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44: Febrile Digest - Gotta CAP 'Em All!
Episode 4430th May 2022 • Febrile • Sara Dong
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Michael Cosimini and Sara Dong chat about pediatric community acquired pneumonia and using games for learning about ID!

You teach me and I’ll teach you, bugs and drugs!!

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Transcripts

Sara Dong:

Hello, everyone.

Sara Dong:

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

Sara Dong:

My name is Sara Dong.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

with me here today, Michael.

Sara Dong:

Can you introduce yourself and say hello?

Michael Cosimini:

Thanks so much for having me here.

Michael Cosimini:

My name is Michael Cosimini.

Michael Cosimini:

I am a pediatrician.

Michael Cosimini:

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

Michael Cosimini:

and this podcast in particular.

Sara Dong:

That's very nice.

Sara Dong:

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

Michael Cosimini:

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

Michael Cosimini:

Absolutely.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

expense of cefdinir, which is fair.

Sara Dong:

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

Sara Dong:

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

Michael Cosimini:

Yeah, absolutely.

Michael Cosimini:

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

Michael Cosimini:

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

Sara Dong:

Yeah.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

What do you think, Michael?

Michael Cosimini:

I think community acquired pneumonia or CAP is a tough

Michael Cosimini:

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

Michael Cosimini:

calling this and how it's diagnosed.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

with lower respiratory tract infections.

Michael Cosimini:

And that feels totally right to me.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

crackles or for reduced breath sounds.

Michael Cosimini:

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

Michael Cosimini:

So this is a hard diagnosis.

Michael Cosimini:

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

Michael Cosimini:

hard to diagnose clinically.

Michael Cosimini:

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

Michael Cosimini:

we think about these studies.

Michael Cosimini:

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

Michael Cosimini:

And that's also not perfectly known in kids.

Michael Cosimini:

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

Michael Cosimini:

Cause like, I think like pediatric pneumonia is not the

Michael Cosimini:

same thing as adult pneumonia.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

also have positive viral testing.

Michael Cosimini:

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

Michael Cosimini:

demonstrate pneumococcal infections in.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

They prove like 5% of them have pneumococcus.

Michael Cosimini:

And so what are we dealing with, right?

Michael Cosimini:

Like what is pneumonia?

Michael Cosimini:

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

Michael Cosimini:

like quote unquote, typical pathogen.

Michael Cosimini:

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

Michael Cosimini:

um, Staph aureus, and Group A Strep.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

I don't know.

Sara Dong:

Yeah.

Sara Dong:

Yeah.

Sara Dong:

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

Sara Dong:

pretty uncommon in younger kids.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

the really much, much younger children.

Michael Cosimini:

Yes.

Michael Cosimini:

It very quickly becomes the most common single identified

Michael Cosimini:

bacteria in kids as you get older.

Michael Cosimini:

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

Michael Cosimini:

But we're not exactly sure.

Michael Cosimini:

We don't typically cover for it.

Michael Cosimini:

We're not sure if coverage helps.

Michael Cosimini:

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

Sara Dong:

Yeah.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

long do we treat children for CAP?

Sara Dong:

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

Sara Dong:

specifically targeted towards low and middle income countries.

Sara Dong:

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

Sara Dong:

somewhere around five to 10 days.

Sara Dong:

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

Sara Dong:

Yes, but they're a bit dated now.

Sara Dong:

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

Sara Dong:

IDSA, ID society of America guidance.

Sara Dong:

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

Sara Dong:

can do shorter durations for mild cases.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

that essentially says the same thing.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

to us for uncomplicated pneumonia.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

between like three and five days.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

six months to 10 years old with CAP.

Sara Dong:

So they had fever.

Sara Dong:

They may have had some respiratory symptoms like tachypnea , or

Sara Dong:

like a primary diagnosis of CAP from the emergency room.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

split three times a day.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

I'll throw it over to Michael.

Michael Cosimini:

Yeah.

Michael Cosimini:

And I love this trial.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

clinic, if not a little bit sicker.

Michael Cosimini:

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

Michael Cosimini:

Love it.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

like a super important outcome.

Michael Cosimini:

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

Michael Cosimini:

adults in that, in that group.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

resistant than it was back in the day.

