Presentation on theme: "common infections of childhood"— Presentation transcript:
1 common infections of childhood Jen Avegno, MDLSU – New Orleans Emergency MedicineResident Conference 2010
2 rule #1: kids get sick.2006 National Hospital Ambulatory Medical Care Survey showed:most common ED diagnosis forkids <1 = upper respiratory infectionkids 2-12 = otitis media/ear disordersIn all, fever is the most common chief complaint of kids presenting to the ED (about 20-30% all peds visits)
3 rule #2. most kids don’t get THAT sick. this lecture is aboutNOT
4 objectivesReview high-yield, commonly encountered, infections of childhoodDiscuss pathophysiology, common organisms, presentations, management and treatment of eachSee LOTS of pictures of my children
5 case # 1Mom brings in a 3-week-old baby girl with a fever for 4 hours. The child was a normal vaginal delivery with no complications and has been feeding and growing well at home. This morning, she began to “spit up” her bottle and had several loose stools. She has been somewhat sleepy but does respond to her parents. Physical exam reveals a child in no distress with a rectal temperature of and a normal exam for age.
7 the dreaded neonatal fever what is the risk of serious bacterial illness (SBI) in kids less than 3 months with fever?SBI = UTI, bacteremia, meningitis, osteo, pneumonia, gastroenteritis, cellulitis, septic arthritisrisk is about 6-10% in these kids, with those younger than 1 month having the highest chance of SBIkids under 3 months may present looking like “viral syndrome” but still have SBI … in one study, kids less than 60 days with temp>38:22% had RSV7% with RSV also had concomitant SBI
8 why do neonates get fever? immature immune systemexposure to pathogens during delivery (esp. GBS)cannot mount immune response to prevent localized infection from disseminating
9 what does temperature really mean? what IS a fever? fever = “a pyrogen-mediated rise in body temperature above normal range”what is a NORMAL temp?the magical 98.6 was set as “normal” by a German guy in the 19th century using a 22cm long mercury glass thermometer … we now think that his instruments may have been OFF by degrees!!normal temps can vary by age in kids from 99.5 (neonates) to 98 (older kids)temps are influenced by age, sex, race, time of day, activity level, ambient temp, site of measurement, type of device
10 what constitutes a fever? NO REAL EVIDENCE to support the hard-and-fast cutoff of (38°C) – evidence suggests that oral temps may be considered febrile depending on situationBEST SITE to measure temperature …the hypothalamic artery. (yeah, right)take-home point: fever is an ARBITRARY number – base your workup on overall clinical impression, not a particular cutoff
11 what about people without thermometers? oh, yeah, the “mom hands” … don’t blow them off!60% of parents use their hands instead of a thermometer to assess feveris this method accurate? studies show:74-90% sensitive76-86% specific85-94% NPVthe exact number or method doesn’t matter … BELIEVING the parents is!
12 common infectious pathogens in the neonate AGEBACTERIALVIRALOTHER0-28 daysGroup B StrepListeriaE. ColiC. trachomatisN. gonorrhoeaeHerpes simplexVaricellaEnterovirusRSVFluBundlingenvironment1-3 monthsH. fluS. pneumoN. meningiditisE. coliflu
13 history length of illness localized symptoms? pertinent PMH, birth hx of both mom & babysick contactsvaccination statusany meds/ABx
14 physical exam findings VITAL SIGNS (yes, ALL of them!!)ABCs – respiratory/airway distress? signs of shock? tachycardia?for infants less than 1 year, HR should increase 10 beats for every 1°CTAKE THOSE CLOTHES OFF!!just remember … in non-immunocompetent kids (neonates) … fever may be the ONLY presenting sign of SBI – do not be reassured by a “normal” exam!!
16 standard managementagain, ABCs … consider intubation for respiratory distress, hypoxia, altered MSfluid resuscitation: 20 ml/kg IV/IO fluids to total of ml/kg (if hypovolemia persists)cultures prior to Abx, if possiblesterilization of CSF can occur as quickly as 15 min – 2 hrs after receiving Abx, so watch results!BROAD SPECTRUM TREATMENT:Ampicillin + (Gentamycin or Cefotaxime) – avoid Rocephin in kids <28 daysVanc? Acyclovir?
