INFECTIONS IN KIDS Community Acquired PNA Pharyngitis TO TREAT OR - PDF document

3/20/2019 Three Common Presentations FEVER DIFFICULTY BREATHING  Fever without a source (SBI)  Pertussis  Urinary Tract Infections INFECTIONS IN KIDS  Community Acquired PNA  Pharyngitis TO TREAT OR NOT TO TREAT? RASH  Infections and Mimickers Andi Marmor, MD, MSED Professor of Pediatrics University of California, San Francisco Zuckerberg San Francisco General Hospital The most likely cause of Xanadu’s Case Presentation: Infant with Fever fever is:  Xanadu is 2 week old girl with a fever Viral infection A.  No symptoms to suggest a source on Urinary tract infection B. exam/history Serious bacterial infection (SBI) C.  VS: T 38.5, P 150, R 40’s, o/w WNL (bacteremia/meningitis)  Exam: well-appearing, no focal findings HSV infection D. to suggest source for fever 1

3/20/2019 Everything you need to know about SBI in febrile infants - on ONE SLIDE 2-3% E.Coli>GBS>S. aureus >enterococcus, S pneumo 13-18% E. Coli THE FEBRILE INFANT <1% E.Coli/GBS  S. pneumo Greenhow, 2014 Schwartz, 2009, Gomez 2010, Greenhow, 2014 Fever without a source (FWS): Fever without a source (FWS): Infants <30 days Infants <30 days  Empiric antibiotics: amp/gent or  Appearance and standard lab criteria do not reliably rule out UTI/SBI in this age group amp/cefotax  Kupperman, 2019: validated prediction rule using  GBS, E. Coli > Staph, enteric GNR’s >> UA, ANC and PCT (n=913) enterococcus, S. pneumo  Neg UA, ANC< 4090/µL, PCT < 1.71ng/mL  Cefotaxime: covers staph, better CSF  2 pts missed by rule, both UTI > 30d (sens 97.7, NPV 99.6) penetration, but broader  Ampicillin: previously included to cover  Option 1: for Listeria- now very rare  Urine, blood, CSF -> admit, empiric abx  Cefotaxime alone being considered in some  Option 2: settings  Urine, blood ->If UA neg, ANC <4090 and PCT < 1.71,  DO NOT treat with gentamicin alone admit without abx or LP 2

3/20/2019 Approach to Infant with FWS FWS: Infants 30-90 days no Stabilize, obtain cultures, Infant well-appearing? start antibiotics  UTI still the most common bacterial source, Start IV treatment yes for pyelo UA+ Obtain urine for UA other SBI less likely no and culture and Infant >30 days? yes Observe off abx UA- blood for culture, ANC and PCT, admit ANC<4090 and  Viral source more reliable PCT<0.71? LP and start yes no empiric abx no  Named viral syndromes or + rapid viral test UA+ Start treatment for UTI/pyelo Infant > 90 days? Obtain urine for UA - Consider obtaining blood and culture (flu, RSV)  SBI unlikely culture if < 2 mo yes UA- RVT+  Consider testing for UTI Obtain rapid viral Supportive care and Close follow up follow up test if available  Inflammatory markers (CBC/CRP/PCT) RVT- WBC > 15 or < 5 CRP > 20mg/L Obtain blood for culture helpful in select infants PCT > 0.5ng/mL and inflammatory markers Ceftriaxone Markers WNL  Well appearing, neg UA AND no viral source Follow cultures for 48h Close follow up Case Continued  Since Xanadu is less than 30 days, and has no source for her fever, you obtain a UA/urine cx and blood cultures and URINARY TRACT INFECTIONS perform an LP (“PYELONEPHRITIS”)  Her UA is positive for LE and nitrites  Now what do you do? 3

3/20/2019 Risk of UTI in Infants with FWS Which infants <3 mo should we test for UTI? 20 20 Girls Girls 18 18 Uncirc Uncirc 16 16 Boys Boys 14 14 Circ Circ ALL infants < 3 mo, T>38 12 12 Boys Boys 10 10 8 8 Testing threshold ~2- 6 6 3% 4 4 2 2 0 0 0 1 m 3m 6m 12m 18m 0 1 m 3m 6m 12m 18m Which infants >3 mo* should we test for UTI? Who should we test for UTI? *T ≥ 39 for ≥ 48hrs 20 Girls  All infants with FWS < 3 mo of age 18  Girls > 3 mo of age Uncirc 16 Boys  FWS (>39) and < 24 months 14 Circ All Girls  Boys > 3 mo of age 12 Boys 10  Circumcised: FWS (>39) and < 6 mo Circ boys <6 mo 8  Uncircumcised: FWS (>39) and < 12 mo Uncirc boys <12 mo 6  Additional Risk Factors: 4  Length of fever (> 2 days) 2 Testing threshold ~5%  Race (non-black) 0 0 1 m 3m 6m 12m 18m 4