Michael Cosimini:

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

Michael Cosimini:

Yeah.

Michael Cosimini:

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

Michael Cosimini:

that one, but I love this study.

Michael Cosimini:

Okay.

Michael Cosimini:

I've got one for you.

Sara Dong:

I'm ready.

Michael Cosimini:

This is SCOUT-CAP.

Michael Cosimini:

A lot of, a lot of good acronyms today.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

not still very sick with that.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

Ooh,

Sara Dong:

your favorite antibiotic

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

at day five and look at their outcomes.

Michael Cosimini:

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

Michael Cosimini:

sort of ranked score sort of thing.

Michael Cosimini:

It would take a while to explain it.

Michael Cosimini:

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

Michael Cosimini:

were the same in the two groups.

Michael Cosimini:

The clinical outcomes were the same in the two groups.

Michael Cosimini:

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

Michael Cosimini:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

read about, uh, that outcome ranking.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

not super clinically applicable for me.

Michael Cosimini:

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

Michael Cosimini:

But it's something to think about.

Sara Dong:

Yeah.

Sara Dong:

All right.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Michael Cosimini:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

three days of amoxicillin.

Sara Dong:

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

Sara Dong:

The median age was about two and a half years.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

And then they did either three or seven days.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

was similar for the two groups about 12%.

Sara Dong:

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

Sara Dong:

can use standard dose amoxicillin.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

perhaps older children, but I think.

Sara Dong:

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

Sara Dong:

encouraging that we can start hopefully shifting towards shorter courses.

Michael Cosimini:

Yeah.

Michael Cosimini:

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

Michael Cosimini:

younger age group, like, right.

Michael Cosimini:

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

Michael Cosimini:

And.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

setting before they got randomized.

Michael Cosimini:

I don't know.

Michael Cosimini:

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

Sara Dong:

Yeah.

Sara Dong:

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

Sara Dong:

I, I made Febrile Digest.

Sara Dong:

So we could talk about things that are current.

Sara Dong:

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

Sara Dong:

All the acronyms are very similar just from this last

Sara Dong:

week that looked at some cases.

Sara Dong:

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

Sara Dong:

and New Zealand and Malaysia.

Sara Dong:

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

Sara Dong:

radiographic confirmed CAP.

Sara Dong:

Uh, it's kind of interesting.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

days or a standard five to six days.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

this point people have really bought in.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

Um, yeah.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

interpretation of all these trials.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

kids those are, is really hard to say.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

of sat that's lower than I expected.

Michael Cosimini:

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

Michael Cosimini:

crackles, but everything else seems fine.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

because most pneumonia is viral.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

bacteria co-infection is pretty common.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

congestion, sore throat or rhinorrhea.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

reduce antimicrobial prescribing?

Michael Cosimini:

And the answer was a very firm no.

Michael Cosimini:

It didn't help.

Michael Cosimini:

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

Michael Cosimini:

but this really goes against.

Michael Cosimini:

Yeah,

Sara Dong:

I really love, I thought this paper was fascinating.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

go out with the smidge of antibiotics.

Michael Cosimini:

Yeah.

Michael Cosimini:

So now that would be Rao, et al.

Michael Cosimini:

in Pediatrics in 2021.

Sara Dong:

Yeah.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

younger than may have a virus, but.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

what really happens in clinic.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

are those kids getting sick right away.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

the first five days of therapy anyways.

Michael Cosimini:

So I thought that was like a nice little fact.

Sara Dong:

Yeah.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

sense of what that number actually is.

Michael Cosimini:

Yeah.

Sara Dong:

Great.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

And at a minimum knows the new acronyms for CAP

Michael Cosimini:

We are in agreement five days for community acquired pneumonia.

Michael Cosimini:

We feel pretty good about that.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

about our beloved bugs and drugs.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

that's just one of several games.

Sara Dong:

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

Michael Cosimini:

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

Michael Cosimini:

going to play a game on the podcast.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

when we're trying to figure something out.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

decision trees as we're seeing patients.

Michael Cosimini:

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

Michael Cosimini:

Sara, do you have your cards ready?

Sara Dong:

I'm ready.

Michael Cosimini:

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

Michael Cosimini:

the one with the diarrhea first.

