Special features of diagnostics and management of purulent inflammation in children. Ass. Prof. Dr. Goshchynskyi Pavlo

Systemic Inflammatory Response Syndrome (SIRS) heart rate > 90 beats/minute temperature > 38°C or < 36°C respiration > 20/min or PaCO2 < 32mm Hg leukocyte count > 12,000/mm3, 10% immature (band) cells

Sepsis SIRS plus a documented infection site (documented by positive culture for organisms from that site). Blood cultures do NOT need to be positive. Bacteremia may be transient, as is seen commonly after injury to a mucosal surface, primary (without an identifiable focus of infection), or more commonly secondary, to an intravascular or extravascular focus of infection

Skin - ecthyma gangrenosum ecthyma gangrenosum ecthyma gangrenosum

THERAPY: three priorities 1. Immediate Stabilization of the Patient 2. The blood must be rapidly cleared of microorganisms 3. The original focus of infection must be treated

The drugs used depends on the source of the sepsis. Community acquired pneumonia a 2 drug regimen is usually utilized. Usually a third (ceftriaxone) or fourth (cefepime) generation cephalosporin is given with an aminoglycoside. Nosocomial pneumonia: Cefipime or Imipenem-cilastatin and an aminoglycoside. Abdominal infection: Imipenem-cilastatin or Pipercillin-tazobactam and aminoglycoside. Nosocomial abdominal infection: Imipenem-cilastatin and aminoglycoside or Pipercillin-tazobactam and Amphotericin B. Skin/soft tissue: Vancomycin and Imipenem-cilastatin or Piperacillin- tazobactam Nosocomial skin/soft tissue: Vancomycin and Cefipime Urinary tract infection: Ciprofloxacin and aminoglycoside Nosocomial urinary tract infection: Vancomycin and Cefipime CNS infection: Vancomycin and third generation cephalosporin or Meropenem Nosocomial CNS infection: Meropenem and Vancomycin

Acute hematogenous osteomyelitis  Acute hematogenous osteomyelitis(AHO)-bacterial infections of bones with subsequent involving of the surrounding soft-tissue  Antacedent infections -Immunological disbalance - widesread by way of bloodstream -hematogenous abscess in the marrow cavity  The most common pathogen culture is Staphyloccus aureus  The male: female ratio is 3:2  The most common involving long tubular bones

Hematogenous osteomyelitis Frequency. The overall prevalence is 1 per 5,000 children. Neonatal prevalence is approximately 1 per 1, % are preschool- aged children

Classification of AHO by clinical pictures:  Toxic (adynamic) type  Septico-pyemic type  Local

Pathogenetic stages of AHO A. Bone marrow phlegmon B. Periosteal abscess C. Soft tissue phlegmone Dermal fistula

Classification of AHO by localization Epiphyseal Metaphyseal Diaphyseal Metadiaphyseal Pelvic Other localization

Bacterial causes of acute hematogenous osteomyelitis: – Newborns (younger than 4 mo): S aureus, Enterobacter species, and group A and B Streptococcus species; – Children (aged 4 mo to 4 y): S aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species; – Children, adolescents (aged 4 y to adult): S aureus (80%), group A Streptococcus species, H influenzae, and Enterobacter species; – Adult: S aureus and occasionally Enterobacter or Streptococcus species

Findings at physical examination Fever (present in only 50% of neonates) Edema Warmth Fluctuance Tenderness to palpation Reduction in the use of the extremity (eg, reluctance to ambulate, if the lower extremity is involved or pseudoparalysis of limb in neonates) Sinus tract drainage (usually a late finding or one that occurs with chronic infection)

pseudoparalysis

Radiographic image depicting long-bone regions (left labels) and bony changes (right labels) due to Staphylococcus aureus osteomyelitis occurring in the distal right humerus of a 12- month-old infant. Conrad D A Pediatrics in Review 2010;31: ©2010 by American Academy of Pediatrics

osteomyelitis of the tibia (X-ray) periosteal elevation medullary lucencies

The involucrum-subperiosteal new bone

Magnetic resonance image (short T1 inversion recovery pulse sequence) depicting long-bone regions (left femur) and extensive marrow edema and significant enhancement of the periosteum and adjacent soft tissues (right femur) due to Staphylococcus aureus osteomyelitis occurring in the distal right femur of a 26-month-old infant. Conrad D A Pediatrics in Review 2010;31: ©2010 by American Academy of Pediatrics

Procedures Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from the vertebral space or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media. Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism. This can be accomplished by needle core often accomplished under radiographic control (fluoroscopy or CT scan).

