Hi, everyone. I just wanted to give a quick introduction for this episode. We were actually lucky enough to do another live recording. This time we were at the 23rd Annual St. Jude PIDS Pediatric Infectious Diseases Research Conference in Memphis, Tennessee. So if you aren't familiar, this is a really awesome conference. It features leaders in pediatric ID research, transplant and immunocompromised host ID, and global health.
In addition to all these topics, there is an emphasis on career development. So we are fortunate to have Dr. Sumanth Cherukumilli, who is the top abstract winner and a pediatric ID fellow at the University of Maryland, as well as faculty members, Dr. Emma Mohr from the University of Wisconsin, and Dr. Paul Spearman from Cincinnati Children's joining. And just to provide a teeny bit of context for the podcast and a couple of the questions in the q and a at the end.
This recording was completed after a presentation I provided on "How to develop and evolve as a digital medical educator". All right, so let's head to the conference. 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. You now, at this point, know me. I'm Sara Dong. I'm your host and a MedPeds ID doc. We have a live recording today.
We are at the to the St.Jude/PIDS Pediatric ID research conference. Thanks to the audience for being here and we have three awesome guests so I'm going to move down the table and ask them to say hello and introduce themselves.
I'm Sumanth. I'm the second year Peds ID fellow from the University of Maryland.
And I would just like to introduce, we asked him to come on the show because his project was selected as the top abstract for this meeting. So, you'll get to see his presentation tomorrow. But, thank you for joining.
All right, I'm next on the table. My name is Emma Mohr, and I'm a pediatric infectious diseases physician and scientist at the University of Wisconsin Madison.
Hi, my name is Paul Spearman. I'm vice chair for clinical translational research at Cincinnati Children's, and I'm here also as a MedPeds ID doc, but practicing Peds ID and because Emma asked me. Thanks.
And as everyone's favorite cultured podcast, we always ask if our guests will share a little piece of culture, basically just something non medical that makes you happy. Please feel free to share something personal or you can also share something about Memphis.
This is not personal or about Memphis, but I am a big fan of trashy TV and Love is Blind has its wedding episode today, which I'm very excited to watch later today.
I really enjoy running, um, and so I run usually a couple times a week and especially love running on trails, and it helps clear my head from everything work and family related.
All right, I have recently taken up sculpture, and I love doing sculpture. It's kind of a total break from everything else, both kind of classical sculptures and weird sculptures, so it's a lot of fun.
Well, I'm excited. I wish we had a weird sculpture centerpiece. We're going to open up with something sort of clinically oriented. We wanted to share some clinical pearls, but then also shift a little bit at the end to talk about career development. And if we have time, we'll also open it up for questions. So I have a mini case I'm going to pitch to Emma and Paul. So you're getting called.
We have a baby boy born at 38 weeks, 5 days gestation, it's been about 24 hours ago, to a 32 year old G1, now P1, previously healthy mom. Mom has become unwell, she's developed a fever, but outside of that her antepartum course and labs have otherwise been negative and uneventful. The baby was initially doing well, but has since developed a fever and worsening respiratory distress, which led to transfer to the NICU for further workup.
He now has worsening hypotension, requiring pressor support, and has been intubated and ventilated. And so I was going to ask if you could talk us through what's going on here. I know we have some earlier learners that maybe haven't been in the clinical setting before, and how you would approach this. Most importantly, we want to talk a little bit about empiric therapy.
Sure, I'll take this early part. So, when I hear about a young baby, usually less than 3 days of age with signs of clinical distress, so sounds like the baby had some increased work of breathing, just not looking good, so other signs of not looking good could be things like lethargy or not feeding, not doing what a newborn baby is asked to do, which is not much, but you do have to wake up to feed yourself.
When they're not doing that, we're worried about something like early onset sepsis or neonatal sepsis, especially less than three days of age or 72 hours is what we usually think of that. And one of the things that we think about is, were they exposed to pathogens from the maternal GU or GI tract during the process of delivery, they can be transferred these bacteria and it can cause sepsis in them or pneumonia at times as well.
So those are the things that I'm thinking about when I'm called to evaluate babies like this.
