From treatment of strep pharyngitis to clinical trials – ID hot takes for winter

Buddy Creech: [00:00:13] Hi, everybody. This is Buddy Creech with Let's Talk ID. I'm at IDWeek 2024, in Los Angeles right now, and I got to sit down with two of my closest colleagues and friends in the field, Jeff Gerber from Children's Hospital of Philadelphia and Jason Newland from Nationwide Children's Hospital in Columbus, Ohio. And we just kind of caught up. It's been a while since we've seen each other. We talked about a variety of clinical trials we've been involved in and maybe more importantly, clinical trials we'd like to see. And so I hope you enjoy some of our meanderings. Listen for the word pugilist. And that's going to be your bingo word of the day. I hope you enjoy this latest episode of Let's Talk ID.

Jason Newland: [00:00:54] Can I just ask you, since we're talking about your childhood.

Buddy Creech: [00:00:57] Sure. Let's go.

Jason Newland: [00:00:59] Why did you do peds ID?

Buddy Creech: [00:01:01] Why did I do peds?

Jason Newland: [00:01:02] Because this is a good story.

Buddy Creech: [00:01:03] Do you really want this? 

Jason Newland: [00:01:05] Yeah, I do think it's important. Right. Because I think that. Everyone's thinking your doughboy, and you are. [laughs] 

Buddy Creech: [00:01:12] [laughs] Or as my friends have now started referring to me as the social pinata. Just easy to hit.

Jason Newland: [00:01:16] Easy to hit.

Buddy Creech: [00:01:17] Yeah. Good. Good. Return on investment.

Jason Newland: [00:01:19] But I want to get it to more to that, actually, you're an upstanding dude. 

Buddy Creech: [00:01:22] No, it's really easy, I really believe in this idea of a prime boost phenomenon. Right. So you got to have prime, and then you get a boost, and then you get the outcome. So the prime was when I was seven, my mom was diagnosed with lupus and was given a very short lifespan. And all this kind of stuff, just died a few years ago.

Jeff Gerber: [00:01:36] Sorry.

Buddy Creech: [00:01:36] And so way to go therapy. But like lupus was tough, right? It was tough. When I was ten, I broke my femur and I was in the hospital for a month in traction.

Jeff Gerber: [00:01:44] Oh, I have a friend who had the same thing. A month in a traction.

Buddy Creech: [00:01:47] It was before we did, like the intramedullary nails and all that kind of jazz, and it was brutal, but it was awesome. And so there was a kid named Johnny Harrington. HIPAA alert. I don't care. This punk of a kid would come in each day and tickle my foot.

Jeff Gerber: [00:02:00] Oh my god.

Buddy Creech: [00:02:01] In traction. Playing baseball together. Great, dude. If he's listening right now, love you. Email me so I can punch you in the neck. And we'll call it even.

Jeff Gerber: [00:02:09] Four months of traction.

Buddy Creech: [00:02:10] And then you know, I was pretty good at science or whatever and knew I wanted to be a pediatrician. That was easy. That was the easy decision. And then when I was an intern, my dad passed away from Group B strep endocarditis. And that was probably like the final kind of booster dose I needed to be like, this is what I'm going to do.

Jason Newland: [00:02:27] And you were with Keith English and all those guys at the time, right? 

Buddy Creech: [00:02:30] Keith I'd had, and Jim Dale, who's a group A strep guy.

Jason Newland: [00:02:34] Oh. 

Buddy Creech: [00:02:34] Um and some other folks in Memphis who had really set me up for that. My wife will say she knew I was probably going to do ID around fourth year med school. And then I figured it out during like internship and then. So get this my first rotation as an ID doc as a second year resident, Terry Dermody.

Jason Newland: [00:02:49] Oh, I love that dude.

Buddy Creech: [00:02:49] Chair of PIDs at Pittsburgh was my attending. John Williams was the fellow and Andrea Cruz. 

Jason Newland: [00:02:57] [gasps]

Buddy Creech: [00:02:57] Was the medical student.

Jeff Gerber: [00:02:58] We talk about context being everything, right?

Jason Newland: [00:03:01] Andrea Cruz? 

Buddy Creech: [00:03:05] Well don't drop the mic. This is a podcast. So what we do is. 

Jason Newland: [00:03:06] They can't see that?

Buddy Creech: [00:03:07] Yeah, they can't see that, Jason.

Jeff Gerber: [00:03:08] Thank god they couldn't see his worm impression. 

