In our Season 5 Finale, Sara wraps up 2025 with Marisu Rueda-Altez (University of Alabama Birmingham) and the Pediatric ID Fellows Cup champions from Children’s National Hospital team “District of Contagion”! After an update on the US ID Fellowship Match, everyone breaks down some of the most commonly missed questions from the competition!

For Pediatric ID Fellows Cup (PIDFC) info, please click on links below!

Call for next round of question writers and mentors

Website: pidfc.notion.site

Follow on Instagram: @pid_fellows_cup

Guests from Children’s National team “District of Contagion”!

Katarina Manzi (first year ID fellow)

Hannah Chase (first year ID fellow)

Lillian Flannigan (second year ID fellow, team captain)

Einar Helgason (second year ID fellow)

Ugur Berkay Balkanci (second year ID fellow)

Sarah Benke (third year ID fellow)

Roya Gordji (third year ID fellow)

Alexandra Yonts (attending)

Nada Harik (attending and fellowship program director)

Other team members not on the recording: Craig Shapiro, Rana Hamdy, Andrea Hahn, Shreya Doshi

Episodes | Consult Notes | Subscribe | Instagram | Merch | febrilepodcast@gmail.com

Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Hi everyone.

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

We use consult questions to dive into ID clinical reasoning, diagnostics

and antimicrobial management.

I'm Sara, your host, and today we are joined by many guests, primarily from

our champions of the pediatric ID Fellows Cup, um, the team District of Contagion!

um, so I am gonna have everyone quickly say hello and introduce

themselves and, then we'll get started.

Hi everyone.

I'm going first.

I'm Marisu Rueda Altez and I'm actually not a, a current member of the team, but

former fellow at Children's National.

I'm currently a Peds [pediatric] ID attending at the University

of Alabama at Birmingham, and I was part of the organizing team

for the first Peds ID Fellow Cup.

Hi everyone, my name is Roya.

I'm one of the third year ID fellows here at Children's National.

Thanks so much for having us.

Hi, my name is Sarah Benke and I'm also one of the third year

ID fellows here at Children's.

Hi everyone.

I'm Lillian Flannigan.

I'm one of the second year fellows here at Children's National, so happy to be here.

Hi, I'm Einar Helgason.

I'm also one of the second year fellows at Children's National.

Very nice to be here.

Hi everyone.

I'm Berkay Balkanci and I'm a second year fellow also at Children's National.

Hi guys.

I'm Hannah.

I'm one of the first year fellows at Children's.

Uh, thanks for having us.

Hello, my name is Katarina Manzi, I'm one of the first year fellows

at Children's National as well.

And I am Alexandra Yonts.

I'm one of the attendings in the peds ID group at Children's

National, um, and a former fellow.

So happy to be here with everybody, including our former fellow Marisu.

Hey everyone, I'm happy to round out this group of the District of Contagion.

I'm Nada Harik.

I am an attending in infectious diseases here at Children's and the program

director for our amazing fellows.

I love it.

I'm smiling so big.

I think this may be a record for a number of fellows that are concurrently

on an episode, which is super exciting.

Um.

So we've made it through another year.

We always take the last episode to celebrate our anniversary.

So this is the fifth anniversary of Febrile as we wrap up 2025.

Uh, yay.

Um, I really just always wanna make sure I share gratitude and appreciation.

There's a lot of people who volunteer their time to be on the show.

and then of course, those who listen and support and share

the resource with others.

And, as an junior faculty member myself, I do sometimes struggle

to get the episodes out to you.

Um, but I am doing my best.

We wanna make sure it's still thoughtful and engaging, and

really just a good resource for everything that's awesome about ID.

Um, and so today we will include our usual update on the US ID Fellowship match, um,

which we've done in prior season wrap ups.

And then we're gonna chat with our guests, go through some of those most missed

questions from our recent inaugural, first round of the Pediatric ID Fellows Cup.

But first, of course, as everyone's favorite cultured podcast, I have to

hear everyone's little piece of culture.

