common infections of childhood Jen Avegno, MD LSU – New Orleans Emergency Medicine
rule #1: kids get sick. • 2006 National Hospital Ambulatory Medical Care Survey showed: • most common ED diagnosis for • kids <1 = upper respiratory infection • kids 2-12 = otitis media/ear disorders • In all, fever is the most common chief complaint of kids presenting to the ED (about 20-30% all peds visits)
rule #2. most kids don’t get THAT sick. this lecture is about NOT
objectives • Review pediatric fever guidelines • Discuss some common infections in childhood • See LOTS of pictures of cute kids!
case # 1 • Mom brings in a 3-week-old baby girl with a fever for 4 hours. The child was a normal vaginal delivery with no complications and has been feeding and growing well at home. This morning, she began to “spit up” her bottle and had several loose stools. She has been somewhat sleepy but does respond to her parents. Physical exam reveals a child in no distress with a rectal temperature of 100.8 and a normal exam for age.
the dreaded neonatal fever • what is the risk of serious bacterial illness (SBI) in kids less than 3 months with fever? • SBI = UTI, bacteremia, meningitis, osteo, pneumonia, gastroenteritis, cellulitis, septic arthritis • risk is about 6-10% in these kids, with those younger than 1 month having the highest chance of SBI • kids under 3 months may present looking like “viral syndrome” but still have SBI … in one study, kids less than 60 days with temp>38: • 22% had RSV • 7% with RSV also had concomitant SBI
why do neonates get fever? • immature immune system • exposure to pathogens during delivery (esp. GBS) • cannot mount immune response to prevent localized infection from disseminating
what does temperature really mean? what IS a fever? • fever = “a pyrogen-mediated rise in body temperature above normal range” • what is a NORMAL temp? • the magical 98.6 was set as “normal” by a German guy in the 19th century using a 22cm long mercury glass thermometer … we now think that his instruments may have been OFF by 1.5-2 degrees!! • normal temps can vary by age in kids from 99.5 (neonates) to 98 (older kids) • temps are influenced by age, sex, race, time of day, activity level, ambient temp, site of measurement, type of device
what constitutes a fever? • NO REAL EVIDENCE to support the hard-and-fast cutoff of 100.4 (38°C) – evidence suggests that oral temps 37.2-37.8 may be considered febrile depending on situation • BEST SITE to measure temperature … • the hypothalamic artery. (yeah, right) • take-home point: fever is an ARBITRARY number – base your workup on overall clinical impression, not a particular cutoff
what about people without thermometers? • oh, yeah, the “mom hands” … don’t blow them off! • 60% of parents use their hands instead of a thermometer to assess fever • is this method accurate? studies show: • 74-90% sensitive • 76-86% specific • 85-94% NPV • the exact number or method doesn’t matter … BELIEVING the parents is!
history • length of illness • localized symptoms? • pertinent PMH, birth hx of both mom & baby • sick contacts • vaccination status • any meds/ABx
physical exam findings • VITAL SIGNS (yes, ALL of them!!) • ABCs – respiratory/airway distress? signs of shock? tachycardia? • for infants less than 1 year, HR should increase 10 beats for every 1°C • TAKE THOSE CLOTHES OFF!! • just remember … in non-immunocompetent kids (neonates) … fever may be the ONLY presenting sign of SBI – do not be reassured by a “normal” exam!!
standard management • again, ABCs … consider intubation for respiratory distress, hypoxia, altered MS • fluid resuscitation: 20 ml/kg IV/IO fluids to total of 60-100 ml/kg (if hypovolemia persists) • cultures prior to Abx, if possible • sterilization of CSF can occur as quickly as 15 min – 2 hrs after receiving Abx, so watch results! • BROAD SPECTRUM TREATMENT: • Ampicillin + (Gentamycin or Cefotaxime) – avoid Rocephin in kids <28 days • Vanc? Acyclovir?
