Transcript Infection
Symptoms, why children were examined at the emergency unit at the University Children´s Hospital Vienna (2012) outpatient 60% 50% 40% 30% 20% 10% vario us cryin g cons t ipat i on ma rash /ecze diarr hea coug h feve r 0% admission The „banal“ Infection Question to parents: Do you know simple actions against….? 70 60 50 yes no 40 30 20 10 0 fe ve r pa in di ar rh ea / vo m iti ng Assessement the severity of disease by parents and nurses (accorting to the Manchester Triage Systeme) parents nurse ning reate li fe t h very seve re seve re mo d erate harm l ess 80% 70% 60% 50% 40% 30% 20% 10% 0% Drug therapy symptomatic vario us cry cons t ipat i on rash diarr hea coug h feve r 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% causal nothing 2013: 80 cases; 6 deaths in <3a and 1 in the age of 13a Which „banal“ decisions must be made • • • • • Acute/chronic Severe/harmless infection no/further diagnostics Immediate treatment in emergency unit treatment at the ward GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE Diarrhea and vomiting Infectious diseases causing causing diarrhea/vomiting • • • • • Gastrointestinal Urogenital ZNS Respiratorisch Cardial Major criteria to identify the child at risk suffering from diarrhea/vomiting • Dehydration general condition vigilance skin turgor fontanelle eyes: tears, dark eye circles (Halo) buccal mucosa: dry Heart rate/blood pressure urine production <5%, 5-10%, >10%-dehydration Juanita; Uni Münster Useful laboratory examination in children with dehydration for further acute management • • • • Electrolytes Blood gas analysis BUN/Creatinin Blood glucose Pathogens • Bacterial (ca. 5%) Salmonella Campylobacter jejunii Shigella Amebae; etc. • Viral (ca. 95%) Rotavirus Adenovirus Norovirus Enterovirus ….. Top 10 drugs frequently prescribed by family doctors in gastrointestinal infections 6.06.2014 Drug therapy in gastrointestinal infections Evidence-based I • carbon: obsolet • Probiotics: - Antibiotics-associated diarrhea (JAMA 2012): 13 patients must be treated to observe benefit in one subject.(Metaanalysis) - Infect-associated diarrhea (Cochrane Database of Systematic Reviews 2010): Shortening of duration of diarrhea from 3 days to 2.6 days, reduction of stool frequency on day 2 by factor 0.8 and so on Drug therapy in gastrointestinal infections Evidence-based II • Electrolyte-solutions: no effect on duration or severity of diesease, „gruesome“ flavour. • Antibiotics: only in septicemia, salmonella infection of the newborn, severe campylobacter infection, immunodeficiency, amebae. Treatment of diarrhea • < 5%: dietary measures (treatment at home): NO COCA COLA!!!! • 5-10%: Compliance, assure that fluid intake is guaranteed, vigilance/GC • > 10%: acute life-threating, immediate parenteral substitution (e.g. 0,9% NaCl 20ml/kg BW) Symptomatic treatment of fever • Thermical (cool wraps, vinegar wraps (heat of evapuration) • drugs: Paracetamol Mefenaminacid Ibuprofen Acetylsalicylic acid Fever-associated symptoms leading to diagnosis: PAIN • Head – many causes • Ear - Otitis media, Parotitis epidemica, Tonsillitis • sore throat – Tonsillitis, Pharyngitis, Laryngitis • thoracal - bronchitis, pneumonia, Pleuritis • abdominal – infection of GIT, urinary tract infection, pneumonia, infection of the upper repiratory tract, appendicitis, meningitis • Micturition – urinary tract infection Possible other symptoms associated with fever: likely diagnosis • rhinitis- infection of the upper respiratory tract • cough - acute bronchitis, pneumonia, pertussis, infection of the upper respiratory tract • dyspnea - pneumonia, bronchiolitis, wheezy bronchitis • vomiting – Meningitis/encephalitis, infection of the GIT, urinary tract infection, upper respiratory tract infection • diarrhea – infection of the GIT, urinary tract infection, upper respiratory tract infection • cerebral seizures – Meningitis/encephalitis, febrile convulsion (roseola infantum) • journey abroad – Malaria, Dengue-Fever Fever without focus: patients at risk • Newborns: Infection, diabetes insipidus • infants: bacterial infections only in 10-15% in the first