Jason Newland: [00:03:12] I thought it was pretty good, no?

Buddy Creech: [00:03:12] Yeah, no it was terrible.

Jason Newland: [00:03:13] Oh, wait. Hold on. But you talked about vaccines. So what about Group B strep vaccine? Is that possible?

Buddy Creech: [00:03:17] Group B strep vaccine? Yeah, 100%.

Jason Newland: [00:03:19] And how's it going to be?

Buddy Creech: [00:03:20] Well, so we've had a few group b strep vaccines that have been developed. We've got some maternal programs. And it just points to the fact that we're going to have a potentially crowded maternal vaccine schedule pretty soon. Right. We've got pertussis with every pregnancy. The UK does RSV vaccine with every pregnancy because they don't have nirsevimab. They probably won't have clesrovimab when it's approved.

Jeff Gerber: [00:03:40] Is everything in the same window, so you can give them the same -

Buddy Creech: [00:03:42] They're a little bit different. The RSV vaccine is so tight.

Jason Newland: [00:03:45] It's so tight because of that [inaudible], that's an interesting -

Buddy Creech: [00:03:48] They think maybe preterm labor but probably not but maybe.

Jason Newland: [00:03:49] But you had the GSK vaccine that they went away from it, right? What do you think?

Buddy Creech: [00:03:54] They went away from it because they had higher rates of preterm labor, but in the vaccine group. But it was still below the national average for prematurity in the place it was done. 

Jason Newland: [00:04:05] But the current RSV vaccine, the trial was 24 to 36 weeks.

Buddy Creech: [00:04:08] For sure.

Jason Newland: [00:04:08] And then they said, look, we're going to do 32 to 36, right? Because they were concerned, right?

Buddy Creech: [00:04:12] Out of abundance of caution. Right. Yeah. So but then if we have a Group B strep vaccine, if we have a CMV vaccine that might be available at some point. I probably wouldn't be giving pregnant women.

Jeff Gerber: [00:04:19] Yeah, probably not.

Buddy Creech: [00:04:20] But maybe beforehand.

Jeff Gerber: [00:04:21] Yeah

Buddy Creech: [00:04:21] But that's where group B strep. There's also a group A strep vaccine that's been in development for years.

Jason Newland: [00:04:27] Let's talk more about that.

Buddy Creech: [00:04:27] You want to talk about group B strep?

Jason Newland: [00:04:30] Keep going.

Buddy Creech: [00:04:31] You're highlighting group B strep for no no-good reason. What's your fascination with, you just like group A strep?

Jason Newland: [00:04:36] I don't, I just -

Buddy Creech: [00:04:38] Where would you rank Group A strep in your pathogen -

Jason Newland: [00:04:40] All right, so here's what I will say.

Buddy Creech: [00:04:41] Patheon? No that's not

Jeff Gerber: [00:04:42] Pateon?

Jason Newland: [00:04:43] Here's what I say is like group A strep feels it should be simple, right? You get group A strep pharyngitis. Right. Like everyone has strep throat.

Buddy Creech: [00:04:52] 17 million doses over 17 million doses of - 

Jeff Gerber: [00:04:55] Units of penicillin.

Jason Newland: [00:04:55] And we think it's simple.

Jeff Gerber: [00:04:57] People don't give the shots enough. I love the shot.

Jason Newland: [00:04:58] The shots are great. But we think it's simple. But we know diagnostically it's not simple, right? We test usually way too much. And then we had last year. Right. And last year we were seeing Group A strep all the time, positivity rates in pediatricians clinics of like 70 to 80%. They're talking about recurrences and they're giving you these stories of oh yeah, they runny nose and coughing, and I looked in their throats and it was like, you know, super red pus. It looked awful.

Jeff Gerber: [00:05:26] Respiratory tract diseases has been jacked up for, you know, since Covid.

Jason Newland: [00:05:30] It's been jacked up.

Jeff Gerber: [00:05:31] Mycoplasma. Group A strep. 

Jason Newland: [00:05:33] Right.

Jeff Gerber: [00:05:33] I mean, pertussis might be more of a vaccine [inaudible] but it's all from that.

Jason Newland: [00:05:37] So I want group A strep to be simple. But I don't think it's that simple. So now I'm like well I'd love a vaccine. So then I have to deal with it maybe.

Buddy Creech: [00:05:43] Yeah, that's going to be a while, if ever.

Jason Newland: [00:05:45] But then now I'm thinking, well, in our country we treat group A strep, at least pharyngitis, which, do we need to treat group A strep pharyngitis?

