Pediatric Infections

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Pediatric Infections

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Bacterial or viral?

• 8 m/o boy, 41 ?C rectally, well-looking.
• WBC in the absence of B/C
• ESR
• Response to acetaminophen
• Extreme height of fever elevated WBC

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Lee and Harper (1998)

• In the postinfluenza era, that height of fever in
  combination with elevated WBC can identify a risk
  group for bacteremia (10 incidence).
• No utility has been shown for ESR, the Yale
  Observation Scale (YOS), or response to
  acetaminophen.

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Which test(s) appropriate?

• 2 y/o girl, fever (38.6 ? C) x 3 d. PE Happy
  and interactive both TM minimal erythema.
• B/C and CBC
• CBC alone
• B/C, CBC, culture and analysis of catheterized
  urine, and CSF culture and cell count
• U/A U/C by bladder catheterization
• CXR

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UTI

• Neonates 1-1.4 (MF2.8 to 41)
• Infants M1.2 F1.1
• Children (1-7y) F7.8 M1.6
• In diapers ? catheterized U/C
• Clinical parameters are unreliable
• Complication Pyelonephritis and irreversible
  renal scarring.

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Which is least important?

• 4 y/o girl, lethargy 18 hours previously, when
  she became febrile and was more difficult to
  arouse). 39.8?C, HR 190, RR 40, and BP 85/40.
• CBC, PT/PTT, and B/C
• IM antibiotics if the first 2 IV attempts failed
• Fluid resuscitation with normal saline (NS) IV
• Rectal antipyretics
• Oxygen

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Septic shock Priority

• ABC
• O2 IV Monitor
• Prompt antibiotics
• Antibiotics without fluid support may result in
  further lysis of bacteria and worsening of an
  already tenuous hemodynamic state. However, this
  is rare and should not delay antibiotics.
• IO / femoral access attempted if IV failed
• Antipyresis is the least important

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CSF study

• August 2 m/o child, fever for 1 d. 38.8C. CSF
  WBC of 50/hpf (LN170), RBC 40/hpf, protein 80
  mg/dl, and glucose 40 mg/dl.
• Enteroviral meningitis
• Meningitis from S. pneumoniae
• Herpetic meningoencephalitis
• Either a viral or bacterial source

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CSF interpretation

• WBC number alone cannot be relied upon to
  differentiate bacterial from viral meningitis
• Management Empirical antibiotic coverage and
  admission until bacterial cultures of the CSF
  provide the definitive answer
• Given the time of year, an enteroviral pathogen
  is a likely suspect and may prove the causative
  agent

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Neck stiffness

• 2 y/o boy, fever, throat pain, parental concern
  that his neck seems "stiff".
• Sinusitis
• Cervical adenitis
• Pneumonia
• Pharyngitis
• Retropharyngeal abscess

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Meningeal irritation

• Meningitis
• Cervical adenitis
• Pneumonia
• Pharyngitis
• Retropharyngeal abscess
• Sinusitis has not been shown to elicit neck pain
  in and of itself !

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Meningitis

• 5 m/o girl, fever, vomiting, and lethargy. CSF
  RBC 20, WBC 1200 (L/N1/80), Gram-positive cocci
  in pairs. She was given IV ampicillin 50 mg/kg at
  LMD 6 hr ago.
• Ceftriaxone (Rocephin) and dexamethasone
• Ceftriaxone and acyclovir
• Ceftriaxone and vancomycin
• Ceftriaxone, vancomycin, and dexamethasone
• Chloramphenicol

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Bacterial meningitis

• Ceftriaxone
• Broad-spectrum
• Vancomycin
• Coverage for resistant S. pneumoniae
• Dexamethasone
• H. influenzae type B
• lt 6 hr since initial antibiotic
• Reduces hearing loss

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Treatment decision

• 9 m/o infant, 38.6C, fussiness, URI symptoms and
  a right tympanic membrane notable for erythema,
  distortion of landmarks, and decreased mobility.
• Previous antibiotic use
• Daycare attendance
• Resistance pattern of pneumococci in your area
• Previous otitis media diagnoses
• Data from a CBC D/C

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Treatment of otitis media

• Patient age
• Daycare attendance
• Recent antibiotic use
• Previous OM courses and how they responded to
  specific antimicrobials
• Resistance patterns for pneumococci

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Purulent nasal discharge

• 3 y/o boy has a history of 1 week of ongoing
  purulent nasal discharge and fever in excess of
  38.5C for the last 3 days. He appears otherwise
  well.
• Impression?
• Next test for his diagnosis?

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Acute sinusitis

• Sinus x-rays Abnormal in almost every child
• CBC data is not helpful in screening
• Gram stain of nasal secretions is not indicated
• Transillurnination of sinuses is not sensitive
• Antral puncture is reserved for severe disease,
  immunocompromised hosts, or persistent illness
  despite adequate oral therapy

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CT scan

• CT scan is most strongly indicated for?
• Retropharyngeal abscess
• Epiglottitis
• Sinusitis
• Lateral pharyngeal abscess
• Peritonsillar abscess

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• Lateral pharyngeal abscess
• CT imaging
• Retropharyngeal abscess
• Lateral neck plain films /- CT imaging
• Epiglottitis
• Clinical diagnosis plain films
• Sinusitis
• Clinical diagnosis
• Peritonsillar abscess
• Clinical diagnosis

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Croup vs Epiglottitis

• Which is more favor of croup?
• Older
• More febrile
• Drooling more
• Coughing more
• None of the above

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Croup vs Epiglottitis

• Croup classically presents with more coughing
  than does epiglottitis
• Older age and drooling, are more typical of
  epiglottis
• Fever can be seen in both (no specific
  temperature range)
• Respiratory distress will vary

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True or false?

• 11 m/o girl, 39.4C, SOB, poor intake and
  vomiting. RR 50, with subcostal retractions BS
  coarse, SpO2 92 CXR ? RLL consolidation small
  PLE.
• S.pneumoniae is the most likely pathogen
• Treat the patient with oral amoxicillin at OPD
• Dehydration is a potential complication
• Thoracentesis is indicated
• There is no utility for blood cultures

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PN PLE in lt 12 m/o

• S. aureus more likely
• Admission to the hospital is warranted
• Dehydration is a potential complication
• Thoracentesis is indicated if the fluid layers
  out and will improve outcome
• Blood cultures may be positive in 50 of cases if
  the pneumonia is caused by S. pneumoniae

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Thank You

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