watch out for … • cancer • toxic shock • autoimmune and/or congenital disorders (cardiac, pulmonary)
case # 2 • Dad comes to the ED with little Maria, age 2, and reports that she has had a fever for the last 2 days (up to 103.4 at home). The parents have tried Tylenol and Motrin to no avail. Maria has not eaten much but is still drinking water and juice. She had a “runny nose” a few days ago, but is not sneezing, coughing, or vomiting. In the ED, Maria has a temperature of 102.8. She looks droopy, but interacts well with her parents.
only slightly less scary … fever between 3-36 months • fever is the most common complaint in this age group!! • unlike neonates, of young children who present with viral illness (RSV, croup, bronchiolitis etc) and fever (>39), less than 0.5% will also be bacteremic
the well-appearing febrile child 3-36 months • concern here is for OCCULT BACTEREMIA • before HiB and Prevnar, the rate of occult bacteremia in the non-focal febrile child was 5% • currently … it is less than 1% with other pathogens more prevalent • N. meningiditis • urinary pathogens
treating a fever • WHY do we treat a fever? • feel better/decrease anxiety • lower morbidity/mortality • prevent febrile seizures • HOW do we treat a fever? • ambient temp control • light clothing/bedding • fluids • sponge bath • warm feet/potatoes or onions in socks (REALLY!) • antipyretics
how do you give Tylenol & Motrin? • Acetaminophen 15 mg/kg every 4-6 hours • Ibuprofen 10 mg/kg every 6 hours • alternate?? • evidence shows some minor benefits in reducing fever faster and lasting longer BUT … • potential for dosage/scheduling errors; synergistic renal toxicity; difficult to understand and comply • detailed information/handout at appropriate reading level on administration of antipyretics should be given to caregivers!!
history • length of illness • localized symptoms? • headache – neck pain – sore throat – pulling @ ears – cough (describe!!) – wheeze – vomiting – RASH – mental status • use of antipyretics (**defervesence after use does NOT exclude bacteremia!) • sick contacts • po intake/output • vaccination status • any meds/ABx
physical exam findings • VITAL SIGNS (yes, ALL of them!!) • ABCs – respiratory/airway distress? signs of shock? tachycardia? • capillary refill is an easy and reliable indicator of perfusion • TAKE THOSE CLOTHES OFF!! • thorough search for focal findings
notes on the workup • most guidelines argue for getting the WBC first, then CXR if WBC > 20k … but who does this? • study showed that rate of pneumococcalbacteremia increased to 0.5% with WBC 10-15k; 3.5% with WBC 15-20k; 18% with WBC>20k • ANC >10k (include all immature forms) increases risk of bacteremia by 10-fold over those with ANC<10k
management & treatment • the post-immunization world has resulted in much lower rates of bacteremia for this age group: • where bacteremia rates in febrile kids >1.5%, the most cost-effective strategy is a WBC, blood CX, and empiric Abx (Rocephin) • when rates <0.5%, clinical judgment alone for treatment & management is most useful to select out high-risk groups • kids 3-6 mo are still relatively non-immunocompetent … recommendations are for all kids in this age group with temp >39 to have WBC & BCx; treat all WBC > 15k with empiric ABx
watch out for … • CANCER • autoimmune disease: JRA, Kawasaki’s • brain tumors
case #3 • Mom brings in a 15-month old girl who woke up last night screaming and with fever to 101.2. She has not eaten much today but is drinking liquids with normal urine output. All of her immunizations are up to date and she is otherwise healthy. On exam, you note a mildly ill appearing, non-toxic child who responds well to mom. The left TM is red and bulging with loss of landmarks.
