Overview Prevention and Screening Vaccine- Preventable Illnesses - - PowerPoint PPT Presentation

3/18/2015 1

Overview of Infectious Diseases in Children

Eliza Hayes Bakken, MD Assistant Clinical Professor of Pediatrics University of California, San Francisco Primary Care Coordinator Children’s Health Center San Francisco General Hospital

I have nothing to disclose.

Overview

• Prevention and Screening
• Vaccine- Preventable Illnesses
• Important Guidelines and Updates
• Visual Diagnosis

Vaccines

“An ounce of prevention is worth a pound of cure.”- Benjamin Franklin

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Standard Schedule Primary Series Boosters Live Attenuated Vaccines

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Hepatitis B Influenza Teen Vaccines

• TdaP at 11yo

(required for 7th grade entrance in CA)

• HPV is 3 doses

(min 6 months between 1st and 3rd)

• MCV4 given at

11yo and 16yo

Hot off the Presses…

• HPV-9

– New 9-valent HPV vaccine newly approved – Adds 4 strains implicated in 20% of cervical cancers – Same protection against previous strains

• Serotype B Meningococcus

– 2 serotype B vaccines are now approved – This type implicated in recent college outbreaks – No current universal vaccination recommendation, but can be used in outbreaks

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Vaccine Contraindications

• Serious reaction to any previous dose

– Anaphylaxis, encephalopathy w/in 7 days (DTaP)

• Life threatening allergy to a component (e.g.

anaphylaxis)

– Neomycin: IPV, MMR, VZV – Gelatin: MMR, VZV – Egg: Influenza (both IIV and LAIV) – Yeast: Hep B, HPV

• Specific to Live Vaccines (RV5, MMR, VZV, LAIV)

– Severe immunodeficiency: SCID, HIV with AIDS – Pregnancy – LAIV only (based on ACIP recommendations): chronic medical conditions including asthma, CKD, heart disease

cdc.gov/vaccines/recs/vac-admin/contraindicatons

Invalid Contraindications

• Mild illness
• Antimicrobial therapy
• Pregnant or immunosuppressed

household contact

• Preterm birth
• Erythema/induration with past vaccine
• Non-life threatening allergy to ingredient

Vaccination Precautions

• Weigh risk, benefits, alternatives with family
• Include:

– Moderate/severe illness without fever – History of Guillain-Barre within 6 weeks of previous vaccine (flu) – Progressive Arthus-type reaction after previous dose of tetanus or diptheria containing vaccine – Unstable neurological condition (pertussis) – Recent receipt of blood product (MMR, VZV) – History of thrombocytopenia (MMR) – DTaP: fever >105 or hypotonic hyporesponsive episode or crying >3 hrs within 48 hours of previous dose

Screening

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Tuberculosis Screening

• Universal Screening NOT recommended

– Screen those with a positive close contact, HIV disease, immigration from or travel to an endemic country, a stay in jail/homeless shelter, or symptoms of disease – PPD recommended for first line screening

• If BCG vaccinated, can use Interferon-gamma release assay (

e.g. Quantiferon)

• OR for confirmation if PPD positive
• Threshold for positive PPD

– 5 mm if HIV +, abnormal CXR, contact w/ case – 10 mm if <4yo, birth/resident of high risk location, medical conditions (diabetes, renal failure), IV drug users, child contact with adult with these risk factors – 15 mm all others

Latent TB Treatment

• Individual more likely to progress to active disease:

– Recent converters – Young children – HIV infected – IV Drug Users – Those on certain immunosuppressants

• Regimen options:

– INH 10-15mg/kg/day x 9 months – Rifampin 10-20mg/kg/day x 6 months – INH + rifapentine x 3 months (dosing being studied)

• Screening labs (i.e. LFTs) are not needed in normal

healthy children taking INH unless symptomatic

Vaccine Preventable Diseases Pertussis: Microbiology

• damaged
• Gram negative

coccobacillus

• Toxin mediated disease

effecting cilia

– Interferes with clearance

• f pulmonary secretions
• Cough of 100 days that

can continue for weeks after the organism is gone

Slide courtesy of Ellen Laves, MD

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Pertussis in the US Pertussis in Children Phases of Pertussis

PHASE TIME COURSE DESCRIPTION

Catarrhal

1-2 weeks Mild fever, cough, rhinorrhea

Paroxysmal

1-6 weeks Older infants/children: Paroxysms of cough, post-tussive emesis, Young infants: apnea, cyanosis, bradycardia, poor feeding

Convalescent

Weeks-Months Improvement in severity and frequency

• f coughing episodes

Slide courtesy of Ellen Laves, MD

Pertussis Case Definition

• Clinical:

In the absence of a more likely diagnosis a cough illness lasting at least 2 weeks with one of the following: – Paroxysms of coughing – Inspiratory “whoop” – Post-tussive vomiting – Apnea (with or without cyanosis)