The diagnosis of osteomyelitis requires 2 of the 4 following criteria 1. Pus on aspiration 2. Positive bacterial culture from bone or blood 3. Presence of classic signs and symptoms of acute osteomyelitis 4. Radiographic changes typical of osteomyelitis

Differential diagnosis Rheumatic fever Monoarthritic rheumatoid arthritis Poliomyelitis Septic arthritis Bacterial cellulitis In newborns and infants in whom osteomyelitis may present as a pseudoparalysis, also consider nervous system disease, cerebral hemorrhage, trauma, scurvy, and child abuse

X-ray findings of neonatal acute hematogenous osteomyelitis

Treatment Medications Drainage Splinting or cast immobilization Surgery Alternative treatment

Initial Antibiotic Regimens for Patients with Osteomyelitis OrganismAntibiotic(s) of first choiceAlternative antibiotics Staphylococcus aureus or coagulasenegative (methicillin- sensitive) Staphylococci Nafcillin (Unipen), 2 g IV every 6 hours, or clindamycin phosphate (Cleocin Phosphate), 900 mg IV every 8 hours First-generation cephalosporin or vancomycin (Vancocin) S. aureus or coagulase-negative (methicillin-resistant) staphylococci Vancomycin, 1 g IV every 12 hoursTeicoplanin (Targocid),* trimethoprim- sulfamethoxazole (Bactrim, Septra) or minocycline (Minocin) plus rifampin (Rifadin) Various streptococci (groups A and B β-hemolytic organisms or penicillin- sensitive Streptococcus pneumoniae) Penicillin G, 4 million units IV every 6 hours Clindamycin, erythromycin, vancomycin or ceftriaxone (Rocephin) Intermediate penicillin-resistant S. pneumoniae Cefotaxime (Claforan), 1 g IV every 6 hours, or ceftriaxone, 2 g IV once daily Erythromycin or clindamycin Penicillin-resistant S. pneumoniaeVancomycin, 1 g IV every 12 hoursLevofloxacin (Levaquin) Enterococcus speciesAmpicillin, 1 g IV every 6 hours, or vancomycin, 1 g IV every 12 hours Ampicillin-sulbactam (Unasyn) Enteric gram-negative rodsFluoroquinolone (e.g., ciprofloxacin [Cipro], 750 mg orally every 12 hours) Third-generation cephalosporin Serratia species or Pseudomonas aeruginosa Ceftazidime (Fortaz), 2 g IV every 8 hours (with an aminoglycoside given IV once daily or in multiple doses for at least the first 2 weeks) Imipenem (Primaxin I.V.), piperacillin- tazobactam (Zosyn) or cefepime (Maxipime; given with an aminoglycoside) AnaerobesClindamycin, 600 mg IV or orally every 6 hours For gram-negative anaerobes: amoxicillin-clavulanate (Augmentin) or metronidazole (Flagyl) Mixed aerobic and anaerobic Organisms Amoxicillin-clavulanate, 875 mg and 125 mg, respectively, orally every 12 hours Imipenem

Treatment of neonatal AHO:Shade’s reduction traction

Immobilization-wide diapering as a prophylactic management of acquired dislocation of the hip

Surgical Care Immediate bone aspiration If signs and symptoms do not resolve within hours of initiation of appropriate antimicrobial treatment, consider repeat bone aspiration to drain the pus Joint aspiration Most well-established bone infections are managed through open surgical procedures during which the destroyed bone is scraped out

Complications Bone abscess Sepsis Fracture Overlying soft-tissue cellulitis Draining soft-tissue sinus tracts

Further complication of AHO:varus deformation and limb contraction

CHRONIC OSTEOMYELITIS X-Ray

Brodie's abscesses radiolucent with adjacent sclerosis

Neonatal phlegmon  Neonatal phlegmon-acute soft- tissue infections in childhood. Types: simple, toxic and septicopyemic.  Etiology: most common- Staphylococcus epidermidis  Typical localizations: lumbar area, back, anterior and lateral superficies of the thorax  Local symptoms: pain, local rise in temperature, hyperemia, swelling.

Neonatal phlegmon

Neonatal phlegmon-surgical treatment

Neonatal mastitis  Neonatal mastitis is a local bacterial infection during the first mounth (first weeks) of life  Causative organisms. Staphylococcal organisms (S.epidermidis,S.aures)  The male:female ratio is 1:1  Physiological enlargement of mammalian glands is a prepodisposatary factor for the development of the disease  General symptoms  Local symptoms (tenderness, swelling, hyperemia, local rise in temperature, fluctuation)

Neonatal mastitis.Surgical management

Special features of conservative treatment of neonates with acute suppurative infections 1. Anti-bacterial therapy. 2. Intensive infusive therapy of hemostatic dysbalance (IV and IM administration of drugs) 3. Passive and active immunization 4. Symptomatic treatment 5. Desensitization and hormonal therapy 6. Administration of physiotherapeutic procedures (compresses, warm baths, ultraviolet therapy) 7. Hyperbaric oxygen therapy.

Special features of surgical methods of management of acute suppurative infections in childhood  Operative aproach (wide excision of the infection site)  Drainage  Collection of pus for culture  Special features of surgical management of neonatal phlegmon (multiple cuts in the zone of the lesion including the border with healthy tissue and frequent dressing every hours)  Special features of surgical management of neonatal mastitis depending on clinical type  Peculiarities of placement and removal of sutures