epidemiology • Most commonly diagnosed disease in kids <15 • By age 3 – estimated that more than 80% of kids have had one episode; 40% have had >3 • Risk factors: • Male • Smoking • Day care • Family history • Anatomic abnormalities • Winter • Bottle feeding
definitions • ACUTE: s/s of acute infxn WITH effusion • aka “acute suppurative” or “prurulent” OM • OME: effusion WITHOUT s/s of acute infxn • aka “serous,” “mucoid,” “secretory,” “nonsuppurative” • CHRONIC: chronic ear discharge from perforated membrane • RECURRENT: >3 episodes in 6 mo or >4 episodes in 1 year
pathophysiology • It’s all about the tube – functions of the eustachian tube: • Ventilates middle ear for pressure equilibration • Drains middle ear • Protects ear from NP secretions • Only open when yawning/chewing/swallowing • When the eustachian tube becomes obstructed … • Middle ear ventilation • Negative middle ear cavity pressure causes fluid to move into middle ear (transudate)and combine with NP secretions & bacteria CHILD
common pathogens in otitis media • S. Pneumoniae • H. flu –higher % in OME • M. catarrhalis • S. aureus • S. pyogenes • gram-negative bacteria • VIRUSES:
history • “Pulling at ears” • Cough • Vomiting & diarrhea • Decreased po intake • Fever – may be present in only ¼ of cases, with less than 10% having temp >40 • URI sx
a normal TM pars flaccida malleus pars tensa umbo eustachian tube opening light reflex
signs/symptoms • What does the TM look like? bulging erythematous hemorrhagic normal
more pictures Middle ear effusions other indicators of AOM: lack of TM mobility *** (MOST RELIABLE SIGN) cloudy, retracted, dull TM 1/3 of cases may NOT have symptoms!
diagnosis AAP/AAFP guidelines state that the following should be present to dx AOM: • Recent, usually abrupt onset of s/s • Presence of middle ear effusion (bulging, limited TM mobility, air-fluid level, otorrhea) • S/s of middle ear inflammation (erythema or otalgia)
treatment • AAP guidelines on management of AOM in kids: • Dx by hx of acute onset + signs of effusion + signs of middle ear inflammation • Assess for pain – if present, treat • Limited role for observation in select patients > 2 years (must have “a ready means of communication with clinician”) • If treat with ABx – start with amox 80-90 mg/kg/day • If treatment failure by 48-72 hours – reconsider dx or change ABx
treatment • Important points: • “treatment failure” = lack of clinical improvement and/or persistent signs of AOM • Bactrim & macrolides often considered 2nd line, but resistance rates approach 30-40% • Courses are generally 10 days in patients < 2 yrs , perf TM, and recurrent OM, recommended in patients <6 years • NO INDICATION for antihistamines, decongestants, steroids, or tubes in single episode AOM • Auralgan may be useful for pain relief • Tx of OME (either alone or following episode of OM) is controversial – ABx? Antihistamines? • Tubes for patients with OME for 4-6 months, failed tmt, and hearing loss
watch out for • otitisexterna • mastoiditis
case #4 • Parents bring an 8 year old boy to the ED with fever of 102.3, and complaints of headache and abdominal pain. He was otherwise healthy until this morning, and his shots are all up to date. The patient is febrile and tachycardic to 120 with normal blood pressure. He is ill-appearing but non-toxic, speaks normally, and is not drooling. His oropharynx is red with bilateral white exudates and tender, palpable cervical lymphadenopathy.
acute pharyngitis • dx of tonsillitis/acute pharyngitis is made more than 7 million times/year • MCC is viral in kids • MCC bacterial pharyngitis is GABHS (15-30%) • kids 5-15 y/o predominantly • Group C & G Strep are likely much more common than typically thought & may be missed by routine testing • about 1 in 4 kids with acute sore throat has serologically confirmed GABHS • MC in winter when respiratory viruses predominate
common infectious pathogens • BACTERIAL: • Strep • Group A • Groups C & G • mixed anaerobic (“Vincent’s angina”) • N. gonorrhoeae • C. diphtheriae • Arcanobacteriumhaemolyticum; Yersinia; tularemia • atypicals