Jeff Gerber: [00:05:52] There we go, Jeffrey Gerber!

Buddy Creech: [00:05:54] Hold on. Okay. I'm just gonna come off the top rope. This is a lava hot take.

Jeff Gerber: [00:05:59] Boom! Yes, yes.

Buddy Creech: [00:05:59] Lava hot.

Jason Newland: [00:05:59] He just said don't treat.

Buddy Creech: [00:06:00] Don't treat group A strep?

Jeff Gerber: [00:06:01] Yeah.

Jason Newland: [00:06:02] How do you feel about that?

Buddy Creech: [00:06:02] I feel very emotional about that.

Jeff Gerber: [00:06:04] Yeah, I can see it. Right.

Buddy Creech: [00:06:06] Like, I'm almost balding. I'm getting so upset about this. I mean, what?

Jeff Gerber: [00:06:09] Yeah. I mean, in some European countries, they don't test. Uh, England? Yeah, actually. So Allison Tribble gave a great talk yesterday at. Or maybe Wednesday. IDWeek 2024. LA. that's where we are. I don't know if we said that.

Buddy Creech: [00:06:24] No, but we're here.

Jeff Gerber: [00:06:25] And talk through, went back to 1950s and went to the original data. And really the data only suggests that therapy is going to be, you know, worthwhile if you're in an endemic or high-risk region or population. So the US really, rheumatologic strains are not endemic except in some populations, European countries. So there was, I forget which country. I think it was a Scandinavian country. They actually, this is great, they test for group based strep only to not use antibiotics because if it's positive, they don't treat. So they'll take, they'll say that's not a you know. So a lot of them don't do it. They if they do treat and it's not a high-risk population, they'll do five days just for symptom relief. Ten days is only for endemic populations which is a really small subset. They're not seeing, you know, raging rheumatic fever.

Buddy Creech: [00:07:18] Well isn't it going to wax and wane? I mean, they're going to be times when a rheumatogenic strain is going to enter into the population. And how are you going to know that if you're not able to do really good diagnostics or really good surveillance of -

Jason Newland: [00:07:27] But you're of this notion that ten days is a must in the prevention of rheumatic fever.

Buddy Creech: [00:07:31] Don't you dare put words in my mouth, Dr. Jason Newland. You calm down.

Jeff Gerber: [00:07:31] That's the other piece. You know, so ten days has been shown to be better than five for eradication. Eradication is this surrogate outcome for rheumatic fever. But is that true? We don’t know.

Jason Newland: [00:07:42] But even in that data, the eradication still only gets you down to like 10 to 20%. It's not like it's completely eradicated. Even with ten days.

Buddy Creech: [00:07:50] Correct.

Jeff Gerber: [00:07:50] Yeah.

Jason Newland: [00:07:51] So while it might be more, I'm not sure five days isn't fine for preventing rheumatic fever when you get your rheumatic genetic strain into our population.

Buddy Creech: [00:07:58] Alright we've done this before. We've tried to do short course therapy studies before. We the three of us have done these. This is how we got to be "friends?"

Buddy Creech: [00:08:05] Eh.

Buddy Creech: [00:08:07] Friendish. We're friends adjacent.

Jason Newland: [00:08:09] That's true. No. That's fine.

Jeff Gerber: [00:08:10] We know each other.

Buddy Creech: [00:08:12] We recognize each other's facial features. Um, because we compared five days to ten days for pneumonia. We've done this called SCOUT-CAP. We've done this for, we haven't done this, but it's been done for otitis media by our colleagues at Pittsburgh especially. It's been done for UTIs. Again, our Pittsburgh colleagues and others. So for some things, we know that five days are probably better than ten. Pneumonia. Don't you dare say three. I know I'm looking at you, Jason. Don't you dare say three days.

Jason Newland: [00:08:39] For three days, please.

Jeff Gerber: [00:08:40] But the challenge for group A strep is the outcome that we care about is a rare outcome.

Buddy Creech: [00:08:44] Is so rare. So rare.

Jeff Gerber: [00:08:45] And it's really. I mean, back to, you know, kudos to Allison Tribble. She did some really cool back of the envelope calculations of number needed to treat. And again, I recognize that if you're, this is for a non-endemic region, but it was somewhere over a million treatment courses to prevent a case of acute rheumatic fever. Now, that's bad stuff, right? Acute rheumatic fever.

Buddy Creech: [00:09:06] Sure.

