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

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

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

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

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

6. 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

7. 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

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

9. 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

10. 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)

11. 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

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

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

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

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

16. 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

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

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

19. 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

20. 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)

21. Common Circulating Respiratory Viruses

22. Current Respiratory Viruses

23. 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

24. 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

25. 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

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)
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)

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 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

32. 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

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

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

35. 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

36. 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)

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

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

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

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

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

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

43. 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

44. 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

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

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

47. 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)

48. 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

49. 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

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

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

52. What is the best outpatient Therapy?

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