Uh, and I agree completely with Emma on this. I think we have several concerning things. The maternal fever would already pique your interest that the baby could have a neonatal infection. It does sound like early onset neonatal sepsis. We don't know mom's GBS status. We'd want to know that, and that would also figure into the risk. But with the baby already having respiratory distress and hypotension, We don't really need a fancy neonatal risk calculator to say what we need to do next, right?
Because this is so much in the category of neonatal sepsis that you'd want to start empiric therapy. And I guess that's our topic also for discussion is what would you, you know, what are the organisms that you would really be worried about and, and what would you start? So at the top, you'd still have group B strep, which is the number one for early onset neonatal sepsis.
Then E. coli and other Enterobacteriaceae, I usually think of those together, although E. coli is by far the most likely you can have other gram negative sources of sepsis, and then a more distant third, Listeria, and we would maybe expect mom to have chorioamnionitis if there's a baby that we're thinking about Listeria. So we think about those kind of categories, and we'd be thinking largely of bacteria at this stage, but you'd want in the back of your mind to think of viral syndromes.
This is a little early for presenting with disseminated HSV or enterovirus or parecho[virus] or something like that, but you'd want to not completely discount those and think about them. And if things are out of line, or if, let's say, the baby has really high LFTs, there's maybe a maternal history, you might think about herpes a little higher on the list. So fungal, probably not so much at this kind of early presentation and in a non premie [premature infant]. Thank you.
So what do we do with this baby when we're called? What labs do we recommend getting? And then how do we treat the baby? One of the big things that you do for these baby is evaluate their blood with a blood culture. Are they growing organisms in there? And you really, really try and get that blood culture before you start antibiotics so we can make an educated decision about what infection they have and what they should be treated with.
So you get that blood culture and then right away administer antibiotics for this baby. So the empiric antibiotics that we think about for these children are things like ampicillin and gentamicin. So we want to make sure that we cover the common organisms that we just talked about, especially GBS and E. coli, which are the most common. Usually we think about sepsis over things like meningitis right away in an infant that's 24 hours of age.
But as they get a little bit older than that, a few days later, maybe meningitis can happen more likely than sepsis as well. So ampicillin and gentamicin in these early days, and then later on, if we're really thinking meningitis and we want better CNS coverage, cephalosporin, something like ceftazidime or others. That's it.
Sort of leading into what we're talking about next is what empiric antibiotics to use in our practice here in the U. S. Ampicillin gentamicin is good based on our common organisms, but it's not like that everywhere in the world.
Yeah, and that's kind of what we wanted to transition about because often times we think about our differential and maybe don't always remember about how screening practices may be different somewhere else. I learned a lot about how GBS screening and prophylaxis varies in different countries and I hadn't really thought about that much until we had done a Febrile episode on it. And I think neonatal sepsis rates are quite variable.
So Sumanth, I wanted to get your perspective because we wanted to also adjust this case a little bit. So we've said ampicillin/gentamicin for our sort of North American audience, but what if we thought about it from a different perspective? And I think that kind of plays into your research that you're presenting about.
Yeah, so I'm not sure if everyone is familiar with the CHAMPS study. It's a study that uses minimally invasive sampling techniques to look at children who have died under the age of five in multiple countries, mostly low and middle income countries. They actually published from their analysis a paper last year that looked at the causes of death in neonates between 2016 and 2021, and the majority of neonates had an infection in their causal chain, like in their causal chain of death.
The most striking thing, there's actually a chart that demonstrates the burden of each infectious disease. The most striking thing is how, in comparison to gram negatives, GBS is not really as big a player in a lot of these different sites. Like gram negative Enterobacterales are really the biggest killers, specifically Klebsiella pneumoniae, and a lot of these isolates are multi drug resistant.
The WHO definitely recommends intrapartum antibiotic prophylaxis for GBS positive moms, but what they write is that it's a conditional recommendation based on weak evidence, and they have a lot of caveats in there about how it really depends on your local epidemiology, and GBS screening is kind of a plus or minus depending on where you are. So, uh, If we just look at the mortality burden, gram negatives are really the biggest players.
That's something definitely important to consider when we're talking about empiric regimens and settings outside the United States and Europe.
Is there anyone in the audience who would not use ampicillin gentamicin, you know, based on the most common organisms at their site. Yeah. I'm sorry, I don't have a mic for you. I can repeat. What is your empirical
I think you said, it kind of follows up with what was just said about local rates, because our ampicillin susceptibility rates for E. coli are not satisfactory at all. They're probably about 50 percent.