Jeff Gerber: [00:09:06] It's bad stuff. But where do you, I mean, this brings up all these philosophical arguments about what's the actual number needed to treat and why does it matter?

Buddy Creech: [00:09:13] Ok this is more compelling. This is a more compelling argument than.

Jason Newland: [00:09:16] He's smarter than me. I'm okay with that.

Buddy Creech: [00:09:18] No, 100%. Yeah.

Jason Newland: [00:09:18] I mean, we all agree with that.

Buddy Creech: [00:09:20] Yeah, bars low.

Jason Newland: [00:09:21] Yeah. That's fine. I'm from Oklahoma.

Buddy Creech: [00:09:24] Did you always know the bar was low with him? Because when did you all meet?

Jeff Gerber: [00:09:27] I mean, it was minutes it took. So we met, I was, I was an intern in Philadelphia Children's Hospital of Philadelphia. He might dispute when we met, but -

Jason Newland: [00:09:41] I will dispute when we met.

Jeff Gerber: [00:09:43] So, Children's Hospital Philadelphia was the OG pediatric stewardship program took the lead from Penn, which was one of the first. Paul Offit and - 

Jason Newland: [00:09:53] Stanley Plotkin, the whole crew. 

Jeff Gerber: [00:09:54] Yeah, they were doing it before it was called stewardship and then people put a name on it. Anyways, you get the job as an intern, if you want any antibiotic other than penicillin or amoxicillin, you have to call the ID fellow. And this was - 

Buddy Creech: [00:10:07] So aggressive.

Jeff Gerber: [00:10:07] Was there one of you or two?

Jason Newland: [00:10:09] Two.

Jeff Gerber: [00:10:10] Two ID fellows. They just literally divide up the 365 days a year, times 24 hours, and they split the pager.

Jason Newland: [00:10:16] Wasn't that bad. But sure. 

Buddy Creech: [00:10:17] That sounds really bad.

Jason Newland: [00:10:19] Yeah, it sounds way worse than it was, but go ahead.

Jeff Gerber: [00:10:20] And so you have to call, and I get on the other end of the call, Jason Newland.

Jason Newland: [00:10:23] And I'm going, is this Jeff Gerber, the pugilist from Notre Dame?

Jeff Gerber: [00:10:30] [laughs]

Buddy Creech: [00:10:30] I hope you use the word pugilist because most individuals not from Oklahoma would say boxer.

Jason Newland: [00:10:34] I actually read a few books since then, so I'd just like to use it.

Buddy Creech: [00:10:38] Boxing books? Like pugilist books? like all the Muhammad Ali memoirs? 

Jason Newland: [00:10:43] But here's the deal. Jeff Gerber was the four-time Bengal Bouts champ at Notre Dame.

Jeff Gerber: [00:10:51] Context is everything.

Jason Newland: [00:10:52] That's okay. We just need to know this. And I was like, he was two years older than me in the same dorm. And you're like.

Jeff Gerber: [00:10:57] I'm older than you.

Jason Newland: [00:10:58] Oh, dude. Like, that's freaking Jeff Gerber, the guy that always beat everybody up. Yeah.

Jeff Gerber: [00:11:03] Come on.

Buddy Creech: [00:11:04] In or outside of the ring or -

Jason Newland: [00:11:06] Definitely inside the ring, but I'm not sure. Outside the ring. And I probably tell this story to pretty much most of our ID colleagues. And he rolls his eyes.

Jeff Gerber: [00:11:15] Sure it's a silly story.

Jason Newland: [00:11:17] Yeah, but then we've been to then we've been doing work together in the stewardship since probably 2008, nine when you were a fellow. And then I was the first time attending and doing some stewardship in Kansas City, and I still worked with these guys. And so we've done all kinds of stuff since then.

Jeff Gerber: [00:11:29] Have we talked about the Newland effect?

[00:11:31] No, we have not. I need to know about this.

Jeff Gerber: [00:11:34] Yeah. Jason Newland, I mean, he's - 

Jason Newland: [00:11:36] Oh, stop.

Jeff Gerber: [00:11:37] So Julie Szymczak, who is a PhD sociologist, who's really academic life is is dedicated to applying her incredible methods to antimicrobial stewardship. She's like the Jane Goodall of antimicrobial stewardship. She embeds herself among surgeons. And I'm not comparing.

Buddy Creech: [00:11:59] So now all I can think about is her sitting there watching Newland, like, eat grapes or something in a call room and like, describing his behavior.

