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

32. QUESTIONS ?