17 major guidelines for fever < 90 days PHILADELPHIAROCHESTERBOSTONAGE29-60 d<60 d28-89 dTEMP>38.1>37.9EXAMwell, no focusLAB VALUES (low-risk)WBC <15Band<0.2UA < 10 wbcCSF < 8 wbcneg CXRWBC 5-15band <1500UA <10 wbcWBC <20CSF <10 wbcHIGH-RISK dispoadmit, IV AbxLOW-RISK dispohome, no Abxhome, empiric AbxHow good is it??sens/specPPV/NPV98%/42%14%/99.7%92%/50%12%/98.9%NPV 94.6%** these rules miss very few kids with SBI **
18 watch out for … cancer toxic shock autoimmune and/or congenital disorders (cardiac, pulmonary)
19 case # 2Dad comes to the ED with little Maria, age 2, and reports that she has had a fever for the last 2 days (up to at home). The parents have tried Tylenol and Motrin to no avail. Maria has not eaten much but is still drinking water and juice. She had a “runny nose” a few days ago, but is not sneezing, coughing, or vomiting. In the ED, Maria has a temperature of She looks droopy, but interacts well with her parents.
21 only slightly less scary … fever between 3-36 months fever is the most common complaint in this age group!!unlike neonates, of young children who present with viral illness (RSV, croup, bronchiolitis etc) and fever (>39), less than 0.5% will also be bacteremic
22 the well-appearing febrile child 3-36 months concern here is for OCCULT BACTEREMIAbefore HiB and Prevnar, the rate of occult bacteremia in the non-focal febrile child was 5%currently … it is less than 1% with other pathogens more prevalentN. meningiditisurinary pathogens
23 treating a fever WHY do we treat a fever? HOW do we treat a fever? feel better/decrease anxietylower morbidity/mortalityprevent febrile seizuresHOW do we treat a fever?ambient temp controllight clothing/beddingfluidssponge bathwarm feet/potatoes or onions in socks (REALLY!)antipyretics
24 how do you give Tylenol & Motrin? Acetaminophen 15 mg/kg every 4-6 hoursIbuprofen 10 mg/kg every 6 hoursalternate??evidence shows some minor benefits in reducing fever faster and lasting longer BUT …potential for dosage/scheduling errors; synergistic renal toxicity; difficult to understand and complydetailed information/handout at appropriate reading level on administration of antipyretics should be given to caregivers!!
25 common infectious pathogens in the young child AGEBACTERIALVIRALOTHER3-36 monthsS. pneumoN. meningiditisE. coliVaricellaEnterovirusRSVFluMonoRoseolaAdenovirusNorwalkCoxsackieLeukemiaLumphomaNeuroblastomaWilms’ tumor
26 history length of illness localized symptoms? headache – neck pain – sore throat – ears – cough (describe!!) – wheeze – vomiting – RASH – mental statususe of antipyretics (**defervesence after use does NOT exclude bacteremia!)sick contactspo intake/outputvaccination statusany meds/ABx
27 physical exam findings VITAL SIGNS (yes, ALL of them!!)ABCs – respiratory/airway distress? signs of shock? tachycardia?capillary refill is an easy and reliable indicator of perfusionTAKE THOSE CLOTHES OFF!!thorough search for focal findings
29 notes on the workupmost guidelines argue for getting the WBC first, then CXR if WBC > 20k … but who does this?study showed that rate of pneumococcal bacteremia increased to 0.5% with WBC 10-15k; 3.5% with WBC 15-20k; 18% with WBC>20kANC >10k (include all immature forms) increases risk of bacteremia by 10-fold over those with ANC<10k
30 management & treatment the post-immunization world has resulted in much lower rates of bacteremia for this age group:where bacteremia rates in febrile kids >1.5%, the most cost-effective strategy is a WBC, blood CX, and empiric Abx (Rocephin)when rates <0.5%, clinical judgment alone for treatment & management is most useful to select out high-risk groupskids 3-6 mo are still relatively non-immunocompetent … recommendations are for all kids in this age group with temp >39 to have WBC & BCx; treat all WBC > 15k with empiric ABx
31 watch out for … CANCER autoimmune disease: JRA, Kawasaki’s brain tumors
32 case #3Mom brings in a 6 year-old boy with “pink eye.” She got a call from school today that the child’s right eye was red and draining yellow gunk, and that she needed to pick him up. The boy is afebrile and non toxic, with no recent illnesses or PMH. Immunizations are up to date. He has mildly injected right conjunctiva with some seropurulent drainage from the eye, as well as mild nasal mucoid rhinorrhea. What now?