• Infants less than 1 year old
• Laboratory Confirmation:

– Isolation of B. Pertussis from clinical specimen – Positive PCR for pertussis

cdc.gov/pertussis

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Pertussis Treatment

• Important to consider whether patient is high risk

(HR) for complications

– CDC definition: Infants under 1 year old – Also consider: < 3mo highest risk of hospitalization, pregnant women near term, prematurity, unimmunized or underimmunized

• Consider treating before testing is resulted in

patients who are high risk

• Treat HR patients within 6 weeks of cough onset

and others within 3 weeks

• Have a lower threshold for testing in patients with

HR contacts

Pertussis Treatment:

• Azithromycin: most commonly used

– If < 6 months: 10mg/kg daily x 5 days – If ≥ 6 months: 10mg/kg/day on day 1, then 5mg/kg daily x 4 days

• Erythromycin

– risk of hypertrophic pyloric stenosis outweighs use if <1 month old

• Clarithromycin
• TMP/SMX

– If >2 months old

Measles Microbiology

• Single- stranded,

enveloped RNA virus with 1 serotype

• Humans are the only

host

• Transmission is from

direct contact with droplets or airborne for up to 2 hours

• 9/10 people who are

exposed and susceptible will contract the disease

Photo credit: http://www.nature.com/news/2008/0806 20/full/news.2008.907.html

Measles in the US

www.cdc.gov/vaccines/pubs/pinkbook.meas.html

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Measles in the US

http://www.cdc.gov/measles/cases-outbreaks.html

Phases of Measles

PHASE TIME COURSE DESCRIPTION

Prodromal

2-3 days High fever (>103), cough, runny nose (coryza), conjunctivitis (fever + 3 C’s)

Exanthem

3-5 days Erythematous maculess that proceed cranial -> caudal. May become confluent. Koplik spots may also be seen.

Recovery

After a few days Fever subsides and rash fade

Measles Diagnosis

• Clinical case definition:

– Generalized rash lasting > 3 days – Temperature > 101 – Cough, coryza, and conjunctivitis

• Laboratory definition:

– Isolation of the virus (respiratory or urine) – Positive RT-PCR (throat swab) – Positive serologic test for specific IgM – Rise in specific IgG titers

Measles Complications

• 1 in 1000 cases will develop acute

encephalitis

• 1-2 in a 1000 children will die from respiratory
• r neurologic complications
• Subacute sclerosing panencephalitis (SSPE)

is a rare, fatal degenerative disease that

• ccurs 7-10 years after infection
• Those at highest risk: <5yo and >20yo,

pregnant women, immunocompromised

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Current Recommendations and Updates

Current Recommendations and Updates

• Serious Bacterial Infections
• Urinary Tract Infections
• Community Acquired Pneumonia
• Bronchiolitis
• Acute Otitis Media
• Influenza

Serious Bacterial Infections Infants <30 days

• Multiple studies show clinically significant

rates of serious bacterial infections (SBI) even in neonates with viral illnesses

– Recommended to obtain full set of cultures

• Some studies support a staged approach to

decision about LP

– Infants should be admitted and placed on emipiric antibiotics

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Work-up for Febrile Infants 30-90 days

• Is the infant well-appearing?

– Toxic infants -> full work-up and empiric antibiotics

• Is there a source?

– Non-specific symptoms do NOT rule out SBI – Named viral syndromes or focal bacterial infections generally do

• Stepwise Approach

– UTI is most common all require urine testing – Rapid viral testing should be done – If viral testing + UA are NEGATIVE then a staged approach can be used:

• Inflammatory markers (CBC/CRP/Procalcitonin)
• If abnormal then proceed with blood cx and empiric antibiotics
• Consider LP if toxic/irritable or giving antibiotics

Summary Courtesy of Marmor 2014

Evaluation and Management of Fever in Infants and Young Children” Hamilton, Jennifer and John, S. Am Fam Physician. 2013 Feb 15; 87(4):254-206.

Urinary Tract Infections

Current Guidelines: Urinary Tract Infections

• Who should have a specimen collected?
• Children 2- 24 months with fever without a source

requiring antibiotics

– Should have urine obtained by catheterization (cath)

• r suprapubic aspiration (SPA)
• Children 2- 24 months with fever without a source

NOT requiring antibiotics

– If low risk then no further assessment needed – If high risk then can follow 2 pathways

• Obtain urine for UA/Cx by Cath or SPA
• Obtain urine for UA/Udip ONLY by any method (includes

bag) THEN do a cath or SPA if nitrite or LE positive

Roberts 2011;Pediatrics128(3):595–610

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Current Guidelines: Urinary Tract Infections

• Risk Factors:

– Absence of another source of infection PLUS – Female: white, <12 mo, temp > 39, fever > 2d, – Males: nonblack, temp > 39, fever > 24 hrs

