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Published byAnnabelle Cook Modified over 9 years ago
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Antibiotic Choices for Infections which Require Hospitalization Rodolfo E. Bégué, MD Chief, Infectious Diseases Pediatrics, LSUHSC rbegue@lsuhsc.edu
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Infections which require hospitalization Examples: r/o sepsis meningitis / encephalitis brain abscess / orbital cellulitis pneumonia / endocarditis acute abdomen urinary tract infection bone & joint skin & skin structures
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Fever r/o sepsis Hyperthermia or hypothermia Tachycardia Tachypnea Leukocytosis or leukopenia Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis.
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Sepsis work-up Cell Blood Count (CBC) Blood Culture Urine analysis Urine Culture Chest roentgenogram Stool NPA Lumbar puncture CSF Culture (CRP, Procalcitonin)
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Etiologies of Sepsis < 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)
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Antibiotics for a child with r/o Sepsis Empiric Antibiotic Treatment: 3 months:Cefotaxime (Vancomycin?) x 7-14 days
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Is it a contaminant? 1 vs >2 positive culture Pathogen vs no pathogen Symptoms vs no symptoms Timing ( 24 h) Plate vs broth (“thio”)
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Central Line Infection Central & Peripheral Blood Culture Gram-positive, Gram-negative, Fungi If possible, change line (Staph, Enteroc, GN, Fungi, Mycobact) vs treat through line If line out: ~ 1 week If line in: ~ 2 weeks Antibiotic lock
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Bacterial Meningitis Diagnosis: LP, LP, LP Should I do an LP? Increased intracranial pressure Prior antibiotics “Bloody tap”
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Bacterial Meningitis: Treatment Neonate:Amp+Gent / Amp+Cefotax Older child:cefotaximeplus vancomycin Modify according to susceptibilities: penicillin cefotaxime vancomycin plus cefotaxime Corticosteroids (?) Rifampin (?)
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Aseptic Meningitis Viral (enterovirus vs others) “Partially treated” Other causes only on special populations
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Encephalitis Not bacterial HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc ADEM
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HSV Encephalitis Acyclovir: 60 mg/kg/d div q 8 hr 750 mg/m 2 /d div q 8 hr x 21 days IV
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Brain abscess Source: Proximity: middle ear, sinuses Meningitis Hematogenous Penetrating: wound, surgery
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Brain abscess Triad: Headache Focal neurologic findings Fever Treatment: Surgery Antibiotics: Cefotax + Vanco + (Metro) for 4-8 weeks (IV)
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Orbital Cellulitis Triad: Proptosis Decreased eye movement Pain on eye movement
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Orbital Cellulitis Treatment: Antibiotics: Cefotax + Vanco + (Metro) Cefotax + Clinda x 10-14 d IV and 7-14 d PO Surgery (ORL, Ophthalmology)
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HSV Keratitis Management: With an ophthalmologist antivirals: 1-2% trifluridine 1% iododeoxyuridine 3% vidarabine x 14-21 days topical corticosteroids contraindicated No need for systemic acyclovir
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Pneumonia Viral: Influenza, RSV Bacterial Streptococcus pneumo Staph aureus Group A Streptococcus TB Chlamydia Mycoplasma Fungal
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Empiric Treatment for Pneumonia If sick enough to require admission (assuming viral panel negative), the regular r/o sepsis regimen is usually OK: Ampi + genta / Ampi + cefotax / Cefotax Usually add a macrolide (erythro or azithro) Add Vancomycin if VERY sick or necrotizing Others (TB, Gram-negative, PCP, fungal) only if a good reason to suspect
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Endocarditis Acute Staph (MRSA) Subacute viridans Strept Antibiotics: Vanco + gentamicin Penicillin + gentamicin X 2 w, 4-6 w Surgery (?)
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Pericarditis “Purulent pericarditis” Strept Pneumo Staph aureus (MRSA) Antibiotics: Ceftriaxone + Vancomycin X 4 weeks Surgery (?)
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Acute Abdomen Diagnosis: Clinical Imaging (XR, US, CT) Treatment Surgery Antibiotics Mild-moderateSevere Ampi/sulb, Ticar/clavPiperac/Tazobactam Imipenem, Meropenem, Ertapenem Cefazolin or cefuroxime + metronidazole Cefotax, ceftriax, ceftaz, cefepime + metronidazole Ampi + genta (Tobra) + Metronidazole (Clinda) Cipro, levoflox, gatiflox + Metronidazole Aztreonam + Metronidazole For 5-7 days IDSA. CID 2010;50:133-64 PO Cipro/Metro or Amox/Clav x 14-21 d
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Urinary Tract Infection 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 Gram stain (“unspun” urine) Etiology Escherichia coli Enterococcus
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Urinary Tract Infection Follow-up US, VCUG DMSA scan Consider prophylaxis Inpatient Treatment Cefotaxime or Ceftriaxone Ampicillin + gentamicin
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Osteomyelitis Staph aureus (Others in especial populations) Clindamycin Vancomycin Linezolid X 4 weeks (IV/PO) Surgery
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Septic arthritis Fever, joint pain/swelling, decreased ROM Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)
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Septic arthritis Treatment: Aspirate vs Surgery: hips, shoulders Antibiotics: Vancomycin (Clinda, Oxacillin) + cefotaxime (cefuroxime) x 3 weeks (IV/PO) Etiologies: Staph aureus Streptococcus (GAS, Strept pneumo) Kingella kingae Salmonella Neisseria (GC, N. meningitidis) (H. influenzae)
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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)
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Skin and Soft Tissue Etiology: Group A Streptococcus Staphylococcus aureus (MRSA) (Strep pneumo / Hib) Treatment: Vancomycin or Clindamycin add rifampin? linezolid?? Drain any abscess
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Any Question?
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