Your kind of year-end picks, things that you have enjoyed.

Who wants to get us started?

Alright, I, I'll go first and I already warned the group that is gonna, I'm

gonna be very uncultured, it's only thing that I can think of about myself

maybe is a little bit interesting.

So English is not my first language, but my biggest sort of school

of learning how to speak English conversationally was watching sitcoms.

I'm a huge Friends and The Office fan and the one thing I can think of

is this, because just last week, my husband and I won like a big Friends

trivia competition here in Birmingham and won like $100 a bunch of friends.

Wow,

And it was really obscure guys.

Really, really obscure.

So we're pretty proud of ourselves.

Congratulations.

I was gonna say, Marisu,, if you didn't say Office or Friends,

I was gonna be disappointed.

You know me, Alex.

Um, my little piece of culture, I've been here for two and a half years now

for ID fellowship, but about a year ago I moved into actual DC proper.

And I love my neighborhood because there's always new, like

restaurants, new coffee shops, and like lots of fun things opening.

But the one thing that opened up recently that I'm really excited about is a

new macaron place that's like right around the corner from where I live.

And what's even better is they have the like French hot cocoa there, the like

really indulgent, like essentially you're sipping chocolate and it's very good.

I can go next.

Um, so I am not sure when this kind of started, but I, I feel like the holidays,

I've associated it with gnomes, so I've kind of started collecting gnomes.

They come out like only during Christmas once the tree's up and I just was gifted

a felt needling kit to make a gnome.

And so I have made, um, it, and it is a lot larger than I was thinking.

Um,

excited for gnome season.

That the only way I'm gonna call December now, gnome season.

Roya, I'm definitely gonna have to come visit you so we can go get some

macarons and hot chocolate, asap.

I have probably like, every single year, at least once or twice, during

the holidays, watch the Muppet Christmas Carol, like, without fail, my entire life.

Like I watched it right after Thanksgiving and I feel like it's

time that maybe I watch it again.

Um, I feel like we need to, we need some of that, uh, love

be in our lives right now.

So, uh, that's, that's my Christmas culture to contribute.

Love it.

If, if I'm supposed to name any piece of culture that I'm kind of obsessed with

right now, it would be a little piece of Icelandic culture that my parents-in-law

brought with them last time they were here, which is those little candies that

are like chocolate covered black licorice.

I'm not sure if, if just everyone would like

Controversial!

That's like a evil hidden surprise, you know?

I

My son hates it.

Yeah, this is Berkay, and I was just thinking through the films when I

saw that we are gonna come, um, we are thinking through like what we

really liked this year and I was just thinking through the movies that

I really, really liked this year.

And I recently saw a movie called Perfect Days and I mean, it blew my mind.

Uh, it's, it's about like just the joy of living and like finding joy

in small things and I think it was very timely and I enjoyed it a lot.

Highly recommend two thumbs up.

It's a great movie.

Yeah.

I think for me, so I'm not usually super into music, but I

was just gifted a record player.

So I've really enjoyed listening to a couple records, uh, lately.

Um, I like to thrift and so I found a Fleetwood Mac old record,

um, and some Stevie Nicks as well.

So I've really enjoyed listening.

On my commute in, I like to listen to audio books or

podcasts, and I really enjoy The Moth podcast.

I never can anticipate whether I'll be sobbing by the end of

the episode or laughing out loud, uh, but it's always good.

That sounds like a risky bet, Katerina.

I dunno.

I get to do it in the privacy of my own vehicle

Absolutely.

Second favorite podcast after Febrile.

Yeah.

Yeah, exactly.

So I'm, I'm Alex.

And, as everyone in this group knows, I'm a huge nerd beyond ID and I

also ring in a hand bell choir, um, actually a community organization.

And this is definitely our, our busiest season.

So all of my weekends in December are nonstop concerts, private

events, those sorts of things.

Um, so, uh, if you haven't ever checked out the, the hand bells,

this is a season to give it a try.

Um, all right.

And I'll go last.

Um, wow.