Jeff Gerber: [00:12:08] And what she's brought out that, you know, I think some people might have said, oh, yeah, that's kind of sure. But she put science to the fact that prescribing antibiotics is a behavioral act more than it is a scientific act.

Buddy Creech: [00:12:22] That's awesome.

Jeff Gerber: [00:12:22] And because of that, it's about relationships. And it's about getting your message across, not just putting a guideline in some front. So back to the Newland effect. So, you know, she wonders sometimes why the same structure of a stewardship program might be more effective than another, even though you have the same guidelines and the same people and the same FTE. But Jason Newland, he's just got that. He's got that charisma or what the kids call it.

Buddy Creech: [00:12:47] The rizz.

Jeff Gerber: [00:12:48] The rizz. He's got that. And so but I mean, you know, I partially joke, but it's real. He's a charismatic dude. Wherever he goes, you know, good things happen.

Buddy Creech: [00:12:57] Is it the facial hair?

Jeff Gerber: [00:12:58] It's some father time. Yeah, it's got the gray. Yeah. No, I don't know what it is, but he's. He's a good dude.

Jason Newland: [00:13:05] I appreciate that.

Jeff Gerber: [00:13:05] So, but no, it's about you know relationships, right. So you have to science things, but then you have to get them across to people because we're dealing with human beings, whether it's the I mean, here, these experiments are not on patients. They're on prescribers, right.

Buddy Creech: [00:13:21] Yeah, on colleagues.

Jeff Gerber: [00:13:22] And it's not easy, right? To get somebody who's gone to, you know, 62 years of school and can prescribe something, they have a license to do it to tell them, well, you can't. And so you have to do it tactfully. 

Buddy Creech: [00:13:35] So do you use your judo training, Jason, to do that? Because you're an old ..judalist? That's not a word. Jude-oer?

Jason Newland: [00:13:44] No, I'm a lover, not a fighter, dude.

Jeff Gerber: [00:13:47] Can we, uh. Is there an edit function on this? C

Buddy Creech: [00:13:50] We're just going to take that off post, because I never know where the phrase I'm a lover come out of Jason Newland's face. [laughs]

Jason Newland: [00:13:58] [laughs]

Buddy Creech: [00:13:59] Um. That's remarkable.

Jeff Gerber: [00:14:01] So Newland was doing it, but he didn't realize he was doing all this cool social -

Jason Newland: [00:14:05] I did not know.

Buddy Creech: [00:14:06] It's Empire Strikes Back. It's like, these are not the droids you're looking for.

Jason Newland: [00:14:09] Correct.

Buddy Creech: [00:14:10] I realize that's from the fourth episode, but I'm mixing my Star Wars up. You don't care, you're a Trekkie.

Jeff Gerber: [00:14:17] Yeah, so the Newland effect, we study it. It's good stuff. Well, the royal we.

Jason Newland: [00:14:21] The royal we. That's fine.

Jeff Gerber: [00:14:22] But yeah.

Jason Newland: [00:14:23] That's the world of stewardship, social game.

Buddy Creech: [00:14:25] So we need to do a group A strep trial, it sounds like.

Jason Newland: [00:14:26] We do. You're now convinced?

Buddy Creech: [00:14:29] No. 100% not.

Jeff Gerber: [00:14:30] [laughs]

Buddy Creech: [00:14:30] But that's why we do trials, right? You don't have to be convinced to be a trial

Jason Newland: [00:14:32] Oh that's true.

Buddy Creech: [00:14:33] What you say is. I have a question. Is it worth studying? Yes.

Jeff Gerber: [00:14:37] Is there equipoise in some way? Is it safe?

Buddy Creech: [00:14:40] Yep. So going to kind of like pivot to PCORI, which is a really great funding agency that does these or sponsors these pragmatic trials and pragmatic, it means lots of things. But in one, in their interpretation, are people doing, in the real world, a couple of different things for the same condition? So do you have situations where for otitis media or for strep throat, some people are giving five days of therapy and some people are giving ten, because that's kind of proof that there is equipoise, right?

Buddy Creech: [00:15:11] Yep, right.

Jeff Gerber: [00:15:11] As long as it's not like 1 or 2 rogue, you know, folks. And so I think,

Jason Newland: [00:15:15] I think it's there.

Jeff Gerber: [00:15:16] There's equipoise, if you have people and, you know, I think where you would reach and I don't know how this would work, but you'd reach to, you know, across the ocean to these European countries where they're - 

Jason Newland: [00:15:26] They're doing this.

