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Common Outpatient Infections Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New Orleans.

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Presentation on theme: "Common Outpatient Infections Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New Orleans."— Presentation transcript:

1 Common Outpatient Infections Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New Orleans

2 Common Outpatient Infections Otitis Media Sinusitis Pharyngitis Lymphadenitis Pneumonia Urinary tract infection Diarrhea Impetigo/cellulitis Wounds/bites Infestations Fungal Parasites Herpes Exanthems

3 Otitis Media Diagnosis Acute onset Inflammation Middle ear fluid Normal AOM

4 Otitis Media Etiology Streptococcus pneumoniae Penicillin-susceptible Penicillin-non susceptible Haemophilus influenzae (non-typeable) Moraxella catarrhalis

5 Otitis Media Treatment ~ 80% resolve spontaneously antibiotics increase resolution to ~ 95% Priority to treat is children < 2 years and severe cases Drug of Choice: AMOXICILLIN80-90 mg/kg/d

6 Otitis Media Failure: Amoxicillin / clavulanate Ceftriaxone (1-3 doses) Tympanocentesis

7 Otitis Media Alternatives: Cefdinir(Omnicef) Cefuroxime(Ceftin) Cefpodoxime(Vantin) Ceftriaxone Azitromycin Clarithromycin

8 Recurrent Otitis Media 3 episodes in 6 months 4 episodes in 12 months Check for environmental factors Chemoprophylaxis: amoxicillin (20 mg/kg/d) sulfisoxazole (35-70 mg/kg/d) Ventilating tubes

9 Otitis Media with Effusion Middle ear fluid No inflammation Must de differentiated from AOM Normal AOMOME

10 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 Media with Effusion

11 AOMT Augmentin CiprodexCiprofloxacin 0.3% Dexamethasone 0.1% Cipro HCCiprofloxacin HCl 0.2% Hydrocortisone 1% FloxinOfloxacin 0.3%

12 Otitis Externa 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)

13 Sinusitis Diagnosis is clinical 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

14 Sinusitis Etiology: Similar to AOM Treatment: Similar to AOM, except that duration is ~ 2 weeks (7 d after patient is free of symptoms)

15 Chronic Sinusitis UNCOMMONSuspect Other etiologies (CF, anatomical) Other explanations (asthma, allergies environmental factors

16 Pharyngitis Viral most common (EBV, rhinovirus, etc) Allergies Bacterial: Group A Streptococcus Other Streptococcus

17 Strept Pharyngitis Diagnosis: Clinical > 2 years old, acute onset, fever, unilateral lymphadenitis, no URI Rapid test Culture (GAS only vs others) Beware of carriers (need ASLO)

18 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

19 Generalized Viral (EBV) Toxoplasmosis Syphilis Single Acute: Staph / Strep Chronic: Bartonella henselae Mycobacteria Lymphadenitis

20 Acute Lymphadenitis Clindamycin, cephalexin, macrolide US  Aspiration Gorup A StreptococcusStaphylococcus aureus

21 Chronic (sub-acute) lymphadenitis To consider: CBC, EBV, PPD, 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. henselaeMAICM. tuberculosis

22 CA Pneumonia Etiologies Viral RSV Influenza Bacterial Strep pneumoniae Atypical Mycoplasma Chlamydia Tuberculosis Treatment Amoxicillin (2m- 5 yrs) Macrolide Erythromycin Azithromycin Antivirals (Oseltamivir)

23 Urinary Tract Infection Not difficult to treat, only difficult to diagnose but the implications of a missed diagnosis may be terrible 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

24 Urinary Tract Infection Etiology Escherichia coli Enterococcus Treatment Amoxicillin TMP / SMX Cefixime Quinolone Follow-up US, VCUG DMSA scan Consider prophylaxis

25 Acute Gastroenteritis “Always” infectious 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

26 Impetigo / cellulitis Etiology: Group A Streptococcus Staphylococcus aureus (MRSA) Treatment: Bacitracin, Mupirocin, Retapalumin Cephalexin, clindamycin, TMP/SMX, erytho, linezolid Drain any abscess

27 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)

28 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

29 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)

30 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) Uncertain significance Entamoeba coli, Endolimax nana, Iodamoeba butschlii Blastocystis hominis, Dientamoeba fragilis Taeniasis Praziquantel, different doses

31 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


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