Pediatric Infection in the Vaccinated Era: Should We Be Concerned? - - PowerPoint PPT Presentation

Pediatric Infection in the Vaccinated Era: Should We Be Concerned?

Dr Bashir Youssef

I do not have any relevant financial relationship with commercial interest to disclose.

DISCLOSURE

Learning Objectives

• Distinguish life threatening from simple pediatric infection
• Discuss the effect of vaccination on the prevalence of bacterial and viral

infection

• Evaluate and apply the available management guidelines.

• Infection/sepsis is one of the leading causes of morbidity/mortality among

children worldwide In USA:

• >42,000 cases of severe sepsis in children <18rs old annually
• 1/2 of children with severe sepsis are infants
• Hospital mortality in children with severe sepsis:10.3%

Pediatr Crit Care Med.2005 May;6(3 Suppl):S3-5

Background

4117 3853 411 146 69 17 17 8 500 1000 1500 2000 2500 3000 3500 4000 4500

Urinary tract infection Pneumonia Sepsis Bacteremia Meningitis Septic arthritis Osteomyelitis Septic shock

Number of Patients Category of Patients Jan 2018 – Nov 2018 PEC Al Saad Total Patient Visited (PEC Al Saad) Jan 2018 – Nov 2018 : 322569

How to Differentiate Between Simple and Serious Infection?

“Searching for a needle in haystack”

• Clinical assessment

ØDetailed history ØThorough clinical examination; ?focus on features consistent with diagnosis ØScreening system, (Yale observing scale score, traffic light system)

• Investigation:

ØCBC(WBCs, ANC…) ØCRP ØPCT ØUrine, CXR, others as indicated

Observation Scales to Identify Serious Illness in Febrile Children “YOS”

320 Febrile children, ED/ primary care; 37 SBI Score ≤10: 2.7% had serious illness Score ≥l6 : 92.3% had serious illness Specificity:88%; sensitivity:77% NB: not applicable to <60days

• ld infant. Pediatric July 2017

PEDIATRICS Vol. 70 No. 5 November 1982

Traffic light system for identifying risk of serious illness in under 5yrs: NICE

NICE, 2013

Management of Children 3 months to 5 years

Assess: look for life-threatening, traffic light and specific diseases symptoms and signs

• Perform test for urinary tract

infection.

• Assess for pneumonia.
• Do

not perform routine blood tests or chest X-ray. Perform (unless deemed unnecessary)

• urine test for urinary tract infection
• full blood count
• blood culture
• C-reactive protein.

Perform chest x-ray if fever higher than 39°C and white blood cell count greater than 20 x 109/litre. Consider lumbar puncture if child is younger than 1- year old. Perform:

• blood culture
• full blood count
• urine test for urinary tract infection
• C-reactive protein.

Consider the following, as guided by clinical assessment:

• lumbar puncture in children of all ages
• chest X-ray
• serum electrolytes
• blood gas.

Consider admission. If admission is not necessary but no diagnosis has been reached, provide a safety net for the parents/carers. If no diagnosis is reached, manage the child at home with appropriate care advice.

MICE, 2013

• 6260 pts
• Nearly all red features had rule-in

value for SI

• only 4 red features significantly raised

the probability of SI:

v ‘‘does not wake/stay awake’’, v ‘‘reduced skin turgor’’, v ‘‘non-blanching rash’’, and v ‘‘focal neurological signs’’.

• Combined 3 red features improved

prediction of SI. LH 5

The Predictive Value of the NICE "Red Traffic Lights" in Acutely Ill Children

Can inflammatory markers help to predict serious infection?

CRP in Febrile Children 1 to 36 Ms With Clinically Undetectable Serious Bacterial Infection

• To find how helpful CRP to predict the risk of SBI
• Prospective cohort study
• 77 children, T >39°C.
• WBCs, ANC, CRP, Urine analysis, BC, ……
• 14 (18%) had a SBI : 6 UTI; 4 pneumonia, 4 bacteremia…

Pulliam et al (2001) Pediatrics. 2001 Dec;108(6):1275-9

C-Reactive Protein in Febrile Children 1 to 36 Months of Age With Clinically Undetectable Serious Bacterial Infection

Variable Cutoff Point Sensitivity (95% CI) Specificity (95% CI) Likelihood Ratio (95% CI) PPV (95% CI) NPV (95% CI) WBC (thousand/mm3)

15.0 64 (35.8, 85.9) 67 (53.6, 77.7) 1.9 (1.1, 3.1) 30 (14.7, 49.4) 89 (76.9, 96.5)

ANC (thousand/mm3)

10.2 71 (42.2, 90.3) 76 (63.6, 85.6) 3.0 (1.7, 5.1) 40 (21.1, 61.3) 92 (81.5, 97.9)

CRP concentration (mg/dL)