Yeah.
So we, very strongly encourage a third generation cephalosporin upfront plus or minus ampicillin if you're worried about Listeria and I think, and we have a very hard time getting our neonatologists to understand that because all the guidelines say amp and gent. But you really do need to use your local epidemiology to make that decision.
Hopefully, folks in the audience could hear most of that, but just talking about the importance of looking at your local epidemiology. And so if there is a high rate of ampicillin resistance, of course, amp would not be the ideal agent. Okay. And so Sumanth, you know, before we move on, I just wanted to follow up with you from your work because we talked about reframing this case from a different perspective using different empiric antibiotics.
Are there any other considerations or challenges in management that you think of in this case or based on your project?
The project that I've been doing is mainly in Mali. It's a country in West Africa, which I'm sure many people are familiar with, that has some of the lowest indices of development in the world. And there we've actually been doing an invasive bacterial infection study since 2002 to look at the causes of bacterial infections in kids under the age of 15.
Initially, the burden was mainly just Hib and Strep pneumo, but the data that we got from the study allowed Milagritos Tapia and Karen Kotloff, my two primary mentors, to introduce vaccines in that setting that really reduced the burden of both. But our burden of gram negative infections, gram negative Enterobacterales specifically, has stayed pretty static and actually maybe has gone up over this time period.
So I really looked at mortality rates between 2021 and 2024, really over a three year period, and I found that kids who had a positive culture had a mortality rate of 49 percent versus 28 percent in kids who had negative cultures, and both are really unacceptably high rates. The issue in Mali, and I'm sure this applies to other places in Sub Saharan Africa, falls into like four major buckets.
Problems with diagnostics, problems with presentation, problems with antibiotics, and problems with supportive care. With diagnostics, there's issues. We are able to get blood cultures in Mali, but that's because, you know, it's supported by a major American institution, but there are lots of places in Mali and Sub Saharan Africa where you can't really get blood cultures, so you don't have anything to really guide your therapy.
That's really a diagnostics issue, and other than microbiologic diagnoses, like, forget about molecular testing. When cultures are difficult. It's also difficult to get labs, things we take for granted like CRPs, lactates, procalcitonins, things like that, which can make it really hard to assess, especially in patient where infection can be subtle, like a neonate, where your patient really stands. And then there's issues with presentation.
And again, I put this into like two different categories, right? So there's the issue with delay in presentation where kids maybe live really far away from the hospital, don't have transport to get to the hospital, and where. So, parents just aren't aware of what a sick kid looks like so they present in extremis and it can be really difficult to treat those kids.
And that's kind of borne out by our data where greater than 50 percent of kids who die, really die within the first 48 hours of presentation. And then the other issue I think with presentation is um.
And then there's seeking care in the community before they come to the hospital, and that can be with traditional healers, where they get medications, we don't know what sometimes is in those medications, those medications themselves can be toxic, and you can get sub therapeutic concentrations of antibiotics in those medications as well.
And then some of these kids get treated out in the community, where they can get injectable antibiotics, but again, they're not getting cultures, so you can have kids that are partially treated, who limp along, limp along, limp along, until they present in overwhelming shock and then antibiotics, right? And I, again, I kind of grouped this into 2 separate categories. The 1st 1 is that, you know, 100 percent of our E. coli strains are resistant to ceftriaxone over the last 3 years.
And that number is greater than 90 percent for Kleb pneumo. So, per Pranita Tamma's excellent talk on your podcast a few months ago, really, if you're thinking about an ESBL organism in a critically ill patient, the treatment of choice is a carbapenem. And it's really hard to get access to carbapenems in that setting because the onus is really on the parents to buy the antibiotics. And these antibiotics are very, very expensive.
And so kids get treated with ineffective antibiotics like ceftriaxone and aminoglycosides, which again, have mortality, like, uh, resistance rates of greater than 50 percent to the most commonly isolated gram negative pathogens. And then the other issue that I think is a global problem is the issue of counterfeit and substandard antibiotics and antimalarials, which is really a huge problem in sub Saharan Africa.