• Probability of a UTI in females:

– </= 2% if no more than 2 risk factors present

• Probability of a UTI in males:

– Uncircumcised: > 2% even with no risk factors – Circumcised </= 2% if no more than 3 are present

• Highest risk

– Uncircumcised males – Females with >2 risk factors – Circumcised males with > 3 risk factors

Roberts 2011;Pediatrics128(3):595–610

Current Guidelines: Urinary Tract Infections

• Diagnosis requires BOTH:

– Positive UA: leukocyte esterase (LE), pyuria, bacteriuria – Positive culture for a uropathogen

• Defined as > 50 colony- forming units
• Must be a catheterized or SPA specimen
• Pearls

– Nitrites are specific but NOT sensitive – Leukocyte esterase is sensitive but NOT specific

Roberts 2011;Pediatrics128(3):595–610

Current Guidelines: Urinary Tract Infections

• Empiric treatment

– PO and parenteral routes are equally efficacious

• Choose parenteral if toxic or not tolerating PO

– Base initial therapy on local resistance patterns – Total course should be 7-14 days

• Screening for anomalies

– Renal-Bladder Ultrasound (RBUS) recommended

• ~15% abnormal,
• 1-2% actionable, 2-3% false positives

– Voiding Cystourethrogram (VCUG) if there are:

• Abnormal RBUS results
• Further episodes of febrile UTI

Roberts 2011;Pediatrics128(3):595–610

Community Acquired Pneumonia

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Community Acquired Pneumonia Pathogens

• 2 to 24 months

– Viral is most common

• RSV, Human metapneumovirus, Parainfluenza, Influenza

A&B

– Bacterial: S. pneumoniae, C. Trachmatis

• 2 to 5 years old:

– Viral is most common (same as in younger) – Bacterial

• S. pneumoniae, M. pneumoniae, H. influenza, C.

pneumoniae

• Over 5 years old:

– Bacterial is most common

• M. pneumoniae, C. pneumoniae, S. pneumoniae

Stuckey-Schrock, K. et al, 2012

Current Guidelines: Community Acquired Pneumonia

• Clinical Diagnosis

– Cincinatti Guideline: Fever PLUS signs or symptoms of an infection and respiratory distress – WHO Criteria: Tachypnea PLUS cough or difficulty breathing – Absence of tachypnea is helpful in excluding the diagnosis

• Laboratory Diagnosis

– Blood cultures and CBC are not required for outpatient management – Viral testing is recommended – Testing for Mycoplasma pneumoniae should be used when suspected to guide antibiotic selection

• Imaging

– Chest x-ray not necessary in outpatient setting – Should be done with 2 views if hypoxic or in distress

Bradley JS, et al. Clin Infect Dis. 2011

Current Guidelines: Community Acquired Pneumonia

• Indications for Hospitalization

– Respiratory distress, hypoxia (< 90%), infants < 6 months – For increased monitoring or parenteral treatment

• Antimicrobials

– Tamiflu if influenza is circulating, don’t wait for test results – Not routinely recommended in preschoolers – Outpatient 1st line treatment:

• Amoxicillin in infants and young children
• Macrolides in school age children/teens

– Inpatient 1st line treatment:

• 3rd generation cephalosporin if not fully vaccinated
• Vancomycin if high levels of resistance, suspicion for MRSA
• Macrolides if suspicion high for M. pneumoniae and C.

pneumoniae

Bradley JS, et al. Clin Infect Dis. 2011

Bronchiolitis

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Bronchiolitis

• Caused by many viruses

– In one study: 76% RSV, 39% rhinovirus, 10% influenza, 3% Human metapneumovirus, 2% coronavirus (Miller 2013) – Viruses lead to inflammation, edema, and epithelial cell necrosis in the small airways

• Burden of disease

– Most common reason for admission in children

Current Guidelines: Bronchiolitis

• Clinical Diagnosis

– In children1-23 months old syndrome characterized by upper respiratory prodrome followed by increased respiratory effort and wheezing – Other signs: rhinorrhea, cough, rales, increased work of breathing (grunting/flaring/retractions)

• Assess severity

– Ensure upper airway clearance prior to exam – Count respiratory rate over a full minute – Radiographs and lab studies should not be done routinely after clinical diagnosis is made

Ralston, SL et al Pediatrics. 2014

Current Guidelines: Bronchiolitis

• Treatment

– Albuterol trial no longer recommended – Corticosteroids not recommended – Epinephrine are not recommended – Hypertonic saline is only recommended inpatient

• Changes in monitoring

– Supplemental O2 not be held for pulse ox > 90% – Continuous pulse ox is not required