I, I feel like I've got a lot of things to choose from, but I have to go with

the one that's most timely right now, I think for me and all of my family, which

is, um, we are huge Stranger Things fans,

Hmm.

Yes!

Oh my God.

We did a lot of streaming over Thanksgiving.

No one can wait for the next episodes, especially for folks like me who grew

up in the time that the show is based, it's just so much fun to watch it.

I just, um, love everything about it.

I know everyone's got their theories.

We won't delve into theories, but I feel like our conversations lately

have been all about what's gonna happen in the next upcoming episodes.

So, yay.

Stranger things.

I love it.

Yeah, I was just rewatching some of the early ones and

they're so cute and talented.

They're so great.

oh, well thanks guys for sharing all those awesome things.

Um, so, like I mentioned, we like to just quickly give an update on Match and

I will say congratulations and welcome to all of the new incoming ID fellows.

We now have at least 272 new adult ID fellows and 44

incoming pediatric ID fellows.

Um, so clapping and excitement and, you know, um, you know, this year's

numbers are a little bit down.

So here are the updates as far as the results for this current

most recent appointment year.

So I'll start with the ID stats for the adult folks.

So there were 184 programs, 83 filled, which is about 45%.

Last year that number was about 50 ish percent.

And then we had for certified positions, there were 447 total, 272 positions

filled, which is 60.9%, which compares to what was about 70% last year.

Um, and so that leaves us with a good number of positions that are available.

And, Nada, and maybe I'll hand it over to you just to give an

update on the pediatric numbers.

Perfect.

Okay, so I'm gonna give the data for the pediatrics programs, for 20 26

start in, uh, pediatric fellowship.

So there were 60 programs that were certified this year in the match.

And of those 27 programs filled, which is 45%, that is up a little bit from

last year where we had 42.2% filled.

There were 33 programs that were unfilled, which is 55%.

There were 86 certified positions, 44 of those 86 were filled, which is 51.2%,

and 48.8% of the positions were unfilled.

So I just wanna say to listeners that are out there that are thinking about

a career in Peds ID or in Adult ID, um, there are lots of great programs out

there with open positions, including our, um, amazing program here in DC.

So if you guys are interested in joining us or any of the other

programs, please reach out.

Love it.

And I know I'm not quite as active, but for the BlueSky, when folks have been

sharing that they have programs with open spots, we've been trying to repost those.

So, um, if folks have those or know about them, of course, share with everyone

and hopefully we'll have, you know, a few additional ID, uh, fellows that will

be joining us in the, in the summer.

We have one open spot here at UAB too.

Please come join me as well.

We have fun here in the south.

Another fantastic program.

Yeah.

And so, now to focus on, of course, why we have so many amazing guests

with us today is we are gonna talk about the Pediatric ID Fellows Cup.

I was gonna hand it over to Marisu to just kind of maybe tell folks

about our sort of newest iteration.

For folks who have been listening to Febrile in the past, they probably, uh,

have a very overlapping Venn diagram with folks who were active participants

in the ID Fellows Cup, which is the version that was launched by the folks

at University of Alabama, Birmingham.

And we had Jeremey Walker on an episode many years ago.

I'll make sure to, um, link it in the Consult Notes

Yes.

Uh, so if you are not familiar with the ID Fellows Cup, it is a friendly

competition designed to basically review some ID fellow level board content,

while integrating available free online resources that can be helpful for your

sort of day-to-day clinical practice and your board preparation as well.

And of course, just to kind of generate communication between different sites

and just unity amongst our ID community.

Uh, and the awesome thing about it is that also the actual materials and questions

are created by trainees themselves within our ID community and mentored by

different faculty across the country.

So it's another opportunity to generate some additional scholarly activity

from the education side of things.

The vision and everything for this was developed by a group of ID physicians

across the country, but led by the University of Alabama where I am right

now, using the Kaizen education software.

So we leveraged that and got a lot of help from our adult ID friends to

create a pediatric version because before the questions were only adult

based with a few peds ID questions sprinkled in there, mostly written

by Sara and some of our other

And others.

