Transcript Common Pediatric Infections

Common Pediatric Infections
Kathryn M. Edwards MD
Professor of Pediatrics
Vanderbilt University
Case 1
• Johnny, a two year old boy, had URI and cough
for two days.
• He awakened suddenly in the middle of the night
with fever to 103oF, cough, and irritability.
• He was given an antipyretic and taken to see
YOU, his physician the next morning.
• His vital signs revealed a temperature of 103oF,
pulse rate of 120 and a respiratory rate of 60
with nasal flaring.
Diagnostic Evaluation
• Chest X-rays (posteroanterior and lateral views
are standard, if there is consolidation or
evidence of effusion obtain decubitus view)
• Sputum is rarely produced by children
• Blood Culture
• Complete Blood Count
• Tuberculin Skin Test
• If afebrile and < 20 weeks of age consider
Chlamydia culture or antigen testing
Chest Film
Facts about Pneumonia
• Pneumonia diagnosed in nearly 2% of infants <
1 year and in 4% of children aged 1 to 5 years.
• Responsible agent determined in < 10%
• Estimated that 90% of pediatric pneumonias are
caused by viral agents.
• Approximately 50% of the documented viral
pneumonias in children are caused by
respiratory syncytial virus; 25% by parainfluenza
virus types 1 and 3
• A smaller number from influenza and adenovirus
• Bacterial and atypical agents also seen
Considerations for Inpatient Management of Pneumonia
Toxic appearance
Respiratory distress
Pleural effusion
Age considerations:
<3 months
<3 years with lobar pneumonia
<5 years with lobar pneumonia (more than 1 lobe)
Existing chronic disease
Pulmonary (including asthma)
Metabolic disorders
Cardiac
Anemia (including sickle cell disease)
Renal
Malignancies
Diabetes Mellitus
Immunocompromised host
Progression during outpatient therapy
Bacterial And Fungal Causes of
Pneumonia Related to Age of the
Pediatric Patient
Age Group
Common Pathogens
0-48 hrs
Group B. Streptococci
1-14 days
Escherichia coli, Klebsiella pneumoniae, other
Enterobacteriaceae, Listeria monocytogenes,
Staphylococcus aureus, anaerobic bacteria, group B
streptococci
2 wks to 2 mos
(premature
neonates)
Enterobacteriaceae, Group B streptococci,
Staphylococcus aureus, Staphylococcus
epidermidis, Candida Albicans, Haemophilus
influenzae, Streptococcus pneumoniae
2 mos to 5 yrs
Haemophilus influenzae, Streptococcus
pneumoniae
5-10 yrs
Streptococcus pneumoniae
10-21 years
Mycoplasma pneumoniae, Chlamydia pneumoniae
(TWAR agent), Streptococcus pneumoniae
Bacterial Pneumonia
Agent
Dosage
Outpatient Pneumonia
Oral amoxicillin
80-90 mg/kg/day ÷
BID
Oral amoxicillinclavulanate
80-90 mg/kg/day of
amoxicillin ÷ BID
Oral cefuroxime axetil
30 mg/kg/day ÷ BID
Oral cefdinir
14mg/kg BID
Inpatient Pneumonia
(Initial empiric
therapy)
Intravenous ceftriaxone
100 mg/kg/day ÷ q12h
Pneumococcal
susceptible Penicillin
MIC < 2 mcg/ml
Intravenous penicillin
Pneumococcal
nonsusceptible to
penicillin, susceptible
to cephalosporin
Pneumococcal
nonsusceptible to
penicillin,
nonsusceptible to
cephalosporin
250,000-400,000
U/kg/day
÷ q4-6h
Intravenous ceftriaxone
or
Intravenous cefotaxime
100 mg/kg/day ÷ q12h
Intravenous
vancomycin
40-60 mg/kg/day ÷ q6h
225-300 mg/kg/day
Case 2
• Bill, a six month old male, had the acute
onset of fever to 102o and irritability.
• He was seen in your office and
examination of the tympanic membranes
revealed the physical findings noted.
Symptoms of Otitis Media
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Unusual Irritability
Difficulty Sleeping
Tugging Or Pulling At One Or Both Ears
Fever
Fluid Draining From The Ear
Loss Of Balance
Unresponsiveness To Quiet Sounds Or
Other Signs Of Hearing Difficulty
Facts about Otitis Media
• Seventy-five percent of children
experience at least one episode of otitis
media by their third birthday.
• Almost half of these children will have
three or more ear infections during their
first 3 years.