Ralston, SL et al Pediatrics. 2014

Current Guidelines: Bronchiolitis

• Comorbid bacterial infections

– Unnecessary to treat febrile infants > 30 days with antibiotics for rule-out sepsis if they have clinical bronchiolitis – If AOM is diagnosed it should be treated per current guidelines

• Changes to Prophylaxis with Synagis

– Preterm infants now only recommended if gestational age at birth was <29w0d – If qualified, 5 doses are recommended for all patients

Ralston, SL et al Pediatrics. 2014

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Acute Otitis Media

Current Guidelines: Acute Otitis Media

• Sets a new “gold standard” for diagnosis

– Moderate to severe bulging or new otorrhea – Mild bulging with recent onset ear pain and intense erythema of the Tympanic Membrane (TM)

• Older (2004) guidelines allow for “uncertain

diagnosis” which may lead to excessive antibiotic use

• Severe symptoms include:

– Temperature >39 – Moderate-sever otalgia – Otalgia > 48 hours

Lieberthal; Pediatrics 2012

AOM: Exam Findings

Current Guidelines: Acute Otitis Media

Age Non-severe Severe

6- 23 months Bilateral: treat x 10days Unilateral: treat or

• bservation

Treat x 10 day 24 months- 12 years Treat or

• bservation

Treat

Lieberthal; Pediatrics 2012

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Current Guidelines: Acute Otitis Media

• First Line Treatments

– Amoxicillin: 80-90mg/kg/day

• If no Amoxicillin in previous 30days, no conjunctivitis

– Amoxicillin-Clavulanate (90mg/kg/day amoxicillin and 6.4 mg/kg/day clavulanate) – Cephlosporin options: cefdinir, cefuroxime, cefpodoxime

• May have slightly lower efficacy against S. pneumoniae
• Treatment failures: persistent severe symptoms for

> 48-72 hours

– Amoxicillin-Clavulanate or Ceftriaxone – Then consult a specialist

Lieberthal; Pediatrics 2012

Current Guidelines: Acute Otitis Media

• Treatment duration

– 6- 23 months: 10 days – 2-5 years: 7 days – > 6 years: 5-7 days

• Recurrent infections, refer for typanostomy

tubes if:

– > 3 infections in 6 months – > 4 episodes in 1 year ( with 1 in last 6 months)

Lieberthal; Pediatrics 2012

Influenza

Percentage of Visits for Influenza- like Illness in the US

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Number of Influenza- Associated Pediatric Deaths Laboratory- Confirmed Influenza Hospitalizations by Age

as of Feb 14, 2015

Flu: Fast Facts

• Most important = immunize!

– Esp. important for those at highest risk: children < 5 (highest risk is < 2), those with comorbid conditions – Immunize household contacts of infants < 6mo

• Treat with antivirals when suspicion is high

– Indications: hospitalization, severe/complicated/progressive course, high risk, decrease time to resolution – Treatment within 48 hrs reduces length of illness and complications; can be started later if severe – Treatment should not be delayed for testing

• Regimens

– Oseltamivir (Tamiflu) weight based dosing BID x 5 days – Zanamivir (Relenza) disk inhaler for children > 7 yo

Visual Diagnosis

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Name that rash…

Hand- foot-mouth disease

Name that rash…

Roseola infantum. Thought to be caused by Herpes virus 6

• r 7

Name that rash…

Scabies in an infant.

Name that rash…

Hot tub associated folliculitis. Classically caused by Pseudomonas.

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Name that rash…

Erythema migrans in the early localized stage of Lyme Disease

Name that rash…

Group A Streptococcal Scarlatina

References

Bradley, J. et al “The Management of Community- Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Disease Society of America.” Clin Inf Dis. 2011 Aug 30. Community acquired pneumonia guideline team, Cincinnati Children's Hospital Medical Center. Evidence-based care guidelines for medical management of community acquired pneumonia in children 60 days to 17 years of age. Guideline 14. Hamilton, J and Sony John “Evaluation of Fever in Infants and Young Children.” 2013 Feb 15;87(4):254-260 Lieberthal, A et al “The Diagnosis and Management of Acute Otitis Media.” Pediatrics 2012-3488 Marmor, A. “Recommendations for Management of Well- Appearing Infant with Fever Without a Source (FWS) in the Post- Pneumococcal Vaccine Era.” UCSF Pediatrics Clinical Guideline. June, 2014. Miller, EK et al. “Viral Etiologies of Infant Bronchiolitis, Croup and Upper Respiratory Ilness during 4 Consecutive Years.” Pediatric Infectious Disease 2013; 32 (9) 950-955. Ralston, S. et al, “Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis.” Pediatrics 2014-2742. Roberts KB; “Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and

• Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in

febrile infants and children 2 to 24 months.” Pediatrics. 2011;128(3):595–610 Stuckey- Schrock, K. “Community Acquired Pneumonia in Children.” Am Fam Physician. 2012 Oct 1;86(7):661-667.