Med-Peds folks that were kind, sneaking some, uh, peds questions that were the

most missed ones by our adult colleagues.

So we wanted to have a peds specific resource because as a recently

graduated fellow and recently victim of the pediatric ID boards,

there are very few resources out there for us to be able to study.

So just generating more of that and, and getting the opportunity to

other people to create those kind of resources was our main goal, and I

wanna say that it was a great success.

Please, uh,

District of Contagion

Yay.

We're really, really excited.

It was an initiative, um, kind of spearheaded by our PIDS Education

Committee and me as an infiltrate of the education committee.

Um.

And we had great participation.

We had 158 players that started the game, and of those 120 answered all of the

questions by the time the cup closed.

And 70% of all of our participants were trainees at different levels,

all the way from residents to third year or or beyond, um, uh, fellows.

We also had a little bit of participation by our ID pharmacist friends.

We had a couple of them, uh, in the cup.

Some research fellows too, and even a couple of, um, advanced practitioners.

So definitely a very diverse cohort that we had for this cup.

And of those participants as well, we had 12, so 10% of the ones that

finished all of the questions, that actually answered every single question

on the day that that was released, which was our original intention.

And, and just big shout out to those 12 players.

Two of them are present here today, Lillian and Berkay.

Thank you so much, uh, for being such great sports and just doing all of your

questions on the release, which was the, the goal of it, just kind of space, little

bits of learning throughout the day and hopefully that was helpful for you guys.

Yeah.

And we thought we would ask you guys as our, you know, now reigning

champions, how you approached the game.

Were you guys interacting and encouraging each other to get to the questions?

Any sort of feedback on the experience, we would love to hear.

Lillian was encouraging.

I think a nice way of saying that I was a task master and I made sure

everyone did their questions on time.

Um, I took my role as team captain very seriously.

I was like, we are gonna win, or we're go down trying.

So I really was such a good sport about me constantly texting them.

The group chat was really helpful.

We had a group chat and that was a great way to remind people to do

their questions, so a little tip.

Very nice.

But there was no cheating there, no answers.

Did you guys feel like there were questions that you debriefed on

after, or asked each other about?

There were definitely some that some of our faculty members

had strong opinions about.

Um, Dr. Shapiro is not with us today, but, uh, yeah, had some debriefing is

maybe the word you could use in the office at least one the questions.

And I wanna say, as part of the organizing team, that I was not great at this

iteration of encouraging this, but for future iterations, I a hundred percent

encourage feedback on the actual structure of the question, or in like specific

words that may have been misleading.

And I know that the adult ID people do this thing called Expert Consults

where we have someone come and say, I would've actually answered

this question a different way.

For this and this reason, and that can also definitely enhance our learning.

So please, everyone, welcome to email our, uh, Peds ID Fellows Cup, uh, official

email, through Instagram or email me directly for future iterations of our cup.

And we're happy to include that in our social media

posts, um, throughout the cup.

For sure.

And our plan is to have these available to folks after the cup is

done, obviously, for you to review.

And so that feedback on the learning point or the structure or any other,

uh, aspects, we can update or provide additional insight on that catalog

or database of those questions.

So definitely, even if it's after the cup now, we still welcome that.

So we can continue to adjust it and make it the best resource that it can be.

Great.

It's so nice to have this extra resource.

Like we were just saying, there's just not too many questions out

there for the peds ID board.

So this was just fabulous.

As a, as a program director, always looking for resources.

Thank you.

And I thought some of the infographics too, like were just a great way

to reference that, um, and kind of help make it really stick

after you answer the question.

Love it.

Yeah.

And hopefully as we build out more resources that are online,

outside, of course, you know, the primary literature, if there are

infographics or podcast episodes or websites that we can link people to.

That's the other goal of the way we prepare the answers that you

can click on those and save 'em on your phone or on your computer.

So hopefully, the more folks participate, the more things we create, the more

things that we can build out and have synergy across all these different

sort of platforms available to us.

