Common Pediatric Infections


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  • Increased concerns for bacterial resistence
  • Visits for acute upper respiratory illnesses, fever, earache, and crying – present in 90% with AOM but also in 72% with viral URI Important to differentiate OME from AOM – OME may accompany viral URIs, prelude an AOM, or be a sequela or AOM – mistaken identification can lead to unnecessary antibiotic prescrtiptions Also need to avoid false-positive diagnosis with otalgia caused by eustachian tube dysfuntion or retraction of the TM
  • Topical agents – additional benefit over acetominophen but brief Limited effectiveness to home remedies such as distraction, external applications or heat or cold, or oil and no controlled studies that directly address pain witih homeopathic agents
  • Guidelines apply to otherwise healthy children without underlying conditions that may alter the natural course of AOM including anatomic abnormalities such as cleft palate, genetic conditions such as Down’s Syndrome, immune system disorders, and cochlear implants. Also excluded are children with a clinical recurrence of AOM within 30 days or AOM with underlying chronic OME. Observation is appropriate only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Non-severe illness is mild otalgia and fever <39C in the past 24 hours. Severe illness is moderate to severe otalgia or fever >39C.
  • Van Buchem and colleagues – only 2.7% of 4860 Dutch children older than 2 given symptomatic treatment and observation developed severe illness (persistent fever, pain, or discharge after 3-4 days) and only 2 developed mastoiditis (both responded promptly to treatment).
  • Gets additional coverage for beta lactamase positive M catarrhalis and H influenza
  • Maxillary - Unique as outflow tract sits high on medial sinus wall negating gravitational effects Ethmoid – multiple air cells with narrow ostia – predisposing to obstruction Ostiometeal complex – area between the middle and inferior turbinates that represents the confluence of the drainage areas of the frontal, ethmoid, and maxillary sinuses – cilia move in opposite directions – potential for infection even without physical obstruction
  • Malodorous breath – often reported in preschoolers, facial pain and headaches are rare, child does not appear ill and if fever present – is usually low grade Physical exam cannot distinguish between viral URIs and ABS
  • CT scans should not be used in patients who have simple upper respiratory tract symptoms because it does no distinguish between mucosal abnormalities due to viral infections vs ABS Complicated ABS – proptosis, impaired vision, limited extraoccular movements, severe facial pain, notable swelling of the forehead or face, deep-seated headaches, or toxic in appearance
  • Use of antibiotics for more that a few weeks is not supported by clinical studies, exposes patients to developing allergic hypersensitivity, and may increase the development of resistant organisms
  • Preseptal or periorbital cellulitis, subperiosteal abscess, orbital abscess, orbital cellulitis, optic neuritis, frontal osteomyelitis (Pott Puffy Tumor), maxillary osteomyelitis, epidural abscess, subdural empyema/abscess, cavernous or sagittal sinus thrombosis, meinigitis, or brain abscess Surgery focus on the ostiomeatal complex – use of the endoscope to enlarge the natural meatus of the maxillary outflow tract and perform an anterior ethmoidectomy
  • Common Pediatric Infections

    1. 1. Common Pediatric Infections Christina Gillespie MD, MPH, FAAFP Georgetown University / Providence Hospital Family Medicine Residency Program Special Thanks to: Thomas C. Newton, MD Major, USAF, MC
    2. 2. Learning Objectives <ul><li>Acute Otitis Media </li></ul><ul><ul><li>Accurately diagnose and treat otitis media according to 2004 AAP/AAFP Guidelines </li></ul></ul><ul><li>Acute Bacterial Sinusitis </li></ul><ul><ul><li>Accurately diagnose and treat bacterial sinusitis according to 2001 AAP guidelines </li></ul></ul>
