Transcript Pediatric Infection - What`s New in Medicine

Common Pediatric
Infections
Scott Lindquist MD MPH
WA State Department of Health
State Epidemiologist for
Communicable Diseases
Common Outpatient
Infections
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Otitis Media
Sinusitis
Pharyngitis
Lymphadenitis
Pneumonia
Urinary tract infection
Diarrhea
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Impetigo/cellulitis
Wounds/bites
Infestations
Fungal
Parasites
Otitis Media
Diagnosis
• Acute onset
• Inflammation
• Middle ear fluid
Normal
AOM
Otitis Media
• What does the TM look like?
bulging
erythematous
hemorrhagic
normal
Otitis Media
Etiology
• Streptococcus pneumoniae
Penicillin-susceptible
• (91-100% from Tri Cities antibiograms)
• Haemophilus influenzae (non-typeable)
• Moraxella catarrhalis
Otitis Media
Treatment
• Approximately 80% resolve spontaneously
and antibiotics increase resolution to ~ 95%
• Priority to treat is children < 2 years and
severe cases
• Drug of Choice:
AMOXICILLIN
Recurrent Otitis Media
• 3 episodes in 6 months
4 episodes in 12 months
• Check for environmental factors
• Chemoprophylaxis:
amoxicillin (20 mg/kg/d)
• Ventilating tubes
Otitis Media with Effusion
• Middle ear fluid
No inflammation
• Must be differentiated from AOM
Normal
AOM
OME
Otitis Media with Effusion
Management
• Intervention only necessary if there is hearing
deficit (bilateral and >20db in “best” ear)
• First 3 months:
watchful waiting (>95% will resolve)
• After 3 months:
hearing testing (> 20 db?)
• > 4 months:
discuss with ENT
consider ventilating tubes
Otitis Externa
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Swimmer’s ear
Staphylococcus aureus, Pseudomonas spp
Cleansing, drying
Neomycin otic solution with polymyxin B and
hydrocortisone (Cortisporin)
Ciprofloxacin with hydrocortisone (Cipro HC Otic)
Ofloxacin otic solution (Floxin Otic)
• 2% acetic acid
Gentamicin ophthalmic (Garamycin)
Tobramycin opthalmic (Tobrex)
Sinusitis
• Diagnosis is clinical/epi
• URI symptoms that
persist > 10 days
• URI symptoms that get
worse after 5 days
• Sinus pain uncommon
• Do not do plain films
• Do not abuse CT
Sinusitis
Etiology:
• Similar to AOM
Treatment:
• Similar to AOM, except
that duration is ~ 2
weeks (7 d after
patient is free of
symptoms)
Chronic Sinusitis
• UNCOMMON
Suspect
• Other etiologies (CF,
anatomical)
• Other explanations
(asthma, allergies
environmental factors
Pharyngitis
• Viral most common (EBV, rhinovirus, etc)
• Allergies
• Bacterial:
Group A Streptococcus
Other Streptococcus
Streptococcal Pharyngitis
Diagnosis:
• Clinical
> 2 years old, acute onset, fever,
unilateral lymphadenitis, no URI
• Rapid test
• Culture
• Beware of carriers
Pharyngitis
Treatment:
• Penicillin V 250 mg PO bid x 10 days
amoxicillin 40 mg/kg/d div bid x 10 days
• Alternatives:
benzathine penicillin G, erythromycin, clindamycin,
cephalexin,
• Others:
clarithromycin, cefuroxime, cefixime, ceftibuten,
cefdinir, cefpodoxime, azithromycin
Lymphadenitis
Generalized
• Viral (EBV)
• Toxoplasmosis
• Syphilis
Single
• Acute:
Staph / Strep
• Chronic:
Bartonella henselae
Mycobacteria
Acute Lymphadenitis
• Clindamycin, cephalexin, macrolide
• US  Aspiration
Group A Streptococcus
Staphylococcus aureus
Chronic (sub-acute) lymphadenitis
• To consider: CBC, EBV, PPD or IGRA, B. henselae
titers, Toxo, others depending on risk factors
• Can treat as for “acute” first
• Watch for 2-3 w and re-evaluate
• If all negative and not any better, consider wait
vs re-test vs aspiration/incision/excision
B. henselae
MAIC
M. tuberculosis
Community Acquired Pneumonia
Etiologies
• Viral
RSV
parainfluenza
Influenza
• Bacterial
Strep pneumoniae
• Atypical
Mycoplasma
Chlamydia
Tuberculosis
Legionella
Coccidioides Immitis
Treatment
• Amoxicillin (2m- 5 yrs)
• Macrolide
Erythromycin
Azithromycin
• Antivirals
(Oseltamivir)
