Dr Pierre Kory
[T]his case [of six-year-old Kayley Fehr in Texas] was tragic and really had nothing, I shouldn’t say nothing to do with measles. But she did not die of measles by any stretch of the imagination. In fact, she died of a pneumonia. But it gets worse than that because she didn’t really die of the pneumonia. She died of a medical error. And that error was a completely inappropriate antibiotic. It was an insufficient antibiotic.
And in reviewing cases, I’ve reviewed cases of pneumonias that went unrecognized or mistreated. And normally when you review a case, it’s difficult to pinpoint blame unless you know exactly what the organism was. And in this case, we did know what the organism was. She died of mycoplasma.
And the tragedy is that mycoplasma is an extremely common what we call immunity acquired organism. This is very commonly circulating in the community. It causes pneumonias. And when you admit someone to the hospital for pneumonia, what you need to do is you treat what’s called empirically, meaning you put them on antibiotics that you think will cover the most common organism.
And that’s why this case is absolutely enraging. It’s infuriating because she died because she got an inappropriate antibiotic. The most common antibiotics that we use, it’s in every guideline. Infectious disease, pulmonary. Every guideline in the country tells you that for a hospitalized child or adult who gets admitted to the hospital, you put them on two antibiotics. One is from a category called beta lactams, which is like penicillin, cephalosporins.
And they got that part correct. They put her on something called ceftriaxone, which was excellent. But you always need to pair it with an antibiotic from a different category, which is called a macrolide or a quinolone. And they did neither of those things. They didn’t put her on the most common, which is azithromycin.
The tragedy is that mycoplasma is an organism that doesn’t have a cell wall. Penicillins and cephalosporins work by disrupting the organism cell wall. But if you don’t have a cell wall, you need a different mechanistic antibiotic, which is azithromycin, which interrupts the protein synthesis and messes with the formation of proteins in the ribosome. But I don’t want to get too geeky with that. I mean, this is like medicine 101. You put them on two antibiotics to cover all the possibilities.
And unfortunately, this case gets a lot worse than that because not only did they use an inappropriate antibiotic, so they used ceftriaxone, which was correct. They added something called vancomycin to it, which works similarly. And it covers very drug resistant organisms like MRSA. There’s no reason to think that this child would come in with MRSA from the community, from a Mennonite community. She’s not coming from a facility where a lot of antibiotics are used. So it was a really a grievous error, and it’s an error which led to her death.
And so when I say it gets worse, she’s in the hospital deteriorating. One of the fundamental teaching points that I’ve made throughout my career to my residents, to my fellows, to my students, is I always tell them, if what you’re doing is not working, change what you’re doing. Although this child was declining, they never changed what they were doing until the test came back from mycoplasma.
This is where it gets really troubling because as an ICU doctor, when I need a new antibiotic, I uncover, identify an organism in someone who’s critically ill when I order that antibiotic. That antibiotic has standards, it should arrive within at least two hours. And from my review of the records, the A\antibiotic was ordered 11pm, approximately 11 pm and as far as I can tell, it was not administered until 9 am the next morning. It was actually written to start the next day.
And so not only did you have several days delay of decline without the appropriate antibiotic, but then when they realized that they were missing the appropriate antibiotic, it took them, as far as I can tell, 10 hours to administer it. And by that time she was already on a ventilator. And approximately 24 hours later, actually less than 24 hours later, she died. And she died rather catastrophically.
As she was declining, she was in a state of what’s called shock and she needed medicines to maintain her blood pressure. And suddenly her blood pressures crashed and she arrested. And that kind of suddenness in an infection suggest some other cardiac event. And in a child like that, with that amount of inflammation, infection and disturbances in the bloodstream, I can only surmise that she died of a catastrophic pulmonary embolism.
But by the time that happened, there’s not a lot you can do. There’s some stuff you can do, you can use clot busting medications. And I’ve done that in the middle of cardiac arrest before and I’ve had a couple of rescues, but it’s not a high probability that you do that. But rather than focusing on that final event that caused her death, it really was all of the missteps that occurred.
And so she was recovering from measles, getting a secondary bacterial pneumonia. Let me give the hospital some credit. They correctly diagnosed her, they very quickly on admission realized that she was coming in with a secondary bacterial pneumonia. And I think that was an absolutely correct diagnosis. The treatment was absolutely incorrect. And this, when I say it has little to do with measles… secondary bacterial pneumonias can happen after any viral infection. And so this is, not everyone’s grandstanding.
And all this outrage over this measles. You see, the media is going nuts about how everyone needs to get vaccinated. I would tell you just simple, straightforward, correct medical care. We’ve been treating pneumonias for decades with antibiotics. And this was Just a tragic error of an insufficient and incorrect antibiotic regimen on admission.
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