7.0 79 (49.0, 94.2) 91 (79.8, 96.0)

8.3 (3.8, 27.3) 65 (38.3, 85.8) 95 (86.1, 99.0)

B E T T E R

Pulliam P N et al. Pediatrics 2001;108:1275-1279 Area under the curve for CRP 0.905; for ANC 0.805 and for WBC 0.761

CRP Concentration (mg/dL) Likelihood Ratio (95% CI) Posttest Probability of SBI >9 9.0 (3.2, 25) 67% 7–9 6.8 (1.4, 31) 60% 5–7 1.8 (0.42, 7.0) 29% <5 0.087 (0.02, 0.38) 1.9%

Pre test probability: 18%

I N C R E A S E

Bedside procalcitonin and C-reactive protein tests in children with fever without localizing signs of infection seen in a referral center

• Prospective study, 99 children, 7 days to 36 ms, with fever >38
• PCT, CRP, and IL-6 values compared with the total WBCs and clinical score
• SBI in 29 pts(29%):

Ø4 occult bacteremia, Ø21 pyelonephritis, Ø2 lobar pneumonia, Ø1 mastoiditis, Ø1 retropharyngeal abscess

Galetto-Lacour A et al. Pediatrics 2003;112:1054-1060

Sensitivity (% [95% CI]) Specificity (% [95% CI]) NPV (%) PPV (%)

PCT (0.5 ng/mL) 93 (77–99) 74 (62–84) 96 60 CRP (40 mg/L) 79 (60–92) 79 (67–88) 90 61 Leukocytes ≥15 G/L 52 (33–71) 74 (62–84) 78 45 Band ≥1.5 G/L 11 (2–28) 93 (84–98) 72 38 38 Leukocytes ≥15 G/L or band ≥1.5 G/L 55 (36–74) 72 (61–83) 80 46 IL-6 (100 pg/L) 36 (13–65) 80 (64–91) 77 38 YOS score >10 23 (5–54) 82 (67–92) 76 30

Sensitivity, Specificity, and Predictive Values of Markers of SBI

Galetto-Lacour A et al. Pediatrics 2003;112:1054-1060

B E T T E R

• Children with SBI more likely to have high inflammatory markers
• PCT and CRP performed better than IL-6, WBC, ANC in predicting SBI
• Using inflammatory markers improve clinicians' abilities in the early

recognition of clinically undetectable SBI.

• A single value gives a probability but never a certainty of presence or

absence of SBI

Learning Objectives

• Distinguish life threatening from simple pediatric infection
• Discuss the Impact of vaccination on the prevalence of bacterial and

viral infection

• Evaluate and Apply the available management guidelines

Bacteremia in Children 3 to 36 Months Old After Introduction of Conjugated Pneumococcal Vaccines PEDIATRICS Volume 139 , number 4 , April 2017

Rate of all bacteremia by organism per 100 000 children per year between 1998 and 2014.

Tara L. Greenhow et al. Pediatrics doi:10.1542/peds.2016-2098

Post PCV13

• Pneumococcal bacteremia in healthy children become rare
• E coli; salmonella ; staph aureus become more common.
• Bacteremia more likely to occur with a source.
• focused examination should be performed and appropriate studies should

be obtained

Impact of meningococcal C conjugate vaccine in the UK J. Med.

• Microbiol. — Vol. 51 (2002), 717–722

J Med Microbiol. 2002 Sep;51(9):717-22. Laboratory-confirmed cases 2001 1999

• - - -, age <20

Impact of Hib vaccination on Haemophilus Influenzae Disease in France

• Epidemiol. Infect. (2013), 141, 1787–1796

24

Pediatric Infection in the Vaccinated Era: Should We Be Concerned?

• Distinguish life threatening from simple pediatric infection
• Discuss the effect of vaccination on the prevalence of bacterial and viral

infection

• Evaluate and Apply the available guidelines

ØSeptic shock management ØBacterial meningitis ØUrinary tract infection ØPneumonia

Septic Shock Optimization Care

• Recognition Bundle
• Trigger tool
• Rapid clinical assessment
• Activation of sepsis resuscitation bundle
• Resuscitation/stabilization bundle
• Securing venous access
• Fluid resuscitation
• Blood culture
• Antibiotics
• Inotropic support
• Monitoring the response
• Performance Bundle

Critical Care Medicine, June 2017 • Volume 45 • Number 6

American Academy of Pediatrics trigger tool for early septic shock recognition, Crit Care Medicine 2017;45:1061.

American College of Critical Care Medicine algorithm for time-sensitive, goal- directed stepwise management of hemodynamic support in infants and children.

