Common Pediatric Infections Kathryn M. Edwards MD Professor of Pediatrics Vanderbilt University Case 1 • Johnny, a two year old boy, had URI and cough for two days. • He awakened suddenly in the middle of the night with fever to 103oF, cough, and irritability. • He was given an antipyretic and taken to see YOU, his physician the next morning. • His vital signs revealed a temperature of 103oF, pulse rate of 120 and a respiratory rate of 60 with nasal flaring. Diagnostic Evaluation • Chest X-rays (posteroanterior and lateral views are standard, if there is consolidation or evidence of effusion obtain decubitus view) • Sputum is rarely produced by children • Blood Culture • Complete Blood Count • Tuberculin Skin Test • If afebrile and < 20 weeks of age consider Chlamydia culture or antigen testing Chest Film Facts about Pneumonia • Pneumonia diagnosed in nearly 2% of infants < 1 year and in 4% of children aged 1 to 5 years. • Responsible agent determined in < 10% • Estimated that 90% of pediatric pneumonias are caused by viral agents. • Approximately 50% of the documented viral pneumonias in children are caused by respiratory syncytial virus; 25% by parainfluenza virus types 1 and 3 • A smaller number from influenza and adenovirus • Bacterial and atypical agents also seen Considerations for Inpatient Management of Pneumonia Toxic appearance Respiratory distress Pleural effusion Age considerations: <3 months <3 years with lobar pneumonia <5 years with lobar pneumonia (more than 1 lobe) Existing chronic disease Pulmonary (including asthma) Metabolic disorders Cardiac Anemia (including sickle cell disease) Renal Malignancies Diabetes Mellitus Immunocompromised host Progression during outpatient therapy Bacterial And Fungal Causes of Pneumonia Related to Age of the Pediatric Patient Age Group Common Pathogens 0-48 hrs Group B. Streptococci 1-14 days Escherichia coli, Klebsiella pneumoniae, other Enterobacteriaceae, Listeria monocytogenes, Staphylococcus aureus, anaerobic bacteria, group B streptococci 2 wks to 2 mos (premature neonates) Enterobacteriaceae, Group B streptococci, Staphylococcus aureus, Staphylococcus epidermidis, Candida Albicans, Haemophilus influenzae, Streptococcus pneumoniae 2 mos to 5 yrs Haemophilus influenzae, Streptococcus pneumoniae 5-10 yrs Streptococcus pneumoniae 10-21 years Mycoplasma pneumoniae, Chlamydia pneumoniae (TWAR agent), Streptococcus pneumoniae Bacterial Pneumonia Agent Dosage Outpatient Pneumonia Oral amoxicillin 80-90 mg/kg/day ÷ BID Oral amoxicillinclavulanate 80-90 mg/kg/day of amoxicillin ÷ BID Oral cefuroxime axetil 30 mg/kg/day ÷ BID Oral cefdinir 14mg/kg BID Inpatient Pneumonia (Initial empiric therapy) Intravenous ceftriaxone 100 mg/kg/day ÷ q12h Pneumococcal susceptible Penicillin MIC < 2 mcg/ml Intravenous penicillin Pneumococcal nonsusceptible to penicillin, susceptible to cephalosporin Pneumococcal nonsusceptible to penicillin, nonsusceptible to cephalosporin 250,000-400,000 U/kg/day ÷ q4-6h Intravenous ceftriaxone or Intravenous cefotaxime 100 mg/kg/day ÷ q12h Intravenous vancomycin 40-60 mg/kg/day ÷ q6h 225-300 mg/kg/day Case 2 • Bill, a six month old male, had the acute onset of fever to 102o and irritability. • He was seen in your office and examination of the tympanic membranes revealed the physical findings noted. Symptoms of Otitis Media • • • • • • • Unusual Irritability Difficulty Sleeping Tugging Or Pulling At One Or Both Ears Fever Fluid Draining From The Ear Loss Of Balance Unresponsiveness To Quiet Sounds Or Other Signs Of Hearing Difficulty Facts about Otitis Media • Seventy-five percent of children experience at least one episode of otitis media by their third birthday. • Almost half of these children will have three or more ear infections during their first 3 years. • It is estimated that medical costs and lost wages due to otitis media account for $5 billion a year in the United States Risk Factors for Otitis Media • • • • • Children cared for in group settings Children who live with adults who smoke Infants who nurse from a bottle while lying down Children who are not breast-fed Cold and allergy medications such as antihistamines and decongestants are not helpful in preventing otitis • Vaccines against the bacteria that most often cause otitis media are the best hope Office Visits with Principal Diagnosis of Otitis Media in the US Office visits per 100 children 120 