Jeff Gerber: [00:15:27] Not prescribing at all.

Jason Newland: [00:15:28] Yep.

Jeff Gerber: [00:15:29] Sometimes giving 5 or 10 days. And then the outcome is tricky though, right. Because we know they all get better -

Buddy Creech: [00:15:35] And it can't be a microbiologic outcome because we're not dumb.

Jason Newland: [00:15:37] No, but I do think it gives us this opportunity to think about what recurrence is, because I think in this most recent increase, people talked about recurrence and you had a hard time. And because testing has been right, we went from rapid antigen and culture to now PCR.

Buddy Creech: [00:15:53] Much more sensitive.

Jason Newland: [00:15:54] Much more sensitive. So now we probably need to come up with a strategy of what recurrence is and when. Maybe you do. One of my colleagues said, hey, if it's a quote unquote recurrence, maybe it's PCR plus culture on the second one within a certain amount of time, because maybe you're just finding genetic material and the culture is there, right? Like is there is that now your approach?

Jeff Gerber: [00:16:16] And it's important because you have to chip away at the heavy hitters.

Jason Newland: [00:16:19] Yes.

Jeff Gerber: [00:16:19] When you think about stewardship, we're thinking, we have a kid in the hospital with, you know, multidrug resistant gram negatives, and you don't want them to be getting the wrong. But the big numbers are in outpatients, right? And so otitis media, we still have some work to do, but people have done some good trials there. After otitis, which is like 30, 35% of prescribing. You then get into pharyngitis and sinusitis, right? So people have done some good work on some observational stuff on sinusitis. Maybe we could do a clinical trial but group A strep, if you just took all the kids who, who were getting antibiotics for group A strep and cut in half the days of therapy.

Buddy Creech: [00:16:52] It would be a huge impact.

Jason Newland: [00:16:52] Huge.

Jeff Gerber: [00:16:52] Millions and millions. It's going into everybody's bodies. It's in the cupboard, the leftover stuff and it costs money. So it's worth a thought.

Jason Newland: [00:17:04] If we get invited to another episode of podcasting can we talk

Buddy Creech: [00:17:07] Yes. Okay.

Jeff Gerber: [00:17:09] Is that what this is?

Buddy Creech: [00:17:10] Yeah. It's called Let's Talk ID.

Jason Newland: [00:17:11] Oh, nice. Okay. Yeah if we get invited again

Buddy Creech: [00:17:15] Oh, welcome to the room. My name is Buddy. Yeah, it's good to meet you.

Jason Newland: [00:17:18] Oh hi. [laughs] Can we talk about MRSA bacteraemia studies?

Buddy Creech: [00:17:23] Oh sweet lord. Yeah, we can talk about anything you want. So okay. Before we. Okay. Yes, we can, because that's a tough one. But it should be easier to, right. This is what we're talking about. Trying to make hard things easier. So real quick, rapid fire. I'm gonna quiz you both. How long do you now treat pneumonia in your hospital?

Jason Newland: [00:17:41] Five days.

Jeff Gerber: [00:17:42] Inpatient?

Buddy Creech: [00:17:42] Yeah.

Jeff Gerber: [00:17:43] Five days.

Buddy Creech: [00:17:43] What if they have a parapneumonic effusion? Need a chest tube?

Jason Newland: [00:17:45] Different.

Jeff Gerber: [00:17:46] [laughs]

Jason Newland: [00:17:46] Uh, no. Here's what we do in ours. Here's what we've done. And there's some studies that have kind of looked at. Look, we sometimes with parapneumonic effusion we try to make every patient the same. Oh you have this. We're gonna give you three weeks, like come on that's crazy, right? These are more complicated infections with different courses of illness. Some are febrile longer, some have bigger effusions, yada, yada, yada. So we've tried to say, well, let's just do it this way. Afebrile, chest tube is out. Let's do one more week. It ends up -

Jeff Gerber: [00:18:14] It's hard to standardize that.

Jason Newland: [00:18:15] It's hard.

Jeff Gerber: [00:18:16] I mean, we're not talking about the trace thing that the radiologist can see, 

Buddy Creech: [00:18:19] No you're talking about chest tube -

Jeff Gerber: [00:18:19] We're talking about empyema. 

Buddy Creech: [00:18:21] Correct. Right.

Jeff Gerber: [00:18:22] And even that, like sometimes they're loculated. Sometimes there might be necrotizing lungs.