34 not just the dreaded pink eye! conjunctivitis = “inflammation of bulbar & palpebral conjunctiva caused by various viral, bacterial, mechanical, allergic & toxic agents”most frequent pediatric eye complaint in the ED
35 common infectious pathogens in the young child viral: adeno, coxsackie, entero, rhino, flu**MOST COMMON**bacterial:S. pneumoH. fluS. aureusM. catarrhalisN. gonorrhoeae (yuck)less common: other Gram negatives (Pseudomonas)
36 history & physicalviral – generally itchy, red, irritated with watery or purulent discharge, preauricular LANassociated with other URI scmay start in one eye & spread to othermay last longer than bacterialbacterial – “pinkeye,” redness, FB sensation, lid swelling, drainage, “eye boogers”usually no photophobia or vision impairmentallergic – very itchy, usually bilateral
40 how do you tell them apart? FINDINGBACTERIALVIRALBilateral at onset50-74%35%Conjunctival dischargemucopurulentwateryPreauricular adenopathylateearlyConcurrent OM20-73%10%
41 management & treatment viral – artificial tears, cool compresses, antihistamine drops if necessarybacterial – warm compresses & topical Abx:sulfa, floxin (ok in kids!), erythromycin, neomycinointment vs. drops??ointment – soothing, prolonged contact with conjunctivadrops – do not blur vision, ?easier to get in?tx for 7 days
42 “Doctor, when can they go back to school???? (desperation)” no established guidelines for ED management/care of conjunctivitis (darn.)bacterial conjunctivitis – most common standard is return to school 24 hours after beginning Abx treatmentviral conjunctivitis – ??If you don’t think it’s pinkeye … SAY SO & DOCUMENT for parents!
43 watch out forophthalmia neonatorum – conjunctivitis within 1st month of lifewithin 1st 2 weeks – gram stain & culture of drainageN. gonorrhoeae – usually from birth canal, within 1st 1-7 days of life – must carefully evaluate for disseminated GCtx = RocephinChlamydia – usually sx between 5-19 days oldtx = topical Erythromycinchemical – from ointment given at birth; dx of exclusionHSV & VZV can affect the eyes and lead to scarring, dry eye
44 case #4Mom brings in a 15-month old girl who woke up last night screaming and with fever to She has not eaten much today but is drinking liquids with normal urine output. All of her immunizations are up to date and she is otherwise healthy. On exam, you note a mildly ill appearing, non-toxic child who responds well to mom. The left TM is red and bulging with loss of landmarks.
46 epidemiology Most commonly diagnosed disease in kids <15 By age 3 – estimated that more than 80% of kids have had one episode; 40% have had >3Risk factors:MaleSmokingDay careFamily historyAnatomic abnormalitiesWinterBottle feeding
47 definitions ACUTE: s/s of acute infxn WITH effusion aka “acute suppurative” or “prurulent” OMOME: effusion WITHOUT s/s of acute infxnaka “serous,” “mucoid,” “secretory,” “nonsuppurative”CHRONIC: chronic ear discharge from perforated membraneRECURRENT: >3 episodes in 6 mo or >4 episodes in 1 year
48 pathophysiology When the eustachian tube becomes obstructed … It’s all about the tube – functions of the eustachian tube:Ventilates middle ear for pressure equilibrationDrains middle earProtects ear from NP secretionsOnly open when yawning/chewing/swallowingWhen the eustachian tube becomes obstructed …Middle ear ventilationNegative middle ear cavity pressure causes fluid to move into middle ear (transudate)and combine with NP secretions & bacteriaCHILD
49 common pathogens in otitis media S. PneumoniaeH. flu –higher % in OMEM. catarrhalisS. aureusS. pyogenesgram-negative bacteriaVIRUSES:
50 history “Pulling at ears” Cough Vomiting & diarrhea Decreased po intakeFever – may be present in only ¼ of cases, with less than 10% having temp >40URI sx
51 a normal TM pars flaccida malleus pars tensa umbo eustachian tube openinglight reflex
52 signs/symptoms What does the TM look like? bulging erythematous hemorrhagicnormal
53 more pictures Middle ear effusions other indicators of AOM: lack of TM mobility *** (MOST RELIABLE SIGN)cloudy, retracted, dull TM1/3 of cases may NOT have symptoms!