1975 100 1980 1985 80 60 40 20 0 <2 2-5 Age in years 6 - 10 1990 Age-Specific Incidence of Otitis Media 60 % Incidence 50 Any AOM 1st AOM 40 30 20 10 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 Age (years) Teele, et al J Infect Dis 1989 Bacteriology of Acute Otitis Media 2,087 ears: Children’s Hospital of Pittsburgh, 1980-89 No growth 16% Strep. pyogenes 3% Staph. aureus 1% Other Others 8% 12% Strep. pneumoniae 35% M. catarrhalis 14% H. influenzae 23% AOM Rates During Respiratory Virus Infection 33% RSV Adenovirus 28% Influenza A & B 28% Parainfluenza 16% Enteroviruses 16% 10% Rhinovirus 7% No Virus 0% 10% 20% Henderson, et al. NEJM, 1982 30% 40% Guidelines for Treatment • • • • • • Schedule an appointment within 24 hours A clinical examination is necessary Educate parents on measures to prevent otitis Prescribe amoxicillin when the diagnosis of otitis media is made. Prescribe second-line antibiotics when patient fails first-line drugs Recheck in 3 to 4 weeks or at next well visit Treatment • First-Line Medications – Amoxicillin (40 mg/kg/day) if low risk (> 2 years, no day care, and no antibiotics for the past three months). – 80 mg/kg/day if not low risk or for resistant AOM if the lower dose was used initially. • Therapeutic (10 day) course of antibiotics. • Consideration may be given to a shortened course of antibiotics (5 days) for children who are at low risk ( i.e., age > 2 years, no history of chronic or recurrent otitis media and intact tympanic membranes). Second Line Agents • Recommended second-line medications include – Amoxicillin/Clavulanate Potassium (Augmentin®) – Cefuroxime Axetil (Ceftin®) – Ceftriaxone Sodium (Rocephin®): Prescribe One Dose For New Onset Otitis Media And A Three-day Course For Resistant Otitis Media Or If Oral Treatment Cannot Be Given. – Cefprozil (Cefzil®) – Loracarbef (Lorabid®) – Cefdinir (Omnicef®) – Cefpodoxime proxetil (Vantin®) Case 3 • Susie, a two year old child, had the acute onset of dysuria and frequency. She was seen in your office. Epidemiology • Gold standard: growth of bacteria in urine • UTI present in 5% of febrile infants and 2% of febrile children < 5 years of age • Recurs in 50% of school-aged girls within 6-12 months • UTI more common in white children • Males have more UTI in first 3 months, but after that females have more than males Facts about UTI • Cystitis classically presents with urgency, frequency, dysuria, secondary enuresis, and foul-smelling urine. • Pyelonephritis presents with spiking fever, flank or abdominal pain, and irritability. • Chronic pyelonephritis presents with recurrent abdominal pain, recurrent fever, and failure to thrive. • A higher index of suspicion is necessary to diagnose UTI in the infant in whom sepsis, lethargy, and jaundice may be the initial symptoms. Other Causes Of Urinary Tract Symptoms • • • • • • • • • Urethritis Meatal irritation Vulvovaginitis Medications Vaginal foreign body Pinworms Candida Trichomonas Trauma (including masturbation and sexual abuse) Diagnostic Studies • Routine Urinalysis White blood cell count 10/high-power field Leukocyte esterase (Correlates with pyuria) Nitrites (bacteria slowly reduce nitrate to nitrite) Bacteria (Presence in unspun urine correlates with 105 bacteria/ml) – White blood cell casts (Indicative of pyelonephritis) – – – – • Serum C-Reactive Protein – Elevated with pyelonephritis Criteria for Culture Diagnosis Specimen Suprapubic aspiration Positive Result >100 Catheterized urine >50,000 Clean-voided (male) >100,000 Clean-voided (female) >100,000 Bagged urine *** *** Only acceptable if culture is negative Not Acceptable Treatment of UTI • Choice based on most likely organism • Clinical trial by Hoberman compared IV cefotaxime (200 kg/kg/day X 3 days, followed by oral cefoxime) with oral cefoxime (16 mg/kg once, followed by 8 mg/kg/day for 14 days) in children with febrile UTI • Comparable outcomes seen • AAP recommends parenteral antibiotics in toxic children or those who cannot tolerate oral intake Hoberman et al. NEJM 2003;348:195-202 Recommendations for Radiographic Evaluation • AAP subcommittee recommends VCUG and ultrasound for all children < 2 years • However, Hoberman et al reported that ultrasound at the time of acute UTI is of little value and that VCUG only useful if prophylactic antibiotics will be given • Area of continued controversy Hoberman et al. NEJM 2003;348:195-202