Common Circulating Respiratory
Viruses
Current Respiratory Viruses
Urinary Tract Infection
• Not difficult to treat, only difficult to diagnose but
the implications of a missed diagnosis may be long
lasting
• Always suspect in febrile children < 2 yrs of age
• Dx of UTI requires a UCx
(bag-specimen not very good)
• UA (WBC), dipstick OK as a guide, especially in
combination
Urinary Tract Infection
Etiology
• Escherichia coli
• Enterococcus
Treatment
• Amoxicillin (50-64%)
• TMP / SMX (65-81%)
• Cefixime (91-100%)
• Quinolone (76-87%)
Follow-up
• Nitrofurantoin(89-96%)
• US if <2 y/o and no history of normal prenatal
US (30-32 wks) or recurrent UTI’s
• VCUG if > 2 UTI’s or 1st UTI with abnormal US or
bug other than e. coli
Acute Gastroenteritis
• Viruses: rotavirus, calicivirus, others
• Bacteria: Campylobacter, Shigella,
Salmonella, Yersinia, E. coli
• Antibiotics usually not required, unless
diarrhea is dysenteric
TMP/SMX, Azithromycin, Quinolones
• Clostridium difficile
Impetigo / cellulitis
• Etiology:
Group A Streptococcus
Staphylococcus aureus (MRSA)
• Treatment:
Bacitracin, Mupirocin, Retapalumin
Cephalexin, clindamycin, TMP/SMX, erytho, linezolid
Drain any abscess
Puncture wounds (foot)
Etiology
• Staph aureus (~ 3 d)
• Pseudomonas spp (~ 7 d)
• Mycobacteria (~ 2-4 w)
Treatment
• Wound care
Tetanus vaccine
Anti-Staph antibiotics
• If no response
Surgical exploration  culture
Ceftazidime  ciprofloxacin (for 2 w)
Bites
Etiology
• Pasteurella multocida
• Eikenella corrodens
• Streptococcus spp /
Staphylococcus spp
• Neisseria spp /
Corynebacterium spp
• Anaerobes
• Polymicrobial
Prophylaxis and Treatment
• Wound care
Tetanus shot
Rabies prophylaxis (?)
• Amoxicillin / clavulanate
• clindamycin + TMP/SMX
Fungal Infections
• Oral candidiasis
oral nystatin or clotrimazole
fluconazole 3 mg/kg qd x 7d
• Tinea corporis
topical clotrimazole or terbinafine bid 2-3 w
+ fluconazole 3 mg/kg/w x 2-3 w
• Tinea capitis
griseofulvin 10 mg/kg qd x 4-8 w
terbinafine 125 mg qd x 4 w (Lamisil)
Parasites
Worms
• Enterobius vermicularis
(Ascaris)
• Scotch tape test
• Mebendazole 100 mg
Pyrantel pamoate 11 mg/kg
Albendazole 400 mg
• All repeat in 1 w
Protozoans
• Giardia (Cryptosporidium)
• Metronidazole 5 mg/kg q8h x 5-10d
Furazolidone 2 mg/kg q6h x 7-10d
Albendazole 400 mg/d x 5d
(Nitazoxanide)
Taeniasis
• Praziquantel, different doses
Uncertain significance
Entamoeba coli, Endolimax nana, Iodamoeba butschlii
Blastocystis hominis, Dientamoeba fragilis
Head Lice
Standard:
• Permethrin: 1% Nix
(Tx of choice)
• Pyrethrins: RID, A-200,
R&C, Pronto, Clear Lice
System
• Lindane 1%: Kwell
Upgrade:
• Permethrin 5%: Elimite
• Malathion 0.5%: Ovide
• Crotamiton 10%: Eurax
• TMP/SMX PO
• Ivermectin PO
200 g/kg
Common Infections Requiring
Inpatient or Subspecialty
Care
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Sepsis
Meningitis
Encephalitis
Brain Abscess
• Orbital Cellulitis
• Endocarditis
• Bone/Joint infections
Sepsis
• Toxicity = clinical picture
- lethargy
- hypoperfusion
- hypo/hyperventilation
• Signs and Symptoms
– Hyperthermia or hypothermia
– Tachycardia
– Tachypnea
– Leukocytosis or leukopenia
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Sepsis work-up
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Cell Blood Count (CBC)
Blood Culture
Urine analysis
Urine Culture
Chest roentgenogram
Stool if needed
NPA for viruses if needed
Lumbar puncture
CSF Culture
Etiologies of Sepsis/Meningitis
< 1 month of age
• Group B Streptococcus
• Escherichia coli
• (Listeria monocytogenes)
3-36 months of age
• Streptococcus pneumoniae (↓)
• Neisseria meningitidis
• (Haemophilus influenzae b)
1-3 months of age
• Streptococcus pneumoniae (↓)
• Group B Streptococcus
• Neisseria meningitidis
• Salmonella spp
• (Haemophilus influenzae b)
• (Listeria monocytogenes)
Bacterial Meningitis
• Diagnosis: LP, LP, LP
• Should I do an LP?