Critical Care Medicine, June 2017 • Volume 45 • Number 6

Crit Care Med. 2014;42(11):2409–17

Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis

OR 1.67 OR 2.43 OR 3.92 OR 3.52

130 pts, Initial management in ED/Inpatient before transfer to PICU PICU mortality 16 (12%) Increased risk of mortality with each hour delay but did not reach significance till 3hrs delay

3hrs delay is independent risk factor

Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome

• Whether early septic shock reversal and use of

resuscitation as (ACCM-PALS Guidelines) associated with improved outcome?

• A 9-year (Jan 1993–Dec 2001) retrospective study
• 91 patients: 26 died(29%)

96% 63% 92% 62% P<.001 P<.001

Conclusion: Early recognition and aggressive resuscitation of septic shock can save lives

PEDIATRICS Vol. 112 No. 4 October 2003

Management of bacterial meningitis in children and young people. Incorporates NICE Bacterial Meningitis and Meningococcal Septicemia Guideline CG102

Journal of Adolescent Health 59 (2016) S21-S28

Management of Bacterial Meningitis in Children and Young People. Incorporates NICE Bacterial Meningitis and Meningococcal Septicaemia Guideline CG102

Journal of Adolescent Health 59 (2016) S21-S28

Reduction in Case Fatality Rate from MD Associated with Improved Healthcare Delivery

1992:new PICU specializing in MD:

• Increased early use of parenteral penicillin by

GPs

• Improved resuscitation in local hospitals
• Development of mobile intensive care
• Centralization of care in specialist PICUs, and

improvements in the management of shock 331 consecutive children with MD admitted to the PICU at St Mary’s Hospital over 5 yrs Case fatality down to 2%

23% 2% Arch Dis Child 2001;85:386–390

Community Acquired Pneumonia

WHO, 2015

• CAP accounted for 15% of deaths in children under 5 years old
• 922 000 deaths in children of all ages
• Overall respiratory viruses (especially in infants); 30-67% (RSV in 30%)
• Streptococcus pneumoniae(most common bacterial); 30-40% of cases
• Mycoplasma pneumonia in children >5yrs, but not unusual in 1-4yrs old
• Consider bacterial pneumonia in children with
• Persistent or recurrent fever ≥38.5°C over the preceding 1-2days with
• Chest wall recession and tachypnea

Iram J Haq et al. BMJ 2017

Community acquired pneumonia (CAP)

Algorithm for assessment and management .

Iram J Haq et al. BMJ 2017 Investigation for complicated pneumonia CBC, U/Es, CRP, BC, ASO titre, serology for viruses, …..

• NPA for viral PCR
• CXR; USS
• pleural fluid for …….

CRP not useful to differentiate viral and bacterial causes Avoid routine CXR Consider xay in severe cases or where complications such as effusion or empyema Indications for referral to ICU

• resp failure requiring ventilation • septicaemia
• clinical features of shock • Recurrent apnoea……….

Treatment

• Oxygen with other supportive care as needed
• Oral antibiotics are safe and effective for children even with severe CAP.
• IV antibiotics in children who:

Ø cannot tolerate oral medicines or Ø With septicaemia or complications

• Which antibiotic?
• 1st line therapy: Amoxicillin
• Macrolides can be added at any age if no response to the above or suspect

mycoplasma

• IV antibiotic : amoxicillin, co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone

for severe

• Follow up 48 hours after starting treatment to monitor response and for any of

complications

Iram J Haq et al. BMJ 2017;356:bmj.j686

AAP Clinical Practice Guideline on UTI in Febrile Infants and Young Children (2-24months): Key Updates

• Abnormal urinalysis and a positive urine culture result needed to confirm

diagnosis

• A positive culture is defined as at least

Ø 50,000 colony-forming units per mL (Cath/SPA)

• Oral treatment as effective as parenteral treatment
• Duration of therapy should be 7to 14 days
• 1. Reaffirmation of AAP Clinical Practice Guidelines: Diagnosis and Management of UTI, Pediatrics 2016
• 2. American Family Physician, November 15, 2012 ◆ Volume 86, Number 10.

AAP Clinical Practice Guideline on UTI in Febrile Infants and Young Children (2-24months): Key Updates

• Patient with 1st UTI should undergo renal and bladder USS
• VCUG should not be performed routinely after 1st febrile UTI
• Antibiotic prophylaxis following UTI in otherwise healthy children not

indicated.

• Stress on urine testing with subsequent febrile illnesses, rather than on

regularly repeated urine cultures after Rx

American Family Physician, November 15, 2012 ◆ Volume 86, Number 10

Summary

• Infection remains one of leading causes of morbidity and mortality in children

worldwide.

• Children under 1 year, and those with comorbidities, appear to be still at

higher risk of invasive bacterial infections.

• Early recognition, resuscitation and stabilization are vital in managing

children with serious infection

• No laboratory test alone appears to be able to reliably rule-in or rule-out

serious bacterial infections.

• Clinicians need to be familiar with local guidelines and clinical pathways and

to follow them