So I look at a recent case of mine,
Term-gestation baby girl presenting to ED at 7 days' of age with febrile illness and tachypnoea. APGAR 9, 9. Septicaemia at 3hr life, all septic screening negative, mother's perinatal testing negative, baby had CRP of 14. Commenced on empirical IM amoxycillin and IM gentamicin and discharged the next day with PO Amoxycillin as clinical well (despite CRP 7), and returned with current presentation. Impression of partially treated neonatal sepsis.This baby had new bloods taken and was found to be positive for Streptococcus sanguinis, a Group B Streptococcus, with patchy lobar pneumonia previously dismissed on CXR at birth.
Now, Group B Strep, Coagulase Negative Staph and GN bugs cover the majority of bacterial causes of neonatal sepsis, and in the past we would have included H. influenzae in pre-vaccination days. Subtracting Haemophilus from the equation, the three sets of species above are often well-covered with a penicillin and an aminoglycoside. Indeed, current practice for neonatal sepsis is parenteral amoxycillin + gentamicin. It'd help to get MCS for targetted treatment for sure.
I began to wonder... why not just treat them IV amoxycillin + IV gentamicin for a week pending cultures? Surely it will reduce the time of sepsis, treat any nidus and prevent further complications such as pneumonia and febrile seizures, via increased bioavailability and since we're already giving these antibiotics it won't be at greater risk of selecting out bugs given the high inhibitory concentrations reached....
My glorious PICO moment had arrived in dapper and timely fashion:
In neonatal sepsis of unknown origin, would a weeks' IV amoxycillin + IV gentamicin be superior to IM injections of the same in reducing the incidence of hospital re-admission?Daydreaming of Nobel glory aside, I had to find a study which asked pretty much the same question above, and analyse it. A search on Medline had no dice, so I discussed this with someone in the faculty:
Students are expected to formulate a PICO question on the basis of a case study, and then search for a study exploring the same, or similar PICO, to evaluate the strengths and limitations of the paper.
Wait. Brakes on. Hard. Stop thinking, now. We're expected to
a) Pick our brains to find a question
b) Research this and hope someone else already has the answer to the same question we asked
c) Mark the answer like a teacher and see what they got right and wrong.
Riiiiiight.
First, this is the antithesis of original scientific thought. Having to ask a question (for the purpose of an original PICO) which was re-visited several thousand times in several thousand RCTs stinks of redundancy. Yes, I understand you'll probably have to have a BMedSci or a PhD to test these original PICOs, but still, why ask a question that everyone else has asked, and everyone else has the same (or similar) and correct (or at the very least highly effective) answer to?
Second, what is the point of making us ask a PICO question, and then merely perform a literature review on ONE (1) published paper? In fact, what is the point of making us ask a PICO question at all?
We may as well find a study on a topic relating to the case (ie. intrapartum antibiotic prophylaxis for GBS), figure out a PICO question to fit the title of the paper (ie. creatively re-wording objective of a paper aka "In expecting mothers, are Clinical Risk Factor-based guidelines superior to GBS culture screening guidelines in preventing neonatal GBS sepsis"), and then just doing a literary review on that, effectively stealing a paper on a related topic and coming up with a PICO "of your own" that coincidentally the same as that asked the paper.
Voila, Faculty-endorsed plagiarism.