This was such a great learning experience for me.

There were definitely questions that I learned from and I've been

doing this for a while, but always, always, uh, room to learn every day.

And so that was great.

I, I do think we did, have some fun, robust discussions about

some of the questions afterwards.

We kind of, at the end of the day, folks who were on service would come out and

we'd make sure everyone had done their questions, and then we'd often just have

a, a discussion about the questions.

So it, it was great.

I love it.

So we have a handful of the top missed questions and we thought we would go

through them to teach people about the learning points that we were intending,

but also, your thought process.

Who wants to start with question one?

So our first question is a 15-year-old male was brought to the ED by his

father after the first episode of generalized tonic clonic seizure.

The seizure stopped after five minutes and he was back at

his baseline before arrival.

He reported a history of intermittent headaches during the past year associated

with nausea, which has improved with over-the-counter medications.

He denied fever, chills, weight change, vision change, weakness, or numbness.

He is originally from Myanmar and immigrated to the

Midwestern US five years ago.

He is in high school.

He is not sexually active.

He loves hiking and gardening.

He's a strict vegetarian and does not eat meat.

He denies having pets, contact with farm animals, recent travel or sick contacts.

A physical exam in the ED was unremarkable without focal neurologic deficit labs,

including CBC, CMP, toxicology screening and HIV screening were unremarkable.

A brain MRI was obtained.

And then it gives us a nice picture of this MRI from

multiple different, uh, views.

The question is what should be done next?

And our answer choices are (a) albendazole monotherapy, (b)

anti-epileptic drug and albendazole, (c) anti-epileptic drug, corticosteroid

and albendazole, (d) antiepileptic drug, corticosteroid, and neurosurgery consult.

Lastly, (e) anti-epileptic drug, corticosteroid, albendazole,

and neurosurgery consult.

What do you guys think is the correct answer?

I think just thinking about not necessarily what the right answer is,

but when I was sort of evaluating which one I was gonna pick, a kid who comes

in with seizures, then you probably want to start an anti-epileptic drug.

So that kind of took off answer, choice a. Um, and then I feel like

any finding in the brain, I'm always like, let's talk to neurosurgery.

So that kind of put that on my like radar too.

Um, so really I was kind of down to D and E

Especially when you have those, uh, ominous red arrows on the MRI.

I say, does anyone wanna describe what the MRI images are showing for

those that aren't able to see them as a part of the question stem?

I think there are cystic lesions, uh, scattered throughout the brain.

I do see one in the cortex and at least one within the ventricles,

and I think that's gonna be one of the keys to this question.

And this is something that I learned from this question too, so thank

you so much to question writers.

Yeah, so maybe someone can take on our, our final correct answer.

Perhaps one of our third year fellows.

So the answer was answer choice D. So having an anti-epileptic

drug, a corticosteroid, and a neurosurgery consult.

And I think the tricky part about this was not including albendazole

or a anti-parasitic agent, because that can lead to a hyper

inflammatory state with treatment.

And then that, that other aspect that was already mentioned that the

neurosurgery consult is important to try to help remove some of the cysts.

And I don't think that we ever actually said this, but what

was, what clinical syndrome was this case vignette describing?

Neurocysticercosis

Yes.

Yeah, absolutely.

Excellent.

I think it was interesting that the question stem also mentioned that

the, this patient was vegetarian.

I think that was like trying to throw us off maybe,

Mm-hmm.

We definitely wanted folks to remember that neurocysticercosis is gonna

potentially be able to occur even in someone who's a strict vegetarian, if

they eat those eggs in contaminated food.

And of course we'll put the resource that has our good old CDC lifecycle

that people can, can review.

I will also say that this is one that was adapted from the adult cup and,

Mac, uh, Chesdachai, who, uh, has been on febrile podcast for one of our state

of the art reviews wrote this question.

So, I'm not even sure he knows that we reuse this question or not, but I'll.

Thanks, Mac!

Thanks Mac.

Awesome.

I was gonna say like the more advanced take home message, like, Berkay mentioned

is really that there are both intra parenchymal and extra parenchymal lesions.

And because there were signs of acute disease, this is maybe different than

the, the classic board stem we see of seizures with a calcified cyst

where there's no management indicated.

So having those in different compartments does require different treatment.

And, like one of our other fellows mentioned, making sure that you

don't treat to trigger a hyper inflammatory response without

steroids and appropriate containment of those active cysts is critical.

I think this was a great question too, because of that, I'll say

I got this question wrong and I was talking to the fellows about

afterwards and we were talking about seeing these intraventricular

lesions with neurocysticercosis, that's not very common.

I actually went and looked it up afterwards because, neurocysticercosis

isn't a thing we see too commonly in the places that I've practiced in

various locations, but I've definitely seen it throughout my career and

I've been doing this a while now, but I've seen maybe about 10 cases.

I've never seen one that actually had intraventricular lesions.

I think that point about management is important because the management is a

little bit different with that lesion as opposed to someone who is a calcified cyst

where we would need to do anti parasitics as, uh, Dr. Yonts was just mentioning.

When I looked it up about only 7 to 20% of cases actually present

with intraventricular disease, but it was right, and I, I

definitely learned something new.

And I love that key point that you went and looked up something else outside

of the app, which is one of the things that we hope that people do just to.

But don't do it on your phone apparently.

Alright.

Uh, who wants to take on this, this next stem

So a 16-year-old previously healthy boy presents with fever, right upper

quadrant abdominal pain, and the following findings on the CT imaging.

And if I were to describe, I think there's a heterogeneous mass slash

cyst looking structure in the liver.

He returned from a two month trip from rural South America three weeks ago.

He's hemodynamically stable and has no known drug allergies.

Which is which of the following is the most appropriate

empiric antimicrobial agent.

Personally this is one of those questions I got wrong.

Uh, when I read the question stem and the travel history, I was thinking about,

okay, so this is gonna be an amoebic, uh, liver abscess, and I was looking

for an answer that will treat that, so I chose one of the wrong options

with metronidazole plus paromomycin.

Unfortunately, I was incorrect.

And I picked the same as Berkay initially as well, I totally fell into that trap.

Yeah, and after this question, there was some heated discussion

among ourselves, you know, some friendly competition about like.

I think my lack of knowledge actually helped me with this question.

I wasn't even thinking about amoebic etiologies and so I was like, okay, intra

abdominal abcess, we're gonna go with ceftriaxone + metronidazole (flagyl).

So I got it right by mistake.

It's still counted towards the points.

So you get

Team leader says, yay.

But yeah, I think, I mean, the tricky thing is, common things are common

everywhere, and you have to really treat and manage those, especially

if your patient is otherwise stable.

And then do your diagnostic workup to look at the more exotic things.

So here horses instead of zebras in a field that we do deal with a lot of

zebras, but it's a little bit tricky.

Yep.

I have to admit, you know, if I try to put myself in those shoes of getting

that call, we have this picture and what are we gonna start this patient on?

I don't see myself saying paromomycin,

Oh, the, yeah.

I wouldn't have selected that option.

I think we had a good discussion about this after the question too,

about this is, they're asking for most appropriate empiric therapy.

So again, yes, we were all thinking about amebic liver abscesses, and we wanted,

uh, or, uh, some, uh, coverage for that.

And so metronidazole does that, and then we want coverage for some

of the other common things that cause pyogenic liver abscesses.

So in kids Staphylococcus aureus.

Um, streptococcal species, gram negatives like Klebsiella and, and so

looking at the options, ceftriaxone plus metronidazole definitely stood out.

Yeah, and I will give a shout out.

The author for this one was Maria Valenzuela, who's one of our

fellows at Boston Children's.

And one of our former residents!

Yeah she was my co-resident!

Okay, so, we will move on to our next question.

I can, I can take that one.

Uh, so the question is, uh, as follows, you're the ID fellow on call and receive

a page from a community pediatrician asking for UTI treatment guidance.

they tell you that the patient is a previously healthy three-year-old

girl with no prior history of UTIs whose parents brought her to the

office for complaints of her belly hurting and fear of urination.

She is afebrile and otherwise well appearing with only

mild suprapubic tenderness.

A clean catch urinalysis reveals 4+ leukocyte esterase, 2+ protein,

2+ blood and positive nitrites.

She was sent home on empiric cephalexin while awaiting urine

culture results, which return with a hundred thousand colonies of E.coli.

Antimicrobial sensitivity report is shown.

Uh, and her pediatrician would like to know what, if any, outpatient antibiotic

treatment options may be suitable.

And so we have sensitivity report, which shows everything as resistant,

uh, except for amikacin and minocycline.

So that includes resistance to ampicillin, but also cefazolin, piperacillin, uh,

cefotaxime, ceftazidime, and levofloxacin.

And Bactrim as well.

And so the answer choices here are (a) continue cephalexin 25 mg/kg per dose

PO TID (three times daily) for seven days, (b) a single dose of IM amikacin,

uh, 15 mg/kg, (c) minocycline two mg/kg per dose PO BID for five days, (d) a

single dose of IM ceftriaxone followed by cefixime eight mg/ kg, uh, po once

daily for five days, (e) recommend direct admission for treatment with IV meropenem.

I thought that one was fairly interesting and made me think of a

case that we had, uh, recently, but, it seems that you're only picking out

the ones that I got wrong is that.

Who feels personally victimized

by

Sara Dong?

Yeah, so someone else wanna talk about their thoughts.

Yeah, like maybe someone can let us know, like how you process

those question answer choices.

Yeah.

Um, I only got this question right because of Dr. Shapiro.

Um, so shout out to him for me this.

Um, so we'd recently had a, it's, I don't know.

I feel like probably a very common call to get after hours about a patient

who has an, you know, a resistant like ESBL organism in their urine and

they don't need to be admitted, but what are we gonna treat them with?

We had recently just treated a patient with a dose of gentamicin.

Um, and so my, my thought process was, well, why couldn't

we do that with amikacin?

That seems like it would make sense.

And so that was kind of how I thought through that question was well,

obviously cephalexin isn't gonna work.

Um.

Minocycline.

Yeah, not really, um, something that I do very often, so I'm

gonna go with not that one.

Um, another cephalosporin for similar reasons and that, because this is

an ESBL producer and then, um, I know our ID pharmacist would come

after me with pitchforks if I ever recommended admitting anyone for

this reason with, um, meropenem.

So I knew that I was not gonna choose that one.

Um, and that is how I ended up with going with amikacin.

I think that this was a really great question in terms of reminding, you know,

clinicians, including myself, that this is a therapeutic option for this population.

I feel like in reality, a lot of times we get that call and we

say, how's the patient doing now?

And most of the time, their symptoms have resolved, um, so likely from

some other benefit of concentration of antibiotics in the urine or not

needing treatment in the first place.

But I think having this in your pocket and this knowledge of the post antibiotic

effect is, is a really helpful option and something that pediatricians, or at

least ER doctors can feel empowered by.

Yeah, I wanna say it was a great question to like sort of demystify how people just

think of aminoglycosides of like, they're just so toxic and so bad and we only use

them as adjuvants for the most part in our practice, but they're actually excellent

antibiotics to treat urinary tract infections, which is actually the system

with like the kidney and nephrotoxicity where people fear them the most.

So I think it was a great reminder that we can, as Alex was saying, empower

primary care doctors, pediatricians, ER docs to, to be able to use them and

avoid an admission that could create even more problems for these patients.

And I wanna shout out, uh, the author of this question, Lindsey Hastings,

a Med-Peds fellow extraordinaire here at the University of Alabama.

Woohoo.

Oh, and to um, Einar's point.

So these are the most missed questions, so you are not alone

on having missed this one.

For the neurocysticercosis question, only 11% of our question

answerers actually got it right.