So even when you're getting the proper antibiotics, if you're not getting them from a good source, there's a high probability that what you're getting isn't good enough to treat your infection. And that I think drives mortality and further antimicrobial resistance. The last issue is supportive care. And again, I think that it falls into two categories.
What we don't have, which in sub Saharan Africa, oftentimes, it's really hard to find mechanical ventilators as well as continuous vasopressor support. And then the problem is what we do have. There's a famous trial that came out in 2011 that looked at the impact of fluid boluses on patient mortality in East Africa in settings without mechanical ventilation. It's called the FEAST trial. It's an excellent paper.
They divided them into several different cohorts, and they looked at the impact of fluid boluses on patient mortality in all these kids. They found that no matter what type of fluid they got, kids with boluses had a significantly higher 48 hour mortality rate than kids who did not get fluid boluses. And these are all kids with suspected bacterial infections, suspected sepsis.
And this is a stunning result because for a long time, the standard of care in the United States and worldwide was if you think someone has shock or sepsis or something like that, you know, fluids are really fluids, fluids, fluids, 60 cc's per kg in the first like 20 minutes of care. And this pushed back against that idea that fluids were always beneficial.
Authors did a secondary analysis a few years later where they found that the majority of kids who died from that initial trial died because they had a cardiovascular collapse, not respiratory failure, which suggests that some kids may have some degree of subacute myocardial dysfunction when they present with sepsis or septic shock that might make it dangerous to administer a lot of fluid therapy.
When you don't have hemodynamic monitoring like we do here with CVP, SVO2, or renal NIRS, it's really hard to tell where we are in our resuscitation, which can make it so that we provide harmful amounts of fluid therapies that could potentially be beneficial. And I think all of these things really contribute to the mortality burden in a place like Mali. It's a lack of resources, but also a problem with the resources that we do have in that context.
I wouldn't be able to do any of this work if it wasn't for the wonderful work that's been done by Millie Tapia and Karen Kotloff, my two primary mentors, Samba So, Adiba Mambiketa, who have been working on the ground to introduce a lot of these vaccines and therapeutics to Malian children and have saved countless Malian lives. Will Still is still one of the co authors on my abstract.
He's a PhD student who's been working on the impact of supportive care on patient mortality and this population and a lot of the data that he actually came up with informed the hypotheses that led to my project. Finally, University of Maryland is a wonderful place to train. If you're considering a fellowship centered around global health and pediatric infectious diseases in a global setting, can't do much better than us.
We have a really wonderful track record of obtaining funding for fellows and partnering people with faculty who are actually working on high impact projects in low resource settings. My mentors from residency, Tom Boyce, who's here right now actually, he's, he is a huge inspiration for me, so I have a lot of people to think and I definitely still have a lot to learn and hopefully can continue to contribute in any way I can.
Wow, that is just the perfect transition and giving a shout out to your mentors and collaborators. Just like this conference, we're getting a mix of clinicals. I'm actually going to pivot. I'm not going to give you the end of the case. So it's just a sneak peek because we actually wanted to talk a little bit about careers in pediatric ID.
So I actually was hoping that Emma and Paul could just tell us a little bit about your career path and maybe one thing that you've, a piece of guidance that you would give to a fellow who's trying to figure out what do I want to do, what kind of pediatric ID doctor I want to be?
Oh, what a great question because there's so many options as we've learned during our career paths session today. I've been set from pretty early on that I wanted to do research and medicine, so I think I've wanted to be a physician scientist for a long time, but I was always scared by the scientist piece because that seemed big and scary and the big world unknown.
I didn't start believing that I could actually do that until later in fellowship, that I could fund my way to doing that and have my own research lab. So I encourage people who are in fellowship to really explore your options. You never know when you're going to be, I don't want to say in the right place at the right time, but when you are going to be called upon because you are the best option for some need that your institution or your lab has.
My opportunity to really establish my research niche fell when I was in fellowship and my PI mentor, he's a straight PhD scientist, wonderful person, Dr. David O'Connor at the University of Wisconsin Madison, his area was in developing non human primate models of infectious diseases. And my fellowship happened to fall right during the time of the Zika pandemic throughout the Americas. And so we, uh, developed the first model of Zika virus infection in non human primates.