    3. 3. Acute Otitis Media <ul><li>Most common bacterial illness in children </li></ul><ul><li>25 million office visits and 20 million prescriptions in 1990 </li></ul><ul><li>Visits decreased to 16 million in 2000 with the same prescribing rate </li></ul>
    4. 4. Diagnosis of Acute Otitis Media (AOM) <ul><li>Recent, usually abrupt onset of illness </li></ul><ul><li>Signs/symptoms of middle ear inflammation </li></ul><ul><ul><li>Otalgia (ear tugging in infant), irritability/crying, otorrhea, and/or fever </li></ul></ul><ul><li>Presence of middle ear fluid or effusion </li></ul><ul><ul><li>Bulging tympanic membrane (highest predictive value) , limited or absent mobility, air fluid level, or otorrhea </li></ul></ul>
    5. 5. Management of AOM <ul><li>If pain is present the clinician should recommend treatment to reduce pain </li></ul><ul><ul><li>Acetominophen and ibuprofen </li></ul></ul><ul><ul><li>Benzocaine/Ametocaine/Phenazone topical agents </li></ul></ul><ul><ul><li>Narcotic analgesia with codeine </li></ul></ul><ul><ul><ul><li>for selected severe pain </li></ul></ul></ul><ul><ul><ul><li>must way potential side effect profile </li></ul></ul></ul>
    6. 6. Treatment of AOM <ul><li>Observation without use of antibacteral agents is an option for selected children based on: </li></ul><ul><ul><li>presence of uncomplicated AOM </li></ul></ul><ul><ul><li>diagnostic certainty </li></ul></ul><ul><ul><li>age </li></ul></ul><ul><ul><li>illness severity </li></ul></ul><ul><ul><li>assurance of follow-up </li></ul></ul>
    7. 7. Criteria for Initial Antibiotic Treatment vs Observation in children with AOM Observation option Antibacterial therapy if severe illness; observation option if non-severe illness 2 to 12 years Antibacterial therapy if severe illness; observation option if non-severe illness Antibacterial therapy 6 months to 2 years Antibacterial therapy Antibacterial therapy < 6 months Uncertain Diagnosis Certain Diagnosis AGE
    8. 8. Comparative AOM Outcomes for Observation versus Antibacterial Agent - 2% Skin Rash/Allergy - 16% Diarrhea/Vomiting 26% 21% Persistent MEE 3 mo. 48% 45% Persistent MEE 4-6 wks 0.17% 0.59% Mastoiditis/Complication 72% 82% Clinical Resolution 71% 79% Relief at 4-7 days 87% 91% Relief at 2-3 days 59% 60% Relief at 24 hours Observation Antibacteral Rx AOM Outcome
    9. 9. Common Pathogens in AOM <ul><li>Streptococcus pneumoniae : 25-50% </li></ul><ul><ul><li>Decrease from 49 to 34% with use of heptavalent pneumococcal vaccine (prevnar) </li></ul></ul><ul><li>Haemophilis influenza : 15-30% </li></ul><ul><li>Moraxella catarrhalis 3-20% </li></ul><ul><li>Viral etiologies 40-75% </li></ul><ul><ul><li>RSV, rhinovirus, coronavirus, parainfluenza, adenovirus, and enterovirus </li></ul></ul>
    10. 10. Initial Antibacterial Agent Choice <ul><li>Amoxicillin 80-90mg/kg/day for 7 to 10 days </li></ul><ul><ul><li>Higher dose to combat alterations in penicillin binding protein in S. Pneumoniae </li></ul></ul><ul><li>Alternates for Penicillin Allergy </li></ul><ul><ul><li>Cefdinir, cefpodoxime, cefuroxime, azithromycin, or clarithromycin </li></ul></ul>
    11. 11. Second Line Antibacterial Agent Choices <ul><li>Amoxicillin-clavulante 90mg/kg/day of the amoxicillin component for 7 to 10 days </li></ul><ul><ul><li>First line for those with severe illness (moderate to severe otalgia or fever >39C) </li></ul></ul><ul><li>Ceftriaxone 50mg/kg dose parenterally for 1-3 consecutive days </li></ul>
    12. 12. Reduction of Risk Factors <ul><li>Breastfeeding for at least the first 6 months </li></ul><ul><li>Avoiding supine bottle-feeding (bottle propping) </li></ul><ul><li>Elimination of pacifier use in the second 6 months of life </li></ul><ul><li>Elimination of exposure to passive tobacco smoke </li></ul>
