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Common Outpatient Infections. Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New Orleans. Otitis Media Sinusitis Pharyngitis Lymphadenitis Pneumonia Urinary tract infection Diarrhea. Impetigo/cellulitis Wounds/bites Infestations Fungal Parasites Herpes Exanthems.

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common outpatient infections

Common Outpatient Infections

Rodolfo E Bégué, MD

Chief, Pediatric Infectious Diseases

LSUHSC, New Orleans

common outpatient infections2
Otitis Media

Sinusitis

Pharyngitis

Lymphadenitis

Pneumonia

Urinary tract infection

Diarrhea

Impetigo/cellulitis

Wounds/bites

Infestations

Fungal

Parasites

Herpes

Exanthems

Common Outpatient Infections
otitis media
Otitis Media

Diagnosis

  • Acute onset
  • Inflammation
  • Middle ear fluid

Normal

AOM

otitis media4
Otitis Media

Etiology

  • Streptococcus pneumoniae Penicillin-susceptible Penicillin-non susceptible
  • Haemophilus influenzae (non-typeable)
  • Moraxella catarrhalis
otitis media5
Otitis Media

Treatment

  • ~ 80% resolve spontaneouslyantibiotics increase resolution to ~ 95%
  • Priority to treat is children < 2 years and severe cases
  • Drug of Choice:

AMOXICILLIN 80-90 mg/kg/d

otitis media6
Otitis Media

Failure:

  • Amoxicillin / clavulanate
  • Ceftriaxone (1-3 doses)
  • Tympanocentesis
otitis media7
Otitis Media

Alternatives:

  • Cefdinir (Omnicef)
  • Cefuroxime (Ceftin)
  • Cefpodoxime (Vantin)
  • Ceftriaxone
  • Azitromycin
  • Clarithromycin
recurrent otitis media
Recurrent Otitis Media
  • 3 episodes in 6 months4 episodes in 12 months
  • Check for environmental factors
  • Chemoprophylaxis: amoxicillin (20 mg/kg/d) sulfisoxazole (35-70 mg/kg/d)
  • Ventilating tubes
otitis media with effusion
Otitis Media with Effusion
  • Middle ear fluidNo inflammation
  • Must de differentiated from AOM

AOM

OME

Normal

otitis media with effusion10
Otitis Media with Effusion

Management

  • Intervention only necessary if there is hearing deficit (bilateral and >20db in “best” ear)
  • First 3 months: watchful waiting (>95% will resolve)
  • After 3 months: hearing testing (> 20 db?)
  • > 4 months: discuss with ENTconsider ventilating tubes
slide11
AOMT
  • Augmentin
  • Ciprodex Ciprofloxacin 0.3% Dexamethasone 0.1%Cipro HC Ciprofloxacin HCl 0.2% Hydrocortisone 1%Floxin Ofloxacin 0.3%
otitis externa
Otitis Externa
  • Swimmer’s ear
  • Staphylococcus aureus, Pseudomonas spp
  • Cleansing, drying
  • Neomycin otic solution with polymyxin B and hydrocortisone (Cortisporin)Ciprofloxacin with hydrocortisone (Cipro HC Otic) Ofloxacin otic solution (Floxin Otic)
  • 2% acetic acidGentamicin ophthalmic (Garamycin)Tobramycin opthalmic (Tobrex)
sinusitis
Diagnosis is clinical

URI symptoms that persist > 10 days

URI symptoms that get worse after 5 days

Sinus pain uncommon

Do not do plain films

Do not abuse CT

Sinusitis
sinusitis14
Etiology:

Similar to AOM

Treatment:

Similar to AOM, except that duration is ~ 2 weeks (7 d after patient is free of symptoms)

Sinusitis
chronic sinusitis
UNCOMMON

Suspect

Other etiologies (CF, anatomical)

Other explanations (asthma, allergies environmental factors

Chronic Sinusitis
pharyngitis
Pharyngitis
  • Viral most common (EBV, rhinovirus, etc)
  • Allergies
  • Bacterial: Group A Streptococcus Other Streptococcus
strept pharyngitis
Strept Pharyngitis

Diagnosis:

  • Clinical > 2 years old, acute onset, fever, unilateral lymphadenitis, no URI
  • Rapid test
  • Culture (GAS only vs others)
  • Beware of carriers (need ASLO)
pharyngitis18
Pharyngitis

Treatment:

  • Penicillin V 250 mg PO bid x 10 daysamoxicillin 40 mg/kg/d div bid x 10 days
  • Alternatives:benzathine penicillin G, erythromycin, clindamycin, cephalexin,
  • Others:clarithromycin, cefuroxime, cefixime, ceftibuten, cefdinir, cefpodoxime, azithromycin
lymphadenitis
Generalized

Viral (EBV)

Toxoplasmosis

Syphilis

Single

Acute:Staph / Strep

Chronