara Dong: 00:06:07

named trials that I think everyone has probably heard over the past year or two.

Sara Dong: 00:06:11

And so we're going to focus on those, the one suggesting somewhere

Sara Dong: 00:06:14

between like three and five days.

Sara Dong: 00:06:16

Um, so I guess I will start with the first one.

Sara Dong: 00:06:19

The one that I have to start off with is the SAFER trial.

Sara Dong: 00:06:23

S A F E R, um, by Pernica and others in JAMA Pediatrics from last year.

Sara Dong: 00:06:28

So this one was a randomized trial at two Canadian centers that looked at children

Sara Dong: 00:06:35

six months to 10 years old with CAP.

Sara Dong: 00:06:38

So they had fever.

Sara Dong: 00:06:39

They may have had some respiratory symptoms like tachypnea , or

Sara Dong: 00:06:43

like a primary diagnosis of CAP from the emergency room.

Sara Dong: 00:06:46

And so they looked at five versus 10 days of high-dose of amoxicillin.

Sara Dong: 00:06:49

So that meant our control arm was amoxicillin at 90 mg/kg/d

Sara Dong: 00:06:54

split three times a day.

Sara Dong: 00:06:56

And then the intervention arm is the amoxicillin at that same dose,

Sara Dong: 00:07:00

but just for five days followed by five days of the placebo.

Sara Dong: 00:07:04

And so the clinical cure for these essentially the same about an 89, 90%.

Sara Dong: 00:07:09

Um, and so that, that's where I'm going to get us started.

Sara Dong: 00:07:13

I'll throw it over to Michael.

Michael Cosimini: 00:07:15

Yeah.

Michael Cosimini: 00:07:15

And I love this trial.

Michael Cosimini: 00:07:16

I feel like these are Canadian ED docs, diagnosing pneumonia.

Michael Cosimini: 00:07:21

It's probably similar to the kids I'm going to say have pneumonia in my

Michael Cosimini: 00:07:24

clinic, if not a little bit sicker.

Michael Cosimini: 00:07:25

So they slightly sicker kids are doing okay on 5 days.

Michael Cosimini: 00:07:29

Love it.

Michael Cosimini: 00:07:30

The two threads I'd pull on on this one is they talk a little bit in one of the

Michael Cosimini: 00:07:34

appendices about caregiver absenteeism, and they find in the younger group

Michael Cosimini: 00:07:39

that the kids on the longer course of antibiotics, the adults miss more work.

Michael Cosimini: 00:07:43

And as an adult with my own like little humans at home, I think that's

Michael Cosimini: 00:07:46

like a super important outcome.

Michael Cosimini: 00:07:47

There's like a, uh, longer median time missing work for the

Michael Cosimini: 00:07:51

adults in that, in that group.

Michael Cosimini: 00:07:54

And this is like TID dosing too, which I know is probably optimal for

Michael Cosimini: 00:07:57

Strep pneumo, but contemporary Strep pneumo is probably less likely to be

Michael Cosimini: 00:08:00

resistant than it was back in the day.

Michael Cosimini: 00:08:03

And maybe BID dosing would help a little bit with that caregiver absenteeism.

Michael Cosimini: 00:08:07

Yeah.

Michael Cosimini: 00:08:07

I don't know, but a couple of threads I wanted to pull out on

Michael Cosimini: 00:08:09

that one, but I love this study.

Michael Cosimini: 00:08:10

Okay.

Michael Cosimini: 00:08:11

I've got one for you.

Sara Dong: 00:08:12

I'm ready.

Michael Cosimini: 00:08:12

This is SCOUT-CAP.

Michael Cosimini: 00:08:14

A lot of, a lot of good acronyms today.

Michael Cosimini: 00:08:16

This one is a study where they enroll about 380 kids.

Michael Cosimini: 00:08:20

These are kids that have previously been diagnosed, whether it's in primary care

Michael Cosimini: 00:08:24

primarily or urgent care, or the emergency room with community acquired pneumonia.

Michael Cosimini: 00:08:29

It's like now it's day three, four or five of antibiotics.

Michael Cosimini: 00:08:32

If they're getting better or they're not having persistent fever, they're

Michael Cosimini: 00:08:35

not still very sick with that.

Michael Cosimini: 00:08:37

They get randomized to complete a 10 day course with their original

Michael Cosimini: 00:08:40

beta lactam, amox mostly, but also some with amox-clav or cefdinir.

Michael Cosimini: 00:08:46

Ooh,

Sara Dong: 00:08:48

your favorite antibiotic

Michael Cosimini: 00:08:52

Um yeah, so they, they randomize either to complete the course

Michael Cosimini: 00:08:55

with the originally prescribed beta lactam for 10 days, or to switch to a placebo

Michael Cosimini: 00:09:01

at day five and look at their outcomes.

Michael Cosimini: 00:09:04

The outcomes in this one is a little bit tricky cause they, they have the

Michael Cosimini: 00:09:07

sort of ranked score sort of thing.

Michael Cosimini: 00:09:09

It would take a while to explain it.

Michael Cosimini: 00:09:11

I'm not going to bother, but basically the antibiotic side effects

Michael Cosimini: 00:09:14

were the same in the two groups.

Michael Cosimini: 00:09:16

The clinical outcomes were the same in the two groups.

Michael Cosimini: 00:09:19

Um, no one got hospitalized and they have less total days of antibiotics in

Michael Cosimini: 00:09:24

the group that got shorter courses of antibiotics, somewhat unsurprisingly.

Sara Dong: 00:09:27

Yeah, and I feel like I'm learning a lot about the way that

Sara Dong: 00:09:31

they did the primary outcome for the, I'll put a link for everyone to

Sara Dong: 00:09:34

read about, uh, that outcome ranking.

Sara Dong: 00:09:38

But I, I summarize it to myself as they have the same clinical response with

Sara Dong: 00:09:43

probably the same adverse effects and the one that has a shorter duration wins,

Sara Dong: 00:09:47

which I think is a very practical way to look at antibiotics and what we do in ID.

Michael Cosimini: 00:09:53

Yeah, and they do one other interesting thing, which is they,

Michael Cosimini: 00:09:56

they, they go back at these kids and look at their rates of antibiotic resistant

Michael Cosimini: 00:09:59

genes and they do show a little bit less, a little bit less of antibiotic

Michael Cosimini: 00:10:04

resistant genes in the kids that got the shorter course of antibiotics, which is

Michael Cosimini: 00:10:08

not super clinically applicable for me.

Michael Cosimini: 00:10:10

Like for the next kid that I see in my outpatient clinic.

Michael Cosimini: 00:10:13

But it's something to think about.

Sara Dong: 00:10:15

Yeah.

Sara Dong: 00:10:15

All right.

Sara Dong: 00:10:16

And then the third kind of major one that we wanted to make sure we talked about

Sara Dong: 00:10:19

is the, I've been saying CAP-IT trial.

Sara Dong: 00:10:22

I hope that's what everyone else has been saying.

Michael Cosimini: 00:10:24

Can you "cap it off" for us, Sara?

Sara Dong: 00:10:27

So this is from, Bielicki and others from JAMA also this past year.

Sara Dong: 00:10:31

Um, and this is what has really been suggesting the push towards

Sara Dong: 00:10:35

three days of amoxicillin.

Sara Dong: 00:10:37

So they had a little under 600 children that were at least six months old.

Sara Dong: 00:10:41

The median age was about two and a half years.

Sara Dong: 00:10:44

Um, and they looked at children discharged from the ED with CAP and

Sara Dong: 00:10:47

treated with amoxicillin at either a lower or standard dose of 35 to

Sara Dong: 00:10:53

50 mg/kg versus the high dose, so 75 to 90, it was dosed twice a day.

Sara Dong: 00:10:59

And then they did either three or seven days.

Sara Dong: 00:11:01

So these, all these patients, I guess I didn't mention where in the UK

Sara Dong: 00:11:04

and Ireland, and so they didn't need x-rays or specific labs to be included.

Sara Dong: 00:11:09

And they showed that the rate of antibiotic retreatment within 28 days

Sara Dong: 00:11:13

was similar for the two groups about 12%.

Sara Dong: 00:11:17

And so this suggested like maybe we can use three days and maybe we

Sara Dong: 00:11:21

can use standard dose amoxicillin.

Sara Dong: 00:11:23

I think that there are some challenges to generalizing it and you know,

Sara Dong: 00:11:28

how do we think about this if we're using other antibiotics or

Sara Dong: 00:11:31

perhaps older children, but I think.

Sara Dong: 00:11:34

I don't know that this was surprising to too many people and it just

Sara Dong: 00:11:38

encouraging that we can start hopefully shifting towards shorter courses.

Michael Cosimini: 00:11:42

Yeah.

Michael Cosimini: 00:11:42

All the, all of these studies really focus on that, that

Michael Cosimini: 00:11:45

younger age group, like, right.

Michael Cosimini: 00:11:46

Like I think the, the, the median in mine was three and two and a half year old.

Michael Cosimini: 00:11:51

And.

Michael Cosimini: 00:11:52

This one, I have a little trouble with, cause some of these kids,

Michael Cosimini: 00:11:54

they also got a little bit of antibiotics in the ED or the inpatient

Michael Cosimini: 00:11:57

setting before they got randomized.

Michael Cosimini: 00:12:00

I don't know.

Michael Cosimini: 00:12:00

I'm not ready to jump to low dose three day.

Sara Dong: 00:12:03

Yeah.

Sara Dong: 00:12:03

Um, and the only other thing I was going to mention, cause

Sara Dong: 00:12:06

I, I made Febrile Digest.

Sara Dong: 00:12:07

So we could talk about things that are current.

Sara Dong: 00:12:09

There actually was a, uh, article from Pediatric ID Journal, sorry.

Sara Dong: 00:12:16

All the acronyms are very similar just from this last

Sara Dong: 00:12:19

week that looked at some cases.

Sara Dong: 00:12:21

Uh, it's a multi-national double-blind trial that was in Australia

Sara Dong: 00:12:24

and New Zealand and Malaysia.

Sara Dong: 00:12:27

And, um, looked at children that had uncomplicated, but

Sara Dong: 00:12:32

radiographic confirmed CAP.

Sara Dong: 00:12:34

Uh, it's kind of interesting.

Sara Dong: 00:12:35

They did like one to three days of IV, then they had a couple of days

Sara Dong: 00:12:39

of oral amox-clavulanate then they got either randomized to 13 to 14

Sara Dong: 00:12:45

days or a standard five to six days.

Sara Dong: 00:12:47

And there's about 300 children with similar clinical cure rates.

Sara Dong: 00:12:52

It found no clinical benefit to doing the extended two week course, but I think at

Sara Dong: 00:12:56

this point people have really bought in.

Sara Dong: 00:12:58

And I don't know that many people are using that duration for an uncomplicated

Sara Dong: 00:13:03

pneumonia, but just another, you know, another one to add to the, to the list.

Sara Dong: 00:13:07

. So I, I think one thing that we haven't really talked about for all

Sara Dong: 00:13:11

these papers is, how much of these children actually just have a virus?

Sara Dong: 00:13:15

Um, yeah.

Sara Dong: 00:13:16

Would they have done well, regardless of whether or not we gave them antibiotics?

Sara Dong: 00:13:20

I don't know how you frame that and fit that into your

Sara Dong: 00:13:23

interpretation of all these trials.

Michael Cosimini: 00:13:25

I think it's so hard because there probably is a large slice

Michael Cosimini: 00:13:28

of kids in all of these studies that needed zero antibiotics and knowing which

Michael Cosimini: 00:13:33

kids those are, is really hard to say.

Michael Cosimini: 00:13:35

I think I feel very comfortable after reviewing these doing a five day course

Michael Cosimini: 00:13:39

of, you know, amoxicillin, uh, for kid I diagnosed with community-acquired

Michael Cosimini: 00:13:43

pneumonia, who's got a little bit of work of breathing or a little bit

Michael Cosimini: 00:13:46

of sat that's lower than I expected.

Michael Cosimini: 00:13:48

Now for that kid, that's got, you know, URI symptoms and I hear focal

Michael Cosimini: 00:13:51

crackles, but everything else seems fine.

Michael Cosimini: 00:13:54

I think that's the kid that I feel maybe a little more comfortable

Michael Cosimini: 00:13:56

saying, Hey, I don't need to give this kind of antibiotics

Michael Cosimini: 00:13:59

because most pneumonia is viral.

Michael Cosimini: 00:14:01

I'm not like 110% sure this kid's got pneumonia in the first place.

Michael Cosimini: 00:14:05

This gives us from ground to stand on for a five day course.

Michael Cosimini: 00:14:08

And I think we always knew we had a little bit of wiggle room for treatment at all

Michael Cosimini: 00:14:11

in those kids that have pneumonia that are not severe in this youngest age group.

Michael Cosimini: 00:14:17

There was a really great study this year, too, that I had to bring up as well about

Michael Cosimini: 00:14:20

viral testing because Hey, we know a lot of these kids have viruses, but virus and

Michael Cosimini: 00:14:25

bacteria co-infection is pretty common.

Michael Cosimini: 00:14:27

And, um, what to do with viral information is a little bit uncertain.

Michael Cosimini: 00:14:31

This was a single center RCT of 900 kids over the age of one with flu

Michael Cosimini: 00:14:37

like illness, which they defined almost a fever, 37.8 plus cough,

Michael Cosimini: 00:14:43

congestion, sore throat or rhinorrhea.

Michael Cosimini: 00:14:45

They do a nasal pharyngeal respiratory panel on all the kids, but only give

Michael Cosimini: 00:14:50

the results to half the docs and they look and say, Hey, does this

Michael Cosimini: 00:14:53

reduce antimicrobial prescribing?

Michael Cosimini: 00:14:55

And the answer was a very firm no.

Michael Cosimini: 00:14:57

It didn't help.

Michael Cosimini: 00:14:59

And I think people will tell you they'll use that information,

Michael Cosimini: 00:15:02

but this really goes against.

Michael Cosimini: 00:15:05

Yeah,

Sara Dong: 00:15:05

I really love, I thought this paper was fascinating.

Sara Dong: 00:15:08

I was really glad that you wanted to talk about it because, um, I think we

Sara Dong: 00:15:13

see a mixture of that where sometimes we think that someone feels confident

Sara Dong: 00:15:17

enough, but there are plenty of cases where we get that answer and they still

Sara Dong: 00:15:21

go out with the smidge of antibiotics.

Michael Cosimini: 00:15:24

Yeah.

Michael Cosimini: 00:15:25

So now that would be Rao, et al.

Michael Cosimini: 00:15:26

in Pediatrics in 2021.

Sara Dong: 00:15:29

Yeah.

Sara Dong: 00:15:29

And I, I mean, I feel like my sort of takeaways were similar to what you

Sara Dong: 00:15:33

were saying is that I think most people agree that pediatric patients who

Sara Dong: 00:15:37

come to clinic that have uncomplicated CAP at most should get five days.

Sara Dong: 00:15:41

And there's, you know, this question of what to do with these kids that are

Sara Dong: 00:15:44

younger than may have a virus, but.

Sara Dong: 00:15:47

It's it's hard because I, I definitely don't see enough kids

Sara Dong: 00:15:51

that I would be deciding if they would get three or five days.

Sara Dong: 00:15:54

Um, so I have to learn from folks like you and tell me, tell me

Sara Dong: 00:15:57

what really happens in clinic.

Michael Cosimini: 00:15:59

Well, the question I would ask you, and we actually had in

Michael Cosimini: 00:16:02

that very first study, is those kids that you take care of in the hospital?

Michael Cosimini: 00:16:05

Are they coming in on day six of amoxicillin, day seven of amoxicillin, or

Michael Cosimini: 00:16:09

are those kids getting sick right away.

Michael Cosimini: 00:16:11

And in that very first study that it was SAFER I believe they said that they

Michael Cosimini: 00:16:16

had seven hospitalizations in that one and six of them were hospitalized in

Michael Cosimini: 00:16:20

the first five days of therapy anyways.

Michael Cosimini: 00:16:22

So I thought that was like a nice little fact.

Sara Dong: 00:16:25

Yeah.

Sara Dong: 00:16:25

I wish I knew what, what I've actually seen.

Sara Dong: 00:16:28

I do feel like that seems to be more common, you know, when I've seen patients

Sara Dong: 00:16:33

who come early on rather than later, but, um, it would be nice to have a

Sara Dong: 00:16:37

sense of what that number actually is.

Michael Cosimini: 00:16:40

Yeah.

Sara Dong: 00:16:41

Great.

Sara Dong: 00:16:41

Well, so, I mean, I don't know that we totally solved it, but

Sara Dong: 00:16:44

hopefully everyone feels more up-to-date and more comfortable.

Sara Dong: 00:16:47

And at a minimum knows the new acronyms for CAP

Michael Cosimini: 00:16:52

We are in agreement five days for community acquired pneumonia.

Michael Cosimini: 00:16:55

We feel pretty good about that.

Michael Cosimini: 00:16:57

I wanted to get a chance to talk a little bit about medical education here with you,

Michael Cosimini: 00:17:00

since you're doing such an interesting project and talk a little bit about games

Michael Cosimini: 00:17:04

for med ed, because I think it's, uh, ID is just a beautiful place to use those.

Michael Cosimini: 00:17:08

There's so many interesting bugs and drugs and things.

Michael Cosimini: 00:17:11

Um, so if I could borrow a little bit of your time for that, I would love it.

Sara Dong: 00:17:13

Yes, of course, this is my secret motive was to get you on

Sara Dong: 00:17:17

the show and tell everyone about how you've been using games to teach

Sara Dong: 00:17:21

about our beloved bugs and drugs.

Sara Dong: 00:17:23

And I mentioned this earlier, but just to remind everyone, Mike is

Sara Dong: 00:17:27

the creator of the Empiric Game, which helps each antibiotics, but

Sara Dong: 00:17:31

that's just one of several games.

Sara Dong: 00:17:33

And we're going to talk a little bit about the perfectly named, Guess Poo

Michael Cosimini: 00:17:37

We are going to try a little bit of an experiment and we're

Michael Cosimini: 00:17:40

going to play a game on the podcast.

Michael Cosimini: 00:17:42

So everyone please imagine in your head, you're holding a handful of 18 cards.

Michael Cosimini: 00:17:48

These 18 cards have a name of a pathogen that causes infectious diarrhea and

Michael Cosimini: 00:17:53

little icons and words that describe the exposure, host factors and symptoms that

Michael Cosimini: 00:17:59

would make you think that that is the type of diarrhea that you're dealing with.

Michael Cosimini: 00:18:04

This is, uh, this is just a little game exercise that's designed to teach semantic

Michael Cosimini: 00:18:08

qualifiers, which is those sort of binary things we, we think about as doctors,

Michael Cosimini: 00:18:13

when we're trying to figure something out.

Michael Cosimini: 00:18:14

Febrile vs not, bloody vs watery, acute vs chronic..

Michael Cosimini: 00:18:18

Those kinds of things that you know, are, are helping us in our little

Michael Cosimini: 00:18:22

decision trees as we're seeing patients.

Michael Cosimini: 00:18:24

And so we're gonna do an experiment where we're going to play this game.

Michael Cosimini: 00:18:28

Sara, do you have your cards ready?

Sara Dong: 00:18:29

I'm ready.

Michael Cosimini: 00:18:31

Okay, so let's have you let's have you be the, um,

Michael Cosimini: 00:18:34

the one with the diarrhea first.

Michael Cosimini: 00:18:36

So pick out one of those cards that is like a patient you can remember

Michael Cosimini: 00:18:40

recently, or just one that you want to think about a little bit.

Sara Dong: 00:18:43

Okay.

Sara Dong: 00:18:43

I'm ready.

Michael Cosimini: 00:18:45

And I am going to ask yes, no questions and try to figure out

Michael Cosimini: 00:18:48

what you're dealing with right here.

Michael Cosimini: 00:18:49

Okay.

Michael Cosimini: 00:18:50

So is your diarrhea bloody?

Sara Dong: 00:18:53

No.

Michael Cosimini: 00:18:54

So it's not a bug that is typically

Michael Cosimini: 00:18:56

associated with bloody diarrhea.

Sara Dong: 00:18:58

Nope.

Michael Cosimini: 00:18:59

Okay.

Michael Cosimini: 00:18:59

So I'm getting rid of Shigella and Vibrio, like non-cholera Vibrio.

Michael Cosimini: 00:19:03

I'm getting rid of non typhoidal salmonella.

Sara Dong: 00:19:07

I wish everyone could see how cool these cards look.

Michael Cosimini: 00:19:10

Not Yersinia, probably.

Michael Cosimini: 00:19:11

Not Campy probably.

Michael Cosimini: 00:19:13

All right.

Michael Cosimini: 00:19:15

How about this?

Michael Cosimini: 00:19:15

Is this diarrhea typically associated with travel?

Michael Cosimini: 00:19:18

Like if I'm, if I live North America, is this associated me traveling

Michael Cosimini: 00:19:21

somewhere and coming back with it?

Sara Dong: 00:19:22

Not necessarily.

Sara Dong: 00:19:25

Um, no.

Michael Cosimini: 00:19:28

All right.

Michael Cosimini: 00:19:28

So I'm thinking probably like less likely cholera, um, or Cyclospora.

Michael Cosimini: 00:19:36

Okay.

Michael Cosimini: 00:19:36

Is this diarrhea associated with recreational water or fresh water?

Sara Dong: 00:19:41

Yes.

Michael Cosimini: 00:19:42

Ooh, we've narrowed it down quite a bit.

Michael Cosimini: 00:19:46

Okay.

Michael Cosimini: 00:19:47

So I think this is cryptosporidium that we're dealing with.

Sara Dong: 00:19:52

Uh,

Michael Cosimini: 00:19:53

No!

Michael Cosimini: 00:19:57

Giardia

Sara Dong: 00:19:58

It is Giardia!

Sara Dong: 00:20:00

Actually I realized like now, based on the questions you

Sara Dong: 00:20:03

said it could have been Crypto.

Sara Dong: 00:20:05

I had Giardia though, my hand.

Michael Cosimini: 00:20:06

Nice.

Sara Dong: 00:20:09

Oh, this is awesome.

Sara Dong: 00:20:11

And the nice thing is that you may, you know, you don't have to have a

Sara Dong: 00:20:15

baseline knowledge of all of these.

Sara Dong: 00:20:19

What's nice about these is you have something in your hands and you're

Sara Dong: 00:20:21

reviewing it in a way that's fun.

Sara Dong: 00:20:24

I think that's, what's been nice about seeing some of these MedEd games

Sara Dong: 00:20:28

is especially thinking about using it for people who are not used to,

Sara Dong: 00:20:31

or not as familiar with either the infection or the antibiotics, which is

Sara Dong: 00:20:35

what most of the ID related ones are.

Sara Dong: 00:20:37

And I think that's really nice because I, I swear the most common

Sara Dong: 00:20:40

question I get when people hear that I like ID and medical education

Sara Dong: 00:20:45

is how do we teach antibiotics?

Michael Cosimini: 00:20:46

Yeah.

Sara Dong: 00:20:47

As if there's like one single, like good answer, there's not,

Sara Dong: 00:20:50

but the more tools like this that we would have to think about teaching, uh,

Sara Dong: 00:20:55

ID or infections or drugs is amazing.

Michael Cosimini: 00:20:59

Yeah.

Michael Cosimini: 00:20:59

I think that you're bringing up a couple of important points about

Michael Cosimini: 00:21:02

games, like it's active learning.

Michael Cosimini: 00:21:03

Right.

Michael Cosimini: 00:21:03

Which is a really good way to learn, to use active strategies.

Michael Cosimini: 00:21:06

And it's like a little bit of a more low stakes environment.

Michael Cosimini: 00:21:09

It's okay to be wrong.

Michael Cosimini: 00:21:10

Like I just demonstrated, um, but very publicly.

Michael Cosimini: 00:21:16

When you're playing a game, right.

Michael Cosimini: 00:21:17

It's, it's easier to be wrong, playing a game than it is when

Michael Cosimini: 00:21:19

someone asks you a question on rounds.

Michael Cosimini: 00:21:21

Right.

Michael Cosimini: 00:21:21

I think that's, that's the goal is to make people feel like they can explore and

Michael Cosimini: 00:21:24

they can experiment and they can practice and get it right over time in a safe way.

Michael Cosimini: 00:21:29

Right.

Michael Cosimini: 00:21:30

And I think games are good for that.

Sara Dong: 00:21:31

Yeah.

Sara Dong: 00:21:32

Okay.

Sara Dong: 00:21:33

Now you have to tell everyone how they can find all these games, because I

Sara Dong: 00:21:37

want everyone to know that I printed these out today, which you could do too.

Michael Cosimini: 00:21:41

Yeah.

Michael Cosimini: 00:21:42

Oh, and here's our double-sided!

Michael Cosimini: 00:21:43

Yours are better than mine.

Sara Dong: 00:21:45

I'm double-sided and color.

Sara Dong: 00:21:47

They look magnificent.

Michael Cosimini: 00:21:48

They're beautiful.

Michael Cosimini: 00:21:49

I so all of my games that I make are free to print.

Michael Cosimini: 00:21:52

It's a bit.ly/printempiric take you there.

Michael Cosimini: 00:21:56

Or if you just go to empiric game.com, all one word, that's like,

Michael Cosimini: 00:22:00

you can find all my stuff there.