54 diagnosisAAP/AAFP guidelines state that the following should be present to dx AOM:Recent, usually abrupt onset of s/sPresence of middle ear effusion(bulging, limited TM mobility, air-fluid level, otorrhea)S/s of middle ear inflammation(erythema or otalgia)
55 treatment AAP guidelines on management of AOM in kids: Dx by hx of acute onset + signs of effusion + signs of middle ear inflammationAssess for pain – if present, treatLimited role for observation in select patients > 2 years (must have “a ready means of communication with clinician”)If treat with ABx – start with amox mg/kg/dayIf treatment failure by hours – reconsider dx or change ABx
56 OTITIS MEDIA - treatment Temp <39.1 or severe otalgia or BOTHInitial TxClinical failure after hrs with initial txNOAmox mg/kg/dayPCN all: cefdinir, cefuroxime, cefpodoxime, azith, clarithAugmentin 90 mg/kg/day (of amox)PCN all: Rocephin (3 day tx), clindaYESPCN all: Rocephin (1-time or 3 day tx)Rocephin (3 days)PCN all: clinda + tympanocentesis
57 treatment Important points: “treatment failure” = lack of clinical improvement and/or persistent signs of AOMBactrim & macrolides often considered 2nd line, but resistance rates approach 30-40%Courses are generally 10 days in patients < 2 yrs , perf TM, and recurrent OM, recommended in patients <6 yearsNO INDICATION for antihistamines, decongestants, steroids, or tubes in single episode AOMAuralgan may be useful for pain reliefTx of OME (either alone or following episode of OM) is controversial – ABx? Antihistamines?Tubes for patients with OME for 4-6 months, failed tmt, and hearing loss
59 case #5Parents bring an 8 year old boy to the ED with fever of 102.3, and complaints of headache and abdominal pain. He was otherwise healthy until this morning, and his shots are all up to date. The patient is febrile and tachycardic to 120 with normal blood pressure. He is ill-appearing but non-toxic, speaks normally, and is not drooling. His oropharynx is red with bilateral white exudates and tender, palpable cervical lymphadenopathy.
61 acute pharyngitisdx of tonsillitis/acute pharyngitis is made more than 7 million times/yearMCC is viral in kidsMCC bacterial pharyngitis is GABHS (15-30%)kids 5-15 y/o predominantlyGroup C & G Strep are likely much more common than typically thought & may be missed by routine testingabout 1 in 4 kids with acute sore throat has serologically confirmed GABHSMC in winter when respiratory viruses predominate
62 common infectious pathogens BACTERIAL:StrepGroup AGroups C & Gmixed anaerobic (“Vincent’s angina”)N. gonorrhoeaeC. diphtheriaeArcanobacterium haemolyticum; Yersinia; tularemiaatypicals
63 common infectious pathogens VIRAL: rhino, corona, adeno, paraflu, flu, CMV;HSV 1 & 2 – oral gingivostomatitisCoxsackie – aka herpangina – fever & painful, white-gray papulovesicular lesions/ulcers in posterior OPEBV - **mono**severe pharyngitis with GENERALIZED LAD (posterior cervical), hepatosplenomegaly, periorbital edema, palatal petechiaeAmoxil rash!!HIV** may be most common presenting sx!