Jason Newland: [00:18:28] So I try to standardize it off how they've responded and then give them -

Buddy Creech: [00:18:33] Give them another week.

Jason Newland: [00:18:34] Another week. And that ends up in some studies, right, it gives you about two weeks -

Buddy Creech: [00:18:39] Which I love because that's what we do for tick borne illness, right. For tick borne illness where we are, where you used to be,

Jason Newland: [00:18:44] Where I used to be.

Buddy Creech: [00:18:45] You treat them until they're better and then for a few more days. That's like the smartest way to treat an infection -

Jason Newland: [00:18:50] We try too much to make everybody the same. Just not the truth.

Buddy Creech: [00:18:53] Oh, man. Just dropping truth bombs.

Jason Newland: [00:18:55] Let's go.

Jeff Gerber: [00:18:56] Yeah.

Buddy Creech: [00:18:56] Let's go. All right. Okay, so that's pneumonia and pneumonia with a chest tube. Um, osteo? We have guidelines on this.

Jason Newland: [00:19:02] I'm now going to be trying to get more to three weeks.

Jeff Gerber: [00:19:06] Yeah. I mean, we're four weeks. 

Buddy Creech: [00:19:08] Because you just don't believe the guidelines? That's fine.

Jeff Gerber: [00:19:10] [laughs] They're three to four, right?

Buddy Creech: [00:19:11] They are. Just messing with you. 

Jason Newland: [00:19:12] But why did that. I just think go more to three weeks on these uncomplicated straightforward stuff.

Buddy Creech: [00:19:15] What's CRP normal -

Jason Newland: [00:19:16] What about septic arthritis. Are you on 10 days?

Buddy Creech: [00:19:18] We're gonna name check it there. Acute bacterial arthritis.

Jason Newland: [00:19:23] Thank you.

Buddy Creech: [00:19:23] I love a two week course for acute bacterial arthritis.

Jason Newland: [00:19:25] 10 days. It says 10 to 14 the guideline.

Buddy Creech: [00:19:26] Well, we said 3 to 4 weeks. You didn't give me a hard time about osteo but you're gonna give me a hard time about 10-14 days.

Jason Newland: [00:19:30] Go back to the recording. You'll see.

Jeff Gerber: [00:19:32] Does it matter if staphauerus grew in the blood versus.

Jason Newland: [00:19:35] Well, that's a good question.

Buddy Creech: [00:19:36] Back to the MRSA bacteraemia question. We used to treat those at Vandy for a long time because we thought it was of a different severity, different type. If it's the first 72 hours, we just don't care usually. Unless they have underlying heart or some other high-risk condition. All right. Appendicitis that ruptures. How long are you treating those? Jeff?

Jeff Gerber: [00:19:56] There was just a good study, well, this is what we try to do. Not everybody does it, but when they leave the hospital, no more antibiotics. And so it's like 4 to 5 days, which matches the complicated intra-abdominal infection guidelines, which are a minimum of four days. So, you know, if they go - source control. Right. So if they've gone in there and they've, you know, cut things out, washed things out, really I think 4 to 7 days is the range. And so we wouldn't really. Somewhere in that range. But I don't know. We don't have a handle. We don't get consult on all those patients. They leave the hospital. We don't discharge stewardship. I can put a plug in for that.

Jason Newland: [00:20:34] There we go. We're doing that?

Buddy Creech: [00:20:35] We do outpatient stewardship. We do inpatient stewardship with that prescription that gets written at the last minute by the random intern who just picks five, 7 or 14.

Buddy Creech: [00:20:41] That's right.

Jeff Gerber: [00:20:42] That's a place where people are starting to focus. And so we're not on top of that as much. But our recommendation is the 4 to 7 days.

Buddy Creech: [00:20:48] That's awesome okay. This is awesome.

Jason Newland: [00:20:51] Thank you.

Buddy Creech: [00:20:51] It's been really fun to be at IDWeek with you guys. This is a chance for us to keep having these kind of conversations, because I think one of the things we've been benefited from as our little, uh, three amigos group here is we've been able to do trials together and SCOUT-CAP together. We did the Covid vaccine trials and kits together. So much of that is based on the collegiality that we get to enjoy.

Jeff Gerber: [00:21:09] And I think PEDs is just better in that way. Right? We're kind of a small community but super powerful. There's so much expertise and we can I know we've gotten together to do these multi-center trials. We know each other. We know our strengths. We complement each other's strengths and weaknesses. It's great.