As a pediatrician and peds ID fellow, I was really, really interested in understanding what happens to the infants after they're born. And these virologists that I was working with are like, what? What's developments? What does that mean? What does it mean like to have neurodevelopmental deficits or microcephaly? So I was really able to add the pediatrician piece to that and establish myself.
That was really a wonderful experience and I thank you for that opportunity to add these other things to the project that would not have been there initially. But that was sort of my experience of using the skills that I had to answer a clinical need that came up. I was there when it was needed.
And so now I run my own research job and it's wonderful, great experience, and I've been fortunate to be involved in these career development sessions and invite wonderful people from all over the country in different clinical niches to help talk with current ID fellows and younger trainees about all the different options within our field.
Maybe we are a somewhat skewed kind of population here because I also am a lab based scientist and went into that during the HIV pandemic, the early days of the HIV pandemic, when it was really the mystery illness at the time and so much to learn. And I wanted to help with that. And so I sought out actually a fellowship where I I could join a retrovirology lab and become a retrovirologist. So that was sort of the early years. And it's been a great career.
So let me just more generalize, because as division chief at two institutions, I have come to appreciate the value of all of the things that we do in Peds ID. We used to maybe have a field bias toward basic research, maybe, but we never should have.
I mean, clinical research, epidemiology, service oriented work, antimicrobial stewardship, infection prevention, government work, industry work, it's all incredibly valuable, and I appreciate that in the faculty that I've had a chance to work with over the years, and in trying to help them just find what is the passion that they have. What part of the field, first of all, are they, are they really good at? And that often marries up with what they're really passionate about.
And how can you develop that into a lifelong career that's very, very satisfying? So that has been enlightening and opens up to all of these different areas of Pete's ID that are great opportunities. Another thing I'll just comment on is that we have a lot of leadership opportunities as you go on. You all will have chances. You may. may or may not be inclined that way, but being a division chief is a terrific way to go. It's a great job.
Uh, or being a leader within a division, a clinical director, all fellowship director, all of those things. And then some of us also take on institutional leadership responsibilities that maybe it's a shift, but it's still, you get to benefit a lot of people and do a lot of good.
You want to find what you're passionate about, and as you go along in your career, you want to know yourself and what makes you tick and when you need to take the kind of break that Sara was talking about earlier, when you need a reboot, and be sensitive to that. One thing I have found helpful, just in my personal journey, is to occasionally do some journaling, where I'm talking to myself, basically, and then I look back.
Sometimes months, sometimes years later, and I can kind of see where I've been and what I was thinking, and it's a tool that some people use. There are many other ways to do it, but I've found that really useful.
Okay, so we have a little bit of time, and I wanted to open it up so that if anyone wanted to ask some questions, and you're welcome to ask questions about career development or comments on the case from earlier.
Could they also ask questions about your presentation that you just finished?
Mine? Yeah. I mean, if, sure. Go for it. Shreya? Looks like there's a mic coming for you.
Sara, that was a great presentation, very inspiring career trajectory. When you were looking for jobs, and I know mostly people are looking for clinic, clinicians to do clinical work. How did you pitch that I also want to, you know, continue pursuing this other interest I have, which I'm very passionate about? Thank you.
So I was looking at heavy clinically oriented jobs. I was usually just pretty honest. I think that a lot of the projects that I had done before expressed for me that those were important and I tried to just share my story of, you know, these are my interests and how I've sort of weaved them together and trying to brainstorm about how that could be incorporated into a job. I will not say that I have it figured out.
I don't think that any medical education job right off the bat is going to be easy, because some of that right place, right time is true. There is only a certain number of educational leadership roles, and they're not going to always be open when you go.
But if you have a division that is passionate about incorporating medical educators, as it's part of their mission that they'll find creative ways to build that in when you start until you have time to get your feet under you and look for those roles that might have true sort of support and FTE behind them.
So I am kind of lucky in my position now I'm getting supported through my division to spend time on my medical education activities to hopefully build them out to where they are into roles that either in educational leadership or something similar. Being upfront and honest because that all those divisions that are going to be excited to talk to you are going to tell you what they're able to do and what they don't think that they can and be honest with you.
So I think the best thing you can do is say, this is what I'm really motivated by. And then just try to think creatively about are there these are all things that can overlap with your interests and you can marry them together. Other thoughts from not the brand new attending?
No, your perspective is great. I mean, you're closer than we are to like, when you start, you want to go into that. And so, you know, I think that's a really important thing to remember. I think that when you're looking for a position with an idea of what you want to do and just express it well, and you don't want to go in and be kind of flat and not say what your passion is. To me, that's really important when you're trying to hire someone.
And it could be clinical work, it can be a mix of clinical and education, it can be any of these other things. But just knowing that. And then maybe showing something you've done that expresses that during your fellowship, that expresses that special interest. It's very helpful to the people that are doing the hiring.
I was going to say also being able to express your passion gives you something to talk about during the multiple interviews that you're going to have that day. So you're going to have to talk about it over and over again. So you want to make sure you really love it and you're really excited about it.
As someone who's been, gosh now, over 20 years in the field, and that's the first time I'm hearing about Febrile, and everyone who raised their hand are probably within five years of fellowship, which is great.
But you hit on a point for promotion, and I think we as leaders, or people talking to the leaders and talking to the chairs, for promotion, we need to be the ones that need to be educated on this is how the new learners are learning, and how important it is, and that we need to start changing. So that's why I'm excited to be part of the promotion committee to say, is there a digital platform? How are people being innovative as someone who sits on the promotion committee for VMC?
Like if I would see your CV, I think there's, uh, enough of us that would advocate to say like this is where she's excelling in education and so I just want to commend you on that and it was inspiring and I already sent it to all the faculty and fellows that are not here to say this is something that we need to incorporate in our teaching for learners because you helped you did a lot of the legwork and we should be able to take advantage of it And so thank you
Thank you. Most places you can look up if your institution just online has those metrics like that impact grid I showed you. Hopefully you are friends with people who are in places that can advocate for changes to that if you are an institution that does not lean towards having opportunities for digital scholarship to show impact. So it's nice.
The one I showed everyone has for example like granular metrics and that's for example what I put in the publication to say there's no way to actually tell you the impact of Febrile, but based on this one grid, this is sort of where they would decide, and I think everyone has to judge for themselves, but ultimately that's the goal, to make it part of, of all the other types of great work that people are doing.
Can we take just a second and say all of us here on the panel in the room think Pediatric ID is the greatest specialty and we hope, we hope all the listeners are considering a career in Pediatric ID.
Nick's asking a question. My co fellow.
So how do you advocate, a lot of medical schools are now doing it. I think we've done an okay job at integrating some of these new teaching technologies and methods, especially for adult learners, but there's still a lot of work to be done. A long way to go, and especially in, as you kind of move along in your training and get a lot of hour to hour and a half sessions of slides being read to you.
How do you, how do you advocate for like integrating more of these interactive technologies and interactive teaching sessions into our medical education landscape?
That is one of the next frontiers for digital education is how to either make things that are standalone curricula or build them into either rotations or local curriculums and rotations. I don't have a great answer because I do think it's a little institution dependent, but pitch these to educational leaders. Oftentimes there are spare blocks in residency lecture spots where they would love to do something creative and out of the box. The other example I'll give is the escape room.
I don't know how many people were able to participate in the ID Week escape room. That was just a, you know, that was a pitch to the ID Week sessions proposal. So I think a lot of times you just have to throw out those ideas and maybe they don't stick the first time, but eventually it'll open up and a lot of the medical students are advocating for these as resources, so hopefully that will eventually help.
So I don't have an easy answer, but I think it's suggesting ideas and, and try them out and pilot things. And if they go well, then you build off of it and refine it. And the other plug I'll give is if you do something like that and it's successful, tell other people and try it out at other centers and like submit it to something like MedEdPortal so that people can replicate it at their own institutions. And then you've made your work count multiple times.
Okay. Well, I think that wraps it up for our episode. Thanks everyone. Thanks so much to you, Sumanth. Paul and Emma for joining Febrile, to the audience for their participation, and to the organizers of the St. Jude PIDS conference. This was really fun. As always, don't forget to check out the website, febrilepodcast. com, where you will find the Consult Notes, which are written complements to episodes, our library of ID infographics, and a link to our merch store.
Febrile is produced with support from the Infectious Diseases Society of America. Editing and mixing is provided by Bentley Brown. Please reach out if you have any suggestions for future shows or want to be more involved with febrile. Thanks for listening, stay safe, and we'll see you next time.