65 history & physicalsick contacts – common in both bacterial & viral causeshow to differentiate viral vs. bacterial sore throat?BACTERIAL (GABHS)VIRALSudden onsetMore gradual+ fever+/- feverheadacheconjunctivitisN/V/abd paindiarrheaTender anterior LADCough, hoarseness, coryzaPatchy discrete exudatesmyalgiasScarlatiniform rash
66 the Centor criteriasingle throat swab & culture is 90-95% sensitive; rapid kits are 90-99%Modified Centor criteria for dx of GABHS in kids:tonsillar exudatestender anterior cervical LAD or lymphadenitisabsence of coughhx of feverage < 15 add 1 pointSCORERISK OF GABHSMGT1-2.5%No testing or Abx15-10%211-17%Culture; Abx for + results328-35%4-551-53%Tx without test
67 management & treatment most common viral causes are self-limited and resolve with supportive txGABHS is generally self-limited and resolves without tx … but … why do we treat with Abx?symptom relief; decrease spread; shorten duration of illness (16 hrs)prevent complications (1 in 1000)suppurative – bacteremia, endocarditis, mastoiditis, meningitis, OM, PTA, RPA, pneumonianonsuppurative – PSGN, RF
68 treatment Abx options: Pen V K po or Pen G IMAmoxPCN allergy – Keflex, Azithromycin (resistance rates near 10% thanks to us!)supportive measures – antipyretics, warm salt water gargles, cool soothing fluids, etc.
69 watch out for mono retropharyngeal abscess peritonsillar abscess (older adolescents)epiglottitis (more common in adults now)scarlet fever – caused by pyrogenic exotoxin-producing form of GABHS in non-immune individualsoutbreaks are cyclicalrash hours after onset of symptoms (may be longer)
70 case #6Two worried parents rush their 1 year old baby to the ER at 2 am because of “breathing problems” and fever. She was a normal healthy infant until she woke up at midnight with a high fever, breathing fast, and wheezing. There is no prior history of asthma and no sick contacts. The baby is febrile to 101.3, breathing 40 times a minute with some retractions and audible wheezes but has a vigorous cry.
72 rsv worldwide phenomenon, usually winter – spring transmitted through secretionsmay manifest asbronchiolitis – may result in bronchial obstructionpneumonia – severe inflammation in alveoli & interstitial tissue – greatest in kids < 1 yrgreatest % of hospitalizations for respiratory reasons in infants (2-5% of those hospitalized will need intubation)increased risk in preemies, congenital conditions, boys, lower socioeconomics
73 croup most likely (75%) caused by parainfluenza virus peak incidence 3 mo – 3 yearsMCC infectious airway obstruction in kids (subglottic … at narrowest diameter)
74 history & physical - RSV 3-5 day incubation period, followed by:coughWHEEZEprolonged expiratory phaseapnea (up to 20% infants with RSV)may have RAPID decompensation (kids have less pulmonary reserve)CXR may be normal, show lobar pneumonia or peribronchial inflammation
75 history & physical - croup steeple sign1-4 day incubation periodbarking, “seal-like” cough with “whistling” (stridor) on inspiration, sneezing, nausea/vomiting, fever, hoarsenessoften worse at night … then gets better when the kid is taken outside to drive to ER …90% of cases are mild! (whew)
76 management - RSV treatment is largely SUPPORTIVE supplemental oxygen secretion managementadmitted kids – consider ribavirin, NO, helioxhigh-risk kids get preventative antibody/immunoglobulinnebulized B-agonists – short-term improvement in oxygenation, unclear if there is a real benefit (same for racemic epi)NO significant benefit for steroids
78 treatment - croupabout 6% kids with croup are hospitalized, only 1% of these are intubatedmoderate – severe croup despite tmt usually means admissionmist inhalers, steam showersnebulized racemic epi?short-lived benefit; sx may recur within 2 hoursmay give q1 hr – but >1 dose often means admissionsteroidsIM or po dexamethasone (0.6 mg/kg) may decrease need for hospitalization and/or return visits
79 watch out for aspirated FBs underlying lung pathology (CF) other causes of pneumonia/bronchitis
80 summary kids will be kids and get SICK fortunately, most of the time they are not TOO SICK(let us all say a prayer of thanks to the guy(s) who invented vaccines)when you hear hoofbeats … it’s OK to consider a zebra, as long as the herd of horses doesn’t trample you while you’re thinking …