year of life, younger than 3 months of age only in 5% CAVE: OCCULT SEPTICEMIA • Increased risk for septicemia in the age up to 6 months if temperature is >40°C, leucocytes are <5000 or >15000/µl, CRP is increased. • Hyperpyrexia: Meningitis, septicemia,pneumonia; (T > 41°C) DD heatstroke • fever with petechiae: septicemia Primary care determines prognosis The first 24 hours determine the outcome Mortality in Austria 5-10% DIAGNOSTICS in suspected meningococcal infection Obtain blood for blood culture There is no need for lumbar puncture – avoid waste of time ANTIBIOTIC TREATMENT • Penicilline G i.v. oder i.m. oder • Cephalosporine Ceftriaxone 100mg/kgKG i.v. oder i.m. Treatment guidelines stable child • Time to hospital ‹ 45 min Antibiotics i.v. or i.m. • Time to hospital › 45min Volume + antibiotics i.v. Treatment guidelines unstable child • VOLUME 20ml/kgKG in 10 min • -300ml/kgKG/24h • antibiotics • intubation • catecholamine Conclusion • Volume i.v. • Immediate antibiotic treatment ofter obtaining blood culture COUGH • IS A PROTECTIVE REFLEX • Cough will be induced in the area of nervus vagus. COUGH • Acute – chronic/recurrent • Patient at risk: yes – no • Accompanying symptoms (Fever, rhinitis, pain, and so on) COUGH • Signs of hazard: Vigilance, GC, shortness of breath, tachypnoea, dyspnoea, cyanosis, accessory muscle use COUGH – differential diagnosis Infections Bronchial hyperreactivity Aspiration Psychogenic Toxic-Environmental Anomalies Autoimmune - disease Tumor COUGH- Infections Upper respiratory tract Lower respiratory tract Upper and lower respiratory tract Drug groups used for the symptomatical treatment of cough • Mucolytics (N-Acetylcystein, Ambroxol, ivy-extracts): Cochrane Database Syst Rev 2010 and Cochrane Database Syst Rev 2002: No benefit in acute respiratory tract infections in children, side-effects (middle ear effusion) • Antitussiva (Codein, Pentoxyferin,Thyme-extract with alcohol (4%): Cochrane Database Syst Rev, 2008: should be avoided in children due to side-effects and blocking of mucociliar clearance Symptomatic treatment of cough in children • Rhinitis + cough: decongesting nose drops • Rhinitis + cough + wheeze: decongesting nose drops + inhaled beta2-Agonists • Pharyngitis/Tonsillitis + cough: nothing • Pharyngitis/Tonsillitis + cough + wheeze: inhaled beta2Agonists • Pneumonia + cough: inhaled beta2-Agonists • Subglottic laryngitis: cold air, (topical or systemic steroids) Does the X-ray help us in identification of the pathogen? • Radiologic findings are frequently not associated with the pathogen in acute pneumonia. Age as possible evidence to the pathogen age bacteria Virus newborns B-Streptoc., E.coli, Listerien, Haem. infl. CMV, Rubella, HSV 2.week – 12.week Strept. pneum., Chlam. trach., Bordatella pert., Haem. infl. -> only 10% of all pneumonia RSV, Parainfluenza 1-3 Influenza, Adenovirus, CMV Older infants/toddlers Streptoc. pneum., Haem. infl., Staph.aur., Mycobacterien, Meningococcus RS Virus, Parainfluenza, Adenovirus., Influenza B, Rhinovirus School-aged children/ adolscents Mycoplasma pneumoniae Haem. Infl., Chlamydia pneum. Adenovirus, EBV, Parainfluenza, Influenza, Rhinovirus, RSV Differenzierung zwischen bakterieller und viraler/atypischer Pneumonie Symptoms/results Bacterial Pneumonia Virale/atypical Pneumonia onset acute creeping fever +++ ++(+) Rhinitis/Pharyngitis rarely commonly dyspnoea ++(+) +(+) Myalgia + +++ wheeze - (+) +(+) Pleural effusion More frequent rare auscultation +++ + Leucozytosis frequently Rare (except Adenovirus) CRP increased Normal to slightly increased ESR Normal to enhanced enhanced Age : Which empiric antibiotics? age Outpatient (p.o.) hopsitalized(i.v.) newborns - Ampicillin/Cefotaxime Aminoglycoside infants<6 Mo - Cephalosporine (e.g. Cefotaxime), Aminopenicilline/Clav. infants >6 Mo toddlers Amox./Clav. Cephalosporine (Cefuroxim, Cefpodoxim, Cefixim) Cephalosporine (e.g. Cefotaxime), Aminopenicilline/Clav. School aged children Macrolide (Clarithromycine, Josamycine) Cephalosporine (Cefuroxime, Cefpodoxime, Cefixime) Amox./Clav. Cephalosporine (Cefuroxime, Cefotaxime), Amox./Clav. Macrolide