3/20/2019 Diagnostic Dilemmas Treatment  Collection of urine  Empiric treatment based on local E. Coli resistance  By c atheter for:  PO cephalexin safe, tasty, narrow spectrum  Infants < 3 mo of age (high risk)  IV if <2 mo, toxic or not tolerating PO  Ill-appearing/getting antibiotics  Consider bag collection for:  Total course: 7-14 days (for pyelo)  Low-risk infant (circ boy> 3 mo, girl/boy>1 year)  Imaging after UTI  If UA +, consider cath for culture  Results:  U/S in infants <3 mo, older kids if recurrent  + UA: start empiric treatment, send for cx  Voiding Cystourethrogram (VCUG) only if high  Neg UA: UTI very unlikely, even in young infants grade VUR/obstruction on U/S  Consider sending for culture in high risk neonate Roberts 2011; Pediatrics 128(3):595–610 What is Zaffre’s “modified Centor Case Continued score?”  Xanadu’s 6 yo brother Zaffre also has a 1 A. fever, and is complaining of a sore throat 2 B.  His temp is 38.9, he has tender cervical 3 C. LAN and no cough or runny nose 4 D. 5 E. www.accesspediatrics.com 5

3/20/2019 Modified Centor Score Modified Centor Score  1 point each:  1 point each:  Exudate or swelling on tonsils  Exudate or swelling on tonsils??  Tender/swollen ant cervical LN’s  Tender/swollen ant cervical LN’s  Temp > 38C  Temp > 38C  Cough absent  Cough absent  Age 3-14  Age 3-14 ____________ ____________ Max score = 5 Score = 4-5 What does this mean? Case Presentation: 3 yo with cough  What is Zaffre’s prior probability of a +  Amaranth is a 3 yo who presents with 2 GAS culture? weeks of cough, keeps her awake, and occasional post-tussive vomiting ~25% A.  She has a PMH of bronchiolitis (6 mo) and ~50% B. is up to date for age on vaccinations ~75% C.  VS: T 38.2, P 130, RR 42, O2 sat 95% ~90% D.  Her mother wants to know if this could be “the whooping cough” 6

3/20/2019 Pertussis Epidemiology Tdap Acellular pertussis PERTUSSIS Phases of Pertussis Pertussis: Clinical Diagnosis  Cough lasting >2 weeks + 1of the following: PHASE TIME COURSE DESCRIPTION  Apnea* Neonates/young Infants Catarrhal 1-2 weeks Mild fever, cough, rhinorrhea  Paroxysms of coughing Paroxysmal 1-6 weeks Older infants/children: Older children  Inspiratory “whoop” Paroxysms, whoop, post-tussive emesis  Post-tussive vomiting ( least specific ) Young infants: apnea, cyanosis, bradycardia, poor feeding *May occur without cough Convalescent Weeks-Months Improvement in severity and frequency of coughing episodes Slide courtesy of Ellen Laves, MD cdc.gov/pertussis 7

3/20/2019 Pertussis: Treatment Pertussis: Laboratory Confirmation  Major benefits:  Lab confirmation ONLY in those with  Prevent severe disease* in those at risk signs/symptoms consistent with pertussis  Prevent spread to high risk (HR) patient  Posterior NP specimen (not pharynx/ant NP)  Empiric treatment: high suspicion and/or HR  PCR for pertussis  Infants <1 year (< 3mo, preemie at highest risk)  False positives may occur  Pregnant women near term  Unimmunized or underimmunized  Culture + for B. Pertussis  Test and treat if +:  Most SPECIFIC test  HR but low clinical suspicion  Most sensitive in first 3 weeks  Patient LR but has HR contacts cdc.gov/pertussis *Only treatment BEFORE paroxyms may shorten course What is the RECOMMENDED next Case Continued step?  Amaranth’s vaccination status and non- Obtain a PA and lateral CXR A. specific clinical symptoms make pertussis Obtain a blood culture and CBC B. less likely Obtain a sputum culture C.  However, her RR (42) and O2 sat (95%) Start PO amoxicillin and discharge with make you concerned for pneumonia D. close follow up  Well-appearing, in minimal resp distress aside from tachypnea Start IV cefuroxime and admit E.  Decreased breath sounds with crackles over the LLL 8

3/20/2019 Pediatric CAP: Diagnosis Bradley JS, et al. Clin Infect Dis. 2011  Clinical  Symptoms of acute illness (ie: fever) + resp distress (tachypnea*, retractions, hypoxia) AND PEDIATRIC COMMUNITY  Focal lung findings on exam OR on CXR  Imaging ACQUIRED PNEUMONIA  Chest x-ray NOT recommended routinely in outpatients  Does not distinguish between pathogens (viral, atypical, etc) *MOST SENSITIVE sign Pediatric CAP: Causes Pediatric CAP: Labs Bradley JS, et al. Clin Infect Dis. 2011 Bradley JS, et al. Clin Infect Dis. 2011  Based on age, severity, local resistance  Routine lab testing NOT recommended  Blood cultures: 2 MO TO 5 YRS: OVER 5 YEARS:  Clinically worsening or hosp with mod/severe disease  Viral testing (flu, RSV)  Viral is most common  M. pneumoniae , C.  IF no evidence of bacterial co-infection pneumoniae > S.  < 2 yrs: S. pneumoniae , C.  CBC/CRP pneumoniae Trachomatis  Not recommended  2-5 yrs S. pneumoniae, M.  Testing for Mycoplasma pneumoniae, S. pneumo pneumoniae , H influenzae,  If available, may guide antibiotic selection C. pneumoniae 9