    13. 13. Acute Bacterial Sinusitis (ABS) <ul><li>Sinusitis </li></ul><ul><ul><li>inflammation of the paranasal sinuses </li></ul></ul><ul><ul><li>can be viral, allergic, or bacterial in origin </li></ul></ul><ul><li>Acute Bacterial Sinusitis </li></ul><ul><ul><li>bacterial infection of the paranasal sinuses that has been present at least 10 days and in most cases less than 30. </li></ul></ul><ul><li>Chronic Sinusitis </li></ul><ul><ul><li>symptoms of at least 12 weeks duration. </li></ul></ul>
    14. 14. ABS Epidemiology <ul><li>Upper respiratory tract symptoms (nasal congestion, rhinorrhea, and cough) are the most common complaint in the pediatric office </li></ul><ul><li>Young children experience 6-8 episodes of viral URIs yearly and 5-10% are complicated by ABS </li></ul><ul><li>Can be challenging to distinguish between viral URIs, allergic rhinitis, and ABS </li></ul>
    15. 15. Sinus Development <ul><li>Maxillary Sinuses – present at birth </li></ul><ul><li>Ethmoid Sinuses – present at birth </li></ul><ul><li>Frontal Sinuses – develop by the 5 th or 6 th birthday </li></ul><ul><li>Sphenoid Sinus– develop by the 5 th or 6 th birthday </li></ul>
    16. 16. Symptoms and Signs of ABS <ul><li>Two Common Clinical Presentations </li></ul><ul><ul><li>“ Persistent” </li></ul></ul><ul><ul><ul><li>respiratory symptoms (>10 days) and: </li></ul></ul></ul><ul><ul><ul><li>nasal discharge of any quality (thin or thick; clear, mucoid, or purulent) </li></ul></ul></ul><ul><ul><ul><li>or a cough present in the daytime, often worse at night </li></ul></ul></ul><ul><ul><li>“ Severe” </li></ul></ul><ul><ul><ul><li>high fever >39C and </li></ul></ul></ul><ul><ul><ul><li>purulent nasal discharge </li></ul></ul></ul><ul><ul><ul><li>Symptoms concurrent for at least 3-4 days </li></ul></ul></ul>
    17. 17. Diagnostic Testing <ul><li>Use of radiographic imaging (plain film or CT) is controversial </li></ul><ul><ul><li>Recent national guideline emphasize the role of clinical diagnosis </li></ul></ul><ul><li>Plain films are appropriate in older children with recurrent ABS, vague symptoms, or a poor response to therapy </li></ul><ul><li>CT should be considered for patients with complicated ABS or surgical candidates </li></ul>
    18. 18. Microbiology of Sinusitis <ul><li>Streptococcus pneumoniae – 30-40% </li></ul><ul><li>Haemophilus influenzae – 20% </li></ul><ul><li>Moraxella catarrhalis – 20% </li></ul><ul><li>Viruses – 10% </li></ul><ul><ul><li>Adenovirus, parainfluenza, influenza, and rhinovirus </li></ul></ul><ul><li>Neither Staphylococci nor respiratory anaerobes are common in ABS </li></ul>
    19. 19. Medical Treatment <ul><li>First Line: </li></ul><ul><ul><li>Amoxicillin 80-90 mg/kg/day for 10-14 days </li></ul></ul><ul><ul><li>Longer treatments may be considered in chronic sinusitis or to avoid surgery </li></ul></ul><ul><li>Alternatives </li></ul><ul><ul><li>Amoxicillin-clavulanate, cefuroxime axetil, cefpodoxime, macrolides </li></ul></ul><ul><ul><li>Consider an alternative if amoxicillin allergy, recent treatment with amoxicillin, or failure of clinical improvement on amoxicillin within 72 hours </li></ul></ul>
    20. 20. Adjuvant Therapies <ul><li>Antihistamines, decongestants, anti-inflammatories </li></ul><ul><ul><li>Little data for use </li></ul></ul><ul><ul><li>Potential risks may outweigh benefits </li></ul></ul><ul><li>Topical intranasal steriods </li></ul><ul><ul><li>Rapid onset prompts consideration for management of acute symptoms, very modest beneficial effects does not generally justify their use </li></ul></ul><ul><li>Nasal irrigation with saline </li></ul><ul><ul><li>positive effect in some patients </li></ul></ul>
    21. 21. Complications and Surgical Considerations <ul><li>Rare </li></ul><ul><li>Contiguous spread of infection to the orbit, bone or central nervous system </li></ul><ul><li>May require surgical intervention </li></ul><ul><ul><li>Patients with chronic or recurrent ABS who fail to improve with maximal medical therapy, may consider sinus surgery </li></ul></ul>