Uh, for the intraabdominal abscess, just 28%.

And for this aminoglycoside question, 52% got it right.

All right, and let's close it out with our last of these most

frequently missed questions.

A 10-year-old male presents after being bitten on the arm by a

bat while playing in the woods.

Classic.

Um, he is otherwise healthy, but completed a full rabies post-exposure

prophylaxis regimen two years ago after a stray dog bit him.

What, what incredible luck this 10-year-old child has.

Which of the following management approaches would best address his need

for rabies prevention at this time?

Funny enough, I saw a patient around the similar time that I think this question

came out where she was receiving rabies prophylaxis, and so that helped me narrow

down the question answers, but I still got it wrong because as compared to this

patient, my patient in real life did not have a previous rabies exposure.

Yeah, uh, I, I think it was relatively easy to rule out the answers with the

rabies immunoglobulin because this person has been immunized before.

But I also learned from this question how they approach these patients because

the number of vaccines, like this is not a clinical situation I have encountered

before, and I have learned from it.

Definitely I feel like get lots of questions about rabies prophylaxis as ID

doctors, it's probably one of our like most common right, um, questions that

the fellows, attendings gets, um, about prophylaxis, but to have someone who's

been previously vaccinated or somebody who was like a veterinarian and previously

vaccinated for pre-exposure, um, is rare.

I don't think I've ever gotten that question.

Shout out to the Red Book and how easy it's to look things up.

So in my brain I don't often, um, keep room for things that I

know I can access pretty quickly.

So I, I definitely know what the regimen and what to do for someone who's been

bitten, who's never had a vaccine before.

But I'll say this particular scenario, I did not know off the top of my head.

So similarly, I was like, well, I don't think they need a RIG again.

They've had it before.

We don't usually do that again.

Um, and, but I was like, yeah, give 'em all the vaccines anyway.

Why not?

So I'll say I definitely got this one wrong

And so maybe is someone willing to walk through and, list what someone would get

for post-exposure prophylaxis if they were previously vaccinated versus not.

Just for the audience members to refresh in their brain too.

Sure.

So for post-exposure prophylaxis and those who are not previously

vaccinated, um, you would do the rabies vaccine on days 0 3, 7 and 14.

If you're immunocompromised, it's a little bit different though.

So just that little asterisk there.

And then they would also receive rabies immunoglobulin at the site of the bite.

Um, if they're previously vaccinated, then you would receive rabies

vaccine at days zero and three.

And then I mentioned the immunoglobulin is not indicated in that case.

And we'll give a shout out to the author of this question, uh, Rebecca

Sturgis, who's at Cincinnati Children's.

Thank you for this awesome question.

So we, we do just in general, want to give a thank you to all the question

writers and mentors who contributed and looked at these questions.

And we will also have a link, you can click on the episode description,

and see that there's a call for our next round of writers and mentors.

It's a really quick Google doc.

Even if you're on the fence, you know, fill it out and we'll be in touch.

So that we can work on our next round of questions.

And we'll also put the link to the Peds ID fellows cup.

We have a website, and if you don't follow our Instagram, you can

follow the Instagram for updates.

But before we close out I'll kind of open it up.

Thanks so much, uh, um, you all the organizers of the ID

Fellows Cup, it was amazing.

Um, we had so much fun doing it and like I said, we learned a lot, so yay.

We're looking forward to the next one.

We will be getting

t-shirts!

Thank you again to our group from Children's National for

joining today and Marisu from UAB.

We were really happy to have them join us.

And again, just a huge thank you to the Febrile community.

Uh, hope to hear from many of you in the coming year and keep bringing

you new and exciting ID learning.

Don't forget to check out our website, febrile podcast.com, where

you can find the Consult Notes, which are written complements to the

episodes, with links to references, our library of ID infographics,

and a link to our merch store.

Febrile is produced with support from the Infectious Diseases Society of America.

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

to be more involved with Febrile.

Thanks for listening.

Stay safe and I'll see you next time.