Infectious Diseases Emergencies

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Infectious Diseases Emergencies

  1. 1. Antibiotic Choices for Infections which Require Hospitalization Rodolfo E. Bégué, MD Chief, Infectious Diseases Pediatrics, LSUHSC rbegue@lsuhsc.edu
  2. 2. Infections which require hospitalization Examples: r/o sepsis meningitis / encephalitis brain abscess / orbital cellulitis pneumonia / endocarditis acute abdomen urinary tract infection bone & joint skin & skin structures
  3. 3. r/o sepsis • Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis. • Hyperthermia or hypothermia • Tachycardia • Tachypnea • Leukocytosis or leukopenia
  4. 4. Sepsis work-up • Cell Blood Count (CBC). • Urine analysis. • Chest roentgenogram. • Lumbar puncture. • Cultures: blood, urine, stool, CSF • Other: NPA • (CRP, Procalcitonin)
  5. 5. Etiologies of Sepsis < 1 month of age • Group B Streptococcus • Escherichia coli • (Listeria monocytogenes) 1-3 months of age • Streptococcus pneumoniae (↓) • Group B Streptococcus • Neisseria meningitidis • Salmonella spp • (Haemophilus influenzae b) • (Listeria monocytogenes) 3-36 months of age • Streptococcus pneumoniae (↓) • Neisseria meningitidis • (Haemophilus influenzae b)
  6. 6. Antibiotics for a child with r/o Sepsis Empiric Antibiotic Treatment: < 1 month: Ampicillin + Gentamicin Ampicillin + Cefotaxime 1-3 months: Ampicillin + Cefotaxime > 3 months: Cefotaxime (Vancomycin?) x 7-14 days
  7. 7. Is it a contaminant? • 1 vs >2 positive culture • Pathogen vs no pathogen • Symptoms vs no symptoms • Plate vs broth (“thio”) • Timing
  8. 8. Central Line Infection • Central & Peripheral Blood Culture • Gram-positive, Gram-negative, Fungi • If possible, change line (Staph, Enteroc, GN, Fungi, Mycobact) • vs treat through line • If line out: ~ 1 week If line in: ~ 2 weeks • Antibiotic lock
  9. 9. Bacterial Meningitis • Diagnosis: LP, LP, LP • Should I do an LP? • Increased intracranial pressure • Prior antibiotics • “Bloody tap”
  10. 10. Bacterial Meningitis: Treatment • Empiric treatment with: cefotaxime plus vancomycin • Modify according to susceptibilities: penicillin cefotaxime vancomycin plus cefotaxime • Corticosteroids (?) • Rifampin (?)
  11. 11. Aseptic Meningitis • Viral (enterovirus vs others) • “Partially treated” • Other causes only on special populations
  12. 12. Encephalitis • Not bacterial • Viral HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc • ADEM
  13. 13. HSV Encephalitis Acyclovir: 60 mg/kg/d div q 8 hr 750 mg/m2 /d div q 8 hr x 21 days IV
  14. 14. Brain abscess Source: • Proximity: middle ear, sinuses • Meningitis • Hematogenous • Penetrating: wound, surgery
  15. 15. Brain abscess Triad: • Headache • Focal neurologic findings • Fever Treatment: • Surgery • Antibiotics: Cefotax + Vanco + (Metro) • for 4-8 weeks (IV)
  16. 16. Orbital Cellulitis Triad: • Proptosis • Decreased eye movement • Pain on eye movement
  17. 17. Orbital Cellulitis Treatment: • Antibiotics: Cefotax + Vanco + (Metro) Cefotax + Clinda x 10-14 d IV and 7-14 d PO • Surgery (ORL, Ophthalmology)
  18. 18. HSV Keratitis Management: • With an ophthalmologist • antivirals: 1-2% trifluridine 1% iododeoxyuridine 3% vidarabine x 14-21 days • topical corticosteroids contraindicated • No need for systemic acyclovir
  19. 19. Pneumonia • Viral: Influenza, RSV • Bacterial Streptococcus pneumo Staph aureus Group A Streptococcus • TB • Chlamydia Mycoplasma • Fungal
  20. 20. Empiric Treatment for Pneumonia • If sick enough to require admission (assuming viral panel negative), the regular r/o sepsis regimen is usually OK: • Ampi + genta / Ampi + cefotax / Cefotax • Usually add a macrolide (erythro or azithro) • Add Vancomycin if VERY sick or necrotizing • Others (TB, Gram-negative, PCP, fungal) only if a good reason to suspect
  21. 21. Endocarditis • Acute  Staph (MRSA) • Subacute  viridans Strept • Antibiotics: Vanco + gentamicin • X 2 w, 4-6 w • Surgery (?) Pericarditis • “Purulent pericarditis” • Strept Pneumo Staph aureus (MRSA) • Antibiotics: Ceftriaxone + Vancomycin • X 4 weeks • Surgery (?)
  22. 22. Acute Abdomen Treatment • Surgery • Antibiotics Mild-moderate Severe Ampi/sulb, Ticar/clav Piperac/Tazobactam Imipenem, Meropenem, Ertapenem Cefazolin or cefuroxime + metronidazole Cefotax, ceftriax, ceftaz, cefepime + metronidazole Gentamicin (Tobra) plus Clinda (Metronidazole) + ampicillin Cipro, levoflox, gatiflox + Metronidazole Aztreonam + Metronidazole For 5-7 days IDSA. CID 2010;50:133-64
  23. 23. Urinary Tract Infection • Always suspect in febrile children < 2 yrs of age • Dx of UTI requires a UCx (bag-specimen not good) • UA (WBC), dipstick OK as a guide, especially in combination • Gram stain (“unspun” urine) Etiology • Escherichia coli • Enterococcus
  24. 24. Urinary Tract Infection Follow-up • US, VCUG • DMSA scan • Consider prophylaxis Inpatient • Cefotaxime or Ceftriaxone • Ampicillin + gentamicin
  25. 25. Septic arthritis • Fever, joint pain/swelling, decreased ROM • Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)
  26. 26. Septic arthritis Treatment: • Aspirate vs Surgery: hips, shoulders • Antibiotics: Oxacillin + cefotaxime Cefuroxime • x 3 weeks (IV/PO) Etiologies: • Staph aureus • Streptococcus (GAS, Strept pneumo) • Kingella kingae • Neisseria (GC, N. meningitidis) • (H. influenzae)
  27. 27. Osteomyelitis • Staph aureus • (Others in especial populations) • Clindamycin Vancomycin Linezolid • X 4 weeks (IV/PO) • Surgery
  28. 28. Puncture wounds (foot) Etiology • Staph aureus (~ 3 d) • Pseudom 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)
  29. 29. Skin and Soft Tissue • Etiology: Group A Streptococcus Staphylococcus aureus (MRSA) Strep pneumo / Hib • Treatment: Vancomycin or Clindamycin add genta or rifampin? linezolid?? • Drain any abscess
  30. 30. D test • MRSA • Erythro R Clinda S • D test negative: OK to use Clinda • D test positive: do not use Clinda Siberry et al. CID 2003;37:1257-1260

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