• Increased intracranial
pressure
• Prior antibiotics
• “Bloody tap”
Encephalitis
• Not usually bacterial
• HSV
Enterovirus
Arbovirus (WNV)
EBV, CMV, etc
• ADEM
Brain abscess
Source:
• Proximity: middle ear, sinuses
• Meningitis
• Hematogenous
• Penetrating: wound, surgery
Brain abscess
Triad:
• Headache
• Focal neurologic
findings
• Fever
Treatment:
• Surgery
• Antibiotics:
Cefotax + Vanco + (Metro)
• for 4-8 weeks (IV)
Orbital Cellulitis
Triad:
• Proptosis
• Decreased eye movement
• Pain on eye movement
Orbital Cellulitis
Treatment:
• Antibiotics:
Cefotax + Vanco + (Metro)
Cefotax + Clinda
x 10-14 d IV and 7-14 d PO
• Surgery
Endocarditis
• Acute  Staph (MRSA)
• Subacute  viridans Strep
• Antibiotics:
Vanco + gentamicin
Penicillin + gentamicin
• X 2 w, 4-6 w depending on organism and antibiotics used
• Involve Cardiology
Pericarditis
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“Purulent pericarditis”
Staph aureus (MRSA)
Strep pnumoniae
Salmonella
Candida
M. tuberculosis
Antibiotics:
Ceftriaxone + Vancomycin
• Drainage
• Treatment is 2-4 weeks depending on organism and
response
Osteomyelitis
• Staph aureus
• (Others in special populations)
• Clindamycin
Vancomycin
Linezolid
• X 4 weeks (IV/PO)
• Surgery
Septic arthritis
• Fever, joint pain/swelling,
decreased ROM
• Diagnosis:
clinical, XR (hip), US,
arthrocentesis, CT (SI)
Septic arthritis
Etiologies:
• Staph aureus
• Streptococcus
(GAS, Strep pneumo)
• Kingella kingae
• Salmonella
• Neisseria
(GC, N. meningitidis)
• H. influenzae
Treatment:
• Aspirate vs Surgery:
hips, shoulders
• Antibiotics:
Vancomycin (Clinda, Oxacillin)
+ cefotaxime (cefuroxime)
• x 3 weeks (IV/PO)
Case Study
• 2 year old healthy Male with fever of 102 F in
September 2016
• Cough for 3 days
• RR 65
• O2 sats of 94%
• Not wheezing
• Ill appearing
What Diagnostics are Most
Helpful?
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A) CBC
B) Blood Culture
C) Chest radiograph
D) Nasal Pharyngeal Aspirate for viral pcr
panel
• E) A,B, and C (correct do not display)
• F) All of the above
What Is The Most Likely
Organism?
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A) Staphylococcus aureus
B) Streptococcus pyogenes
C) Streptococcus pneumoniae (correct)
D) Mycoplasma pneumonia
E) Haemophilus influenzae
What is the best outpatient
Therapy?
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Azithromycin
Amoxicillin
Cefuroxime
Levofloxacin
TMP/SMX
What is the best outpatient
Therapy?
What is the best outpatient
Therapy?
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Azithromycin
Amoxicillin (correct answer)
Cefuroxime (correct answer)
Levofloxacin
TMP/SMX