Michael Cosimini:

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

Michael Cosimini:

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

Sara Dong:

Okay.

Sara Dong:

I'm ready.

Michael Cosimini:

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

Michael Cosimini:

what you're dealing with right here.

Michael Cosimini:

Okay.

Michael Cosimini:

So is your diarrhea bloody?

Sara Dong:

No.

Michael Cosimini:

So it's not a bug that is typically

Michael Cosimini:

associated with bloody diarrhea.

Sara Dong:

Nope.

Michael Cosimini:

Okay.

Michael Cosimini:

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

Michael Cosimini:

I'm getting rid of non typhoidal salmonella.

Sara Dong:

I wish everyone could see how cool these cards look.

Michael Cosimini:

Not Yersinia, probably.

Michael Cosimini:

Not Campy probably.

Michael Cosimini:

All right.

Michael Cosimini:

How about this?

Michael Cosimini:

Is this diarrhea typically associated with travel?

Michael Cosimini:

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

Michael Cosimini:

somewhere and coming back with it?

Sara Dong:

Not necessarily.

Sara Dong:

Um, no.

Michael Cosimini:

All right.

Michael Cosimini:

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

Michael Cosimini:

Okay.

Michael Cosimini:

Is this diarrhea associated with recreational water or fresh water?

Sara Dong:

Yes.

Michael Cosimini:

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

Michael Cosimini:

Okay.

Michael Cosimini:

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

Sara Dong:

Uh,

Michael Cosimini:

No!

Michael Cosimini:

Giardia

Sara Dong:

It is Giardia!

Sara Dong:

Actually I realized like now, based on the questions you

Sara Dong:

said it could have been Crypto.

Sara Dong:

I had Giardia though, my hand.

Michael Cosimini:

Nice.

Sara Dong:

Oh, this is awesome.

Sara Dong:

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

Sara Dong:

baseline knowledge of all of these.

Sara Dong:

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

Sara Dong:

reviewing it in a way that's fun.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

what most of the ID related ones are.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

is how do we teach antibiotics?

Michael Cosimini:

Yeah.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

ID or infections or drugs is amazing.

Michael Cosimini:

Yeah.

Michael Cosimini:

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

Michael Cosimini:

games, like it's active learning.

Michael Cosimini:

Right.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

It's okay to be wrong.

Michael Cosimini:

Like I just demonstrated, um, but very publicly.

Michael Cosimini:

When you're playing a game, right.

Michael Cosimini:

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

Michael Cosimini:

someone asks you a question on rounds.

Michael Cosimini:

Right.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

Right.

Michael Cosimini:

And I think games are good for that.

Sara Dong:

Yeah.

Sara Dong:

Okay.

Sara Dong:

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

Sara Dong:

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

Michael Cosimini:

Yeah.

Michael Cosimini:

Oh, and here's our double-sided!

Michael Cosimini:

Yours are better than mine.

Sara Dong:

I'm double-sided and color.

Sara Dong:

They look magnificent.

Michael Cosimini:

They're beautiful.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

you can find all my stuff there.

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Michael Cosimini:

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

Sara Dong:

You know, Febrile needed more Pokemon references.

Sara Dong:

So I really appreciate your Pokemon.

Michael Cosimini:

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

Sara Dong:

I know that's what I'm saying.

Sara Dong:

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

Sara Dong:

Well, this is so awesome.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

people can use these and, and spread the

Sara Dong:

word.

Michael Cosimini:

I really appreciate you letting me join this

Michael Cosimini:

community here and be on the show.

Michael Cosimini:

Thank you so much, Sara.

Sara Dong:

Yeah.

Sara Dong:

Thanks for joining.

Sara Dong:

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

Sara Dong:

Thank you so much to Michael for joining Febrile today.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

one day with new learners.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

Kuitunen et al.

Sara Dong:

in mid May.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

children over six months of age with CAP.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

back with Daniel Griffin and myself.

Sara Dong:

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

Sara Dong:

we found interesting or entertaining.

Sara Dong:

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

Sara Dong:

whatever podcast directory.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

to you show your support for Febrile.

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

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

Sara Dong:

to be more involved with Febrile.

Sara Dong:

Thanks for listening.

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