Daughter with Pneumonia, etc.

[sagnet]

I have a 2-1/2 yr old daughter who is allergic to Penicillins and Cephalosporins that has been in PSL for 11 days now.

Nov 17 - Surgery was done to clear dense fluid and tube to drain fluid to treat bacteria pneumonia.   Vancomycin was used as antibiotic.
Nov 18-Nov 23
-  difficulties getting Vanomycins to Therapeutic levels
-  culture fluid from lungs showed streptococcus pneumoniae
-  Switch antibiotic to Bactrim due to sensitivity
-  Spiking fevers but has slowly shown improvement in blood number and fever level.
Nov 24
- Concern over fevers and spot on X-ray with subsequent CT scan reveal abscess of 4cm x 5 cm on right lung.
- Surgeon removed option of surgically removing abscess off the table due to risks.
- Staph Infection was found in central line.  Blood cultures have been done to ascertain if Staph has enter bloodstream.
- Medications were switch to Vancomycin and Clenomycin to cover options for addressing the abscess.  
- No Fever past two days
Nov 25
- low grade Fever spiked, but was treated with Tylenol,  could have masked true peak - No growth from blood culture yet.  
- Dr. Suspect fever could be from staph.  Talking about release based on blood, fever, markers.  Treatment: home antibiotics for 4 weeks as well as feeding tube.
Nov 26
- fever spike again at night to 102.5 F.  During this fever spike skins seem to flush purple and spotty. What's this?

Essentially Abscess, Pneumonia, Staph Infection and allergy to penicillin.     Questions are:

1)  Is their some outstanding question that is getting missed?  
2)  Abscess is concerning are there other options to address this?  
3)  Can a high grade fever be the staph infection or is it the scary abscess?
4)  Is this treatment plans thus far valid or is there other options that can be used to treat this?
5)  Opened to pushing to involved others to this team or even transfer facilities to do what's best.

[sagnet]

Thanks so much for the reply.  First a quick updated on my daughter and a few follow up questions.  The Staph infection turn out to be Staphylococcus epidermidis only found on the central line and not in the bloodstream.  She ended up staying at the hospital another 5 days.  The pediatric ID has her going through a 10 day regime for the Staph and all blood cultures have come up negative and another 3 week regime of Clindamycin for the abcess at home.

As a follow up question, I am still concerned about the abscess and it seems that everyone is just going on the pediatric surgeon's advice that antibiotic therapy will work for the abscess.  Originally, the ID doc had concerns about antibiotics pentrating the membrane of the abscess.  It makes me nervous that we are solely relying on CAT scans to tell if it's shrinking or not.  Plus, even if it shows that it is indeed shrinking, that doesn't necessary give me comfort that the fluid in the abscess is going to stay dormant. There is not a pediatric pulmonologist on the team right now and I am definitely moved to follow your advice on this.   How do I go about getting a doctor of this specialty involved?  Is there one that your recommend in Denver? Does insurance cover second opinions?  Regardless...my daughter is worth it.

Lastly, where would the answer of inherited or acquired immunodeficiency state question lead me?

Thanks again.

[National Jewish Health]

Your concerns are warranted.  This is a scary series of events and, unless there have been signs of progressive improvement since your last report of November 26, one might question the appropriateness of discharging your daughter from the hospital, with the diagnoses of lung abscess and staph septicemia.  I assume that your daughter’s antibiotic therapy is being managed by a pediatric infectious disease (ID) specialist; if not, you should seek such consultation.  You would also want to ask the ID specialist if there might be an alternative antibiotic to vancomycin, such as linezolid, if that medicine were deemed appropriate for a 2½ year old child.

You should also consider getting another opinion regarding management of the lung abscess, which is probably the source of staph in your daughter’s blood.  It is often difficult and sometimes impossible to eradicate a lung abscess, without surgical drainage.  As the surgeon indicated, this would be a high risk procedure but a decision against surgery also carries risk.  You should seek another opinion regarding treatment of the abscess from another surgeon and/or a pediatric pulmonologist and you should request that the pulmonologist, the ID specialist and the surgeon convene to discuss the pros and cons of the available and feasible approaches.  Do not hesitate to request information or additional consultants, out of fear of offending your daughter’s physicians.  There is too much at stake.

Finally you should ask her doctors if the infection might be due to an inherited or acquired immunodeficiency state.

Good luck.