• It is estimated that medical costs and lost
wages due to otitis media account for $5
billion a year in the United States
Risk Factors for Otitis Media
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Children cared for in group settings
Children who live with adults who smoke
Infants who nurse from a bottle while lying down
Children who are not breast-fed
Cold and allergy medications such as
antihistamines and decongestants are not
helpful in preventing otitis
• Vaccines against the bacteria that most often
cause otitis media are the best hope
Office Visits with Principal
Diagnosis
of Otitis Media in the US
Office
visits per 100 children
120
1975
100
1980
1985
80
60
40
20
0
<2
2-5
Age in years
6 - 10
1990
Age-Specific Incidence of Otitis
Media
60
% Incidence
50
Any AOM
1st AOM
40
30
20
10
0
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7
Age (years)
Teele, et al J Infect Dis 1989
Bacteriology of Acute Otitis Media
2,087 ears: Children’s Hospital of Pittsburgh, 1980-89
No growth
16%
Strep. pyogenes 3%
Staph. aureus 1% Other
Others 8%
12%
Strep.
pneumoniae
35%
M. catarrhalis
14%
H.
influenzae
23%
AOM Rates During Respiratory Virus Infection
33%
RSV
Adenovirus
28%
Influenza A & B
28%
Parainfluenza
16%
Enteroviruses
16%
10%
Rhinovirus
7%
No Virus
0%
10%
20%
Henderson, et al. NEJM, 1982
30%
40%
Guidelines for Treatment
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Schedule an appointment within 24 hours
A clinical examination is necessary
Educate parents on measures to prevent otitis
Prescribe amoxicillin when the diagnosis of
otitis media is made.
Prescribe second-line antibiotics when patient
fails first-line drugs
Recheck in 3 to 4 weeks or at next well visit
Treatment
• First-Line Medications
– Amoxicillin (40 mg/kg/day) if low risk (> 2 years, no
day care, and no antibiotics for the past three
months).
– 80 mg/kg/day if not low risk or for resistant AOM if the
lower dose was used initially.
• Therapeutic (10 day) course of antibiotics.
• Consideration may be given to a shortened
course of antibiotics (5 days) for children who
are at low risk ( i.e., age > 2 years, no history of
chronic or recurrent otitis media and intact
tympanic membranes).
Second Line Agents
• Recommended second-line medications include
– Amoxicillin/Clavulanate Potassium (Augmentin®)
– Cefuroxime Axetil (Ceftin®)
– Ceftriaxone Sodium (Rocephin®): Prescribe One
Dose For New Onset Otitis Media And A Three-day
Course For Resistant Otitis Media Or If Oral
Treatment Cannot Be Given.
– Cefprozil (Cefzil®)
– Loracarbef (Lorabid®)
– Cefdinir (Omnicef®)
– Cefpodoxime proxetil (Vantin®)
Case 3
• Susie, a two year old child, had the acute
onset of dysuria and frequency. She was
seen in your office.
Epidemiology
• Gold standard: growth of bacteria in urine
• UTI present in 5% of febrile infants and
2% of febrile children < 5 years of age
• Recurs in 50% of school-aged girls within
6-12 months
• UTI more common in white children
• Males have more UTI in first 3 months, but
after that females have more than males
Facts about UTI
• Cystitis classically presents with urgency,
frequency, dysuria, secondary enuresis, and
foul-smelling urine.
• Pyelonephritis presents with spiking fever, flank
or abdominal pain, and irritability.
• Chronic pyelonephritis presents with recurrent
abdominal pain, recurrent fever, and failure to
thrive.
• A higher index of suspicion is necessary to
diagnose UTI in the infant in whom sepsis,
lethargy, and jaundice may be the initial
symptoms.
Other Causes Of Urinary Tract
Symptoms
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Urethritis
Meatal irritation
Vulvovaginitis
Medications
Vaginal foreign body
Pinworms
Candida
Trichomonas
Trauma (including masturbation and sexual abuse)
Diagnostic Studies
• Routine Urinalysis
White blood cell count  10/high-power field
Leukocyte esterase (Correlates with pyuria)
Nitrites (bacteria slowly reduce nitrate to nitrite)
Bacteria (Presence in unspun urine correlates with
105 bacteria/ml)
– White blood cell casts (Indicative of pyelonephritis)
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• Serum C-Reactive Protein
– Elevated with pyelonephritis
Criteria for Culture Diagnosis
Specimen
Suprapubic aspiration
Positive Result
>100
Catheterized urine
>50,000
Clean-voided (male)
>100,000
Clean-voided (female)
>100,000
Bagged urine ***
*** Only acceptable if culture is negative
Not Acceptable
Treatment of UTI
• Choice based on most likely organism
• Clinical trial by Hoberman compared IV
cefotaxime (200 kg/kg/day X 3 days, followed by
oral cefoxime) with oral cefoxime (16 mg/kg
once, followed by 8 mg/kg/day for 14 days) in
children with febrile UTI
• Comparable outcomes seen
• AAP recommends parenteral antibiotics in toxic
children or those who cannot tolerate oral intake
Hoberman et al. NEJM 2003;348:195-202
Recommendations for
Radiographic Evaluation
• AAP subcommittee recommends VCUG
and ultrasound for all children < 2 years
• However, Hoberman et al reported that
ultrasound at the time of acute UTI is of
little value and that VCUG only useful if
prophylactic antibiotics will be given
• Area of continued controversy
Hoberman et al. NEJM 2003;348:195-202