Common Pediatric Infections Scott Lindquist MD MPH WA State Department of Health State Epidemiologist for Communicable Diseases

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

Otitis Media Diagnosis Acute onset Inflammation Middle ear fluid Normal AOM

Otitis Media What does the TM look like? bulging erythematous hemorrhagic normal

Otitis Media Etiology Streptococcus pneumoniae Penicillin-susceptible (91-100% from Tri Cities antibiograms) Haemophilus influenzae (non-typeable) Moraxella catarrhalis

Otitis Media Treatment Approximately 80% resolve spontaneously and antibiotics increase resolution to ~ 95% Priority to treat is children < 2 years and severe cases Drug of Choice: AMOXICILLIN

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

Otitis Media with Effusion Middle ear fluid No inflammation Must be differentiated from AOM AOM OME Normal

Otitis Media with Effusion 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 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)

Sinusitis Diagnosis is clinical/epi 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

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

Chronic Sinusitis UNCOMMON Suspect Other etiologies (CF, anatomical) Other explanations (asthma, allergies environmental factors

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

Streptococcal Pharyngitis Diagnosis: Clinical > 2 years old, acute onset, fever, unilateral lymphadenitis, no URI Rapid test Culture Beware of carriers

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

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

Acute Lymphadenitis Clindamycin, cephalexin, macrolide US  Aspiration Group A Streptococcus Staphylococcus aureus

Chronic (sub-acute) lymphadenitis To consider: CBC, EBV, PPD or IGRA, 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. henselae MAIC M. tuberculosis

Community Acquired Pneumonia Etiologies Viral RSV parainfluenza Influenza Bacterial Strep pneumoniae Atypical Mycoplasma Chlamydia Tuberculosis Legionella Coccidioides Immitis Treatment Amoxicillin (2m- 5 yrs) Macrolide Erythromycin Azithromycin Antivirals (Oseltamivir)

Common Circulating Respiratory Viruses

Current Respiratory Viruses

Urinary Tract Infection Not difficult to treat, only difficult to diagnose but the implications of a missed diagnosis may be long lasting Always suspect in febrile children < 2 yrs of age Dx of UTI requires a UCx (bag-specimen not very good) UA (WBC), dipstick OK as a guide, especially in combination

Urinary Tract Infection Etiology Escherichia coli Enterococcus Treatment Amoxicillin (50-64%) TMP / SMX (65-81%) Cefixime (91-100%) Quinolone (76-87%) Nitrofurantoin(89-96%) Follow-up US if <2 y/o and no history of normal prenatal US (30-32 wks) or recurrent UTI’s VCUG if > 2 UTI’s or 1st UTI with abnormal US or bug other than e. coli

Acute Gastroenteritis 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

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

Puncture wounds (foot) Etiology Staph aureus (~ 3 d) Pseudomonas 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)

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

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)

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

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

Common Infections Requiring Inpatient or Subspecialty Care Sepsis Meningitis Encephalitis Brain Abscess Orbital Cellulitis Endocarditis Bone/Joint infections

Sepsis Toxicity = clinical picture - lethargy - hypoperfusion - hypo/hyperventilation Signs and Symptoms Hyperthermia or hypothermia Tachycardia Tachypnea Leukocytosis or leukopenia

Sepsis work-up Cell Blood Count (CBC) Blood Culture Urine analysis Urine Culture Chest roentgenogram Stool if needed NPA for viruses if needed Lumbar puncture CSF Culture

Etiologies of Sepsis/Meningitis < 1 month of age Group B Streptococcus Escherichia coli (Listeria monocytogenes) 1-3 months of age Streptococcus pneumoniae (↓) Group B Streptococcus Neisseria meningitidis Salmonella spp (Haemophilus influenzae b) (Listeria monocytogenes) 3-36 months of age Streptococcus pneumoniae (↓) Neisseria meningitidis (Haemophilus influenzae b)

Bacterial Meningitis Diagnosis: LP, LP, LP Should I do an LP? Increased intracranial pressure Prior antibiotics “Bloody tap”

Encephalitis Not usually bacterial HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc ADEM

Brain abscess Source: Proximity: middle ear, sinuses Meningitis Hematogenous Penetrating: wound, surgery

Brain abscess Triad: Treatment: Headache Surgery Focal neurologic findings Fever Treatment: Surgery Antibiotics: Cefotax + Vanco + (Metro) for 4-8 weeks (IV)

Orbital Cellulitis Triad: Proptosis Decreased eye movement Pain on eye movement

Orbital Cellulitis Treatment: Antibiotics: Cefotax + Vanco + (Metro) Cefotax + Clinda x 10-14 d IV and 7-14 d PO Surgery

Endocarditis Acute  Staph (MRSA) Subacute  viridans Strep Antibiotics: Vanco + gentamicin Penicillin + gentamicin X 2 w, 4-6 w depending on organism and antibiotics used Involve Cardiology

Pericarditis “Purulent pericarditis” Staph aureus (MRSA) Strep pnumoniae Salmonella Candida M. tuberculosis Antibiotics: Ceftriaxone + Vancomycin Drainage Treatment is 2-4 weeks depending on organism and response

Osteomyelitis Staph aureus (Others in special populations) Clindamycin Vancomycin Linezolid X 4 weeks (IV/PO) Surgery

Septic arthritis Fever, joint pain/swelling, decreased ROM Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)

Septic arthritis Etiologies: Staph aureus Streptococcus (GAS, Strep pneumo) Kingella kingae Salmonella Neisseria (GC, N. meningitidis) H. influenzae Treatment: Aspirate vs Surgery: hips, shoulders Antibiotics: Vancomycin (Clinda, Oxacillin) + cefotaxime (cefuroxime) x 3 weeks (IV/PO)

Case Study 2 year old healthy Male with fever of 102 F in September 2016 Cough for 3 days RR 65 O2 sats of 94% Not wheezing Ill appearing

What Diagnostics are Most Helpful? A) CBC B) Blood Culture C) Chest radiograph D) Nasal Pharyngeal Aspirate for viral pcr panel E) A,B, and C (correct do not display) F) All of the above

What Is The Most Likely Organism? A) Staphylococcus aureus B) Streptococcus pyogenes C) Streptococcus pneumoniae (correct) D) Mycoplasma pneumonia E) Haemophilus influenzae

What is the best outpatient Therapy? Azithromycin Amoxicillin Cefuroxime Levofloxacin TMP/SMX

What is the best outpatient Therapy?

What is the best outpatient Therapy? Azithromycin Amoxicillin (correct answer) Cefuroxime (correct answer) Levofloxacin TMP/SMX