Michael Cosimini: 00:22:02

Um, my big one is empiric, which is, uh, an antibiotic card games.

Michael Cosimini: 00:22:05

Kind of like, you know, learn your antibiotics the way you learn your

Michael Cosimini: 00:22:08

Pokemon with a little bit of, you know, antibiotics with iconography that

Michael Cosimini: 00:22:12

helped you learn the important bugs your, your, um, your MRSAs and such a.

Michael Cosimini: 00:22:17

And color-coding that helps you kind of encode those spectrum of activity

Michael Cosimini: 00:22:21

from back when we had to memorize that with your beta lactams being blue and,

Michael Cosimini: 00:22:24

you know, a rainbow kind of teaching you the, uh, the spectrum of activity.

Sara Dong: 00:22:29

You know, Febrile needed more Pokemon references.

Sara Dong: 00:22:31

So I really appreciate your Pokemon.

Michael Cosimini: 00:22:34

I don't know if that I've heard one yet.

Sara Dong: 00:22:36

I know that's what I'm saying.

Sara Dong: 00:22:38

It's been a lack of Pokemon or Pikachu references.

Sara Dong: 00:22:42

Well, this is so awesome.

Sara Dong: 00:22:44

So I'll make sure that for everyone who listens, I'll put a link to this,

Sara Dong: 00:22:47

obviously on our Twitter as well, and on the website, because I hope that

Sara Dong: 00:22:52

people can use these and, and spread the

Sara Dong: 00:22:54

word.

Michael Cosimini: 00:22:55

I really appreciate you letting me join this

Michael Cosimini: 00:22:58

community here and be on the show.

Michael Cosimini: 00:22:59

Thank you so much, Sara.

Sara Dong: 00:23:01

Yeah.

Sara Dong: 00:23:01

Thanks for joining.

Sara Dong: 00:23:03

Well, I hope it was quite obvious that I had a lot of fun with this episode.

Sara Dong: 00:23:07

Thank you so much to Michael for joining Febrile today.

Sara Dong: 00:23:10

And I hope you'll all check out Empiric game and Guess Poo.

Sara Dong: 00:23:13

Uh, maybe consider using it to kick off your consult rounds

Sara Dong: 00:23:16

one day with new learners.

Sara Dong: 00:23:18

I will mention that after we recorded this, there actually was a new manuscript

Sara Dong: 00:23:21

in CID on antibiotic treatment duration for CAP in outpatient children and

Sara Dong: 00:23:26

high-income countries, a systematic review and meta analysis from Dr.

Sara Dong: 00:23:31

Kuitunen et al.

Sara Dong: 00:23:33

in mid May.

Sara Dong: 00:23:34

And that came to a similar conclusion that we've been talking about on the

Sara Dong: 00:23:37

show that short treatment for three to five days was seen as equally

Sara Dong: 00:23:41

effective and safe, compared to longer recommendations for seven to 10 days for

Sara Dong: 00:23:46

children over six months of age with CAP.

Sara Dong: 00:23:49

So we'll try to do our best to still have some literature updates here

Sara Dong: 00:23:52

on Febrile Digest episodes, but you can also check out Puscast which is

Sara Dong: 00:23:57

back with Daniel Griffin and myself.

Sara Dong: 00:24:00

We provide a review of the ID literature for the last two weeks that

Sara Dong: 00:24:03

we found interesting or entertaining.

Sara Dong: 00:24:05

So you can find that online at microbe.tv/puscast or in

Sara Dong: 00:24:09

whatever podcast directory.

Sara Dong: 00:24:11

In some other news there now is also Febrile merchandise available on our

Sara Dong: 00:24:17

online store in case you want to get some swag, like a shirt, mug or lanyard

Sara Dong: 00:24:21

to you show your support for Febrile.

Sara Dong: 00:24:23

You can check out the website, febrilepodcast.com to find the link to

Sara Dong: 00:24:26

the store as well as links to the papers mentioned today in our Consult Notes,

Sara Dong: 00:24:31

the written complements of the show, and lastly, the link to our new and

Sara Dong: 00:24:35

upgraded infographic library, which is now much easier to sort and is searchable!

Sara Dong: 00:24:41

Please reach out if you have any suggestions for future shows or want

Sara Dong: 00:24:44

to be more involved with Febrile.

Sara Dong: 00:24:46

Thanks for listening.