    22. 22. Summary <ul><li>Acute otitis media and acute bacterial sinusitis are the 2 most common bacterial infections treated in the pediatric outpatient arena </li></ul><ul><li>Clinical history and examination are the hallmark to proper diagnosis and these conditions rarely require additional diagnostic testing </li></ul>
    23. 23. Review Questions <ul><li>The 2 bacterial pathogens that play the largest role in acute otitis media are: </li></ul><ul><ul><li>A) Haemophilis influenzae </li></ul></ul><ul><ul><li>B) Streptococcus pneumoniae </li></ul></ul><ul><ul><li>C) Moraxella Catarrhalis </li></ul></ul><ul><ul><li>D) Staphylococcus aureus </li></ul></ul>
    24. 24. A) H. influenzae & B) Streptococcus pneumoniae
    25. 25. Review Questions <ul><li>You see a healthy 5-year-old girl with no significant past medical history in your office for ear pain that started last night. She has no fever and is otherwise well. You diagnose acute otitis media. Your best initial management is: </li></ul><ul><ul><li>A) Treatment with amoxicillin 40-50mg/kg per day </li></ul></ul><ul><ul><li>B) Treatment with amoxicillin 80-90mg/kg per day </li></ul></ul><ul><ul><li>C) Myringotomy and treatment only if cultures are positive for a bacterial etiology </li></ul></ul><ul><ul><li>D) Treatment with acetominophen for pain and follow-up in 2 to 3 days if no change in symptoms or is symptoms worsen </li></ul></ul>
    26. 26. D) Treatment with acetominophen for pain and follow-up in 2 to 3 days if no change in symptoms or is symptoms worsen
    27. 27. Review Questions <ul><li>You are seeing a 15-month-old boy in your office for ear tugging, excessive crying, and fever of 39.5C. He is otherwise healthy though last month he received amoxicillin for treatment of AOM. Today you diagnosis AOM. Best management at this time includes: </li></ul><ul><ul><li>A) amoxicillin 80-90 mg/kg per day </li></ul></ul><ul><ul><li>B) cefuroxime axetil </li></ul></ul><ul><ul><li>C) ceftriaxone parenterally 50mg/kg per day </li></ul></ul><ul><ul><li>D) amoxicillin-clavulaunate 80-90 mg/kg per day of the amoxicillin component </li></ul></ul><ul><ul><li>E) treatment with acetominophen and follow-up in 2 to 3 days </li></ul></ul>
    28. 28. D) amoxicillin-clavulaunate 80-90 mg/kg per day of the amoxicillin component
    29. 29. Review Questions <ul><li>In considering empiric therapy for a 7-year-old boy in whom you suspect acute sinusitis, you should prescribe: </li></ul><ul><ul><li>A) amoxicillin 80-90 mg/kg per day </li></ul></ul><ul><ul><li>B) cefotaxime 300mg/kg per day </li></ul></ul><ul><ul><li>C) Cefuroxime axetil </li></ul></ul><ul><ul><li>D) Erythromycin succinate </li></ul></ul><ul><ul><li>E) Sulfamethoxazole - trimethoprim </li></ul></ul>
    30. 30. A) amoxicillin 80-90 mg/kg per day
    31. 31. Review Questions <ul><li>Acute bacterial sinusitis is best distinguished from a viral upper respiratory tract infection by: </li></ul><ul><ul><li>A) cough </li></ul></ul><ul><ul><li>B) duration of symptoms for greater than 10 days </li></ul></ul><ul><ul><li>C) facial pain and headache </li></ul></ul><ul><ul><li>D) presence of fever for 1 to 2 days </li></ul></ul><ul><ul><li>E) purulent nasal discharge </li></ul></ul>
    32. 32. B) duration of symptoms for greater than 10 days
    33. 33. Review Questions <ul><li>A diagnosis of acute bacterial sinusitis should be based on: </li></ul><ul><ul><li>A) a precise clinical history regarding quality and duration of symptoms </li></ul></ul><ul><ul><li>B) bacterial culture from the nasopharynx </li></ul></ul><ul><ul><li>C) CT of the paranasal sinuses </li></ul></ul><ul><ul><li>D) physical examination of the nose and pharynx </li></ul></ul><ul><ul><li>E) plain film radiographs of the paranasal sinuses </li></ul></ul>
    34. 34. A) a precise clinical history regarding quality and duration of symptoms
    35. 35. Questions???