Buddy Creech: [00:21:27] It's the Gerber, Newland, Creech effect. No, that's not a thing. We'll edit that out too.

Jason Newland: [00:21:32] GNC, like the supplements?

Buddy Creech: [00:21:34] CNG?

Jeff Gerber: [00:21:36] It's not us.

Buddy Creech: [00:21:37] What's your favorite supplement that you take for your skin, Jason?

Jeff Gerber: [00:21:41] It's not working. [laughs]

Buddy Creech: [00:21:46] One question Jeff had earlier was is that what you're trying to accomplish with your hair or are you, what happened there?

Jason Newland: [00:21:54] Offline.

Buddy Creech: [00:21:55] Is it intentional?

Jeff Gerber: [00:21:56] We'll keep this as radio, right. Audio only. Please.

Buddy Creech: [00:22:00] Well, this may be the only time we're invited to do this for, I think, clear and obvious reasons, but it's been really fun. A lot of these trials, we've talked about SCOUT-CAP, otitis media studies, studies around UTI. These are in your friendly neighborhood journal. A lot of these ended in Journal of Pediatric ID Society. So go to the JPIDS website. Pull down some of these osteo guidelines are out. If we can be helpful to any of the listeners, let us know. At the end of the day, what we want to be able to do is treat kids well, give them just enough antibiotics and not a drop more. And I'm almost convinced that we need to do a Group A strep short-course trial.

Jason Newland: [00:22:34] I appreciate that.

Buddy Creech: [00:22:35] I'm really close. I'm going to miss you guys.

Jeff Gerber: [00:22:37] Yeah, same. This was great seeing you.

Jason Newland: [00:22:37] We'll see you soon. We'll see you soon. 

Buddy Creech: [00:22:40] Yeah, next year in Hotlanta.

Jason Newland: [00:22:42] No, I'll come to Vandy.

Buddy Creech: [00:22:42] You'll come to Vandy, okay.

Jason Newland: [00:22:43] Yeah, yeah, I'll come watch them win a national championship in football. 

Buddy Creech: [00:22:47] Okay. One second. Can we talk about this.

Jeff Gerber: [00:22:48] Oh my god.

Jason Newland: [00:22:49] That is -

Jeff Gerber: [00:22:50] I texted Buddy right after it and that was just such, oh my god.

Buddy Creech: [00:22:54] I'm telling you. Right. So my son was at the game and there's a picture of him hanging on the goalpost at the end. And I'm like, I recognize that you crossed Vanderbilt $100,000. But we're in. Yeah. And then what happened? This is where I'm going to brag on Vandy for a second. They fished the goalpost out of the Cumberland River that we threw it in there, and then chopped it up into pieces and -

Jeff Gerber: [00:23:12] And sold it?

Buddy Creech: [00:23:13] Oh, yeah.

Jeff Gerber: [00:23:13] I would buy that if I was.

Jason Newland: [00:23:14] And you were there and didn't get it signed?

Jeff Gerber: [00:23:17] That was perfect, I loved it.

Buddy Creech: [00:23:18] And this is a shout to you guys, who's our head coach and what's his alma mater, Clark Lee. Defensive coordinator. 

Jeff Gerber: [00:23:24] Notre Dame. Go Irish.

Buddy Creech: [00:23:25] Go Irish. There it is.

Jason Newland: [00:23:26] Go, Irish. 

Jeff Gerber: [00:23:27] Maybe that's a bowl game. Vandy, Notre Dame, I don't know.

Jason Newland: [00:23:30] No, we're gonna be in the playoffs.

Jeff Gerber: [00:23:31] They might be.

Buddy Creech: [00:23:34] Stop. Like nobody asked you that question.

Jason Newland: [00:23:36] Vandy's not gonna be in the playoffs. They’re still Vandy.

Jeff Gerber: [00:23:38] Oh, wow. That just went dark. And we need to -

Buddy Creech: [00:23:41] I think on that note. 

Jason Newland: [00:23:43] I'm never.

Buddy Creech: [00:23:44] Jason and I are gonna go putalize.

Jason Newland: [00:23:45] This is gonna be good. Yeah. Nobody wins. We all lose. For thinking about that, for seeing it for. 

Buddy Creech: [00:23:57] A lot of scratching and clawing.

Jeff Gerber: [00:23:59] Orthopedic surgeons win that. The business they give.

Buddy Creech: [00:24:00] All right. Thanks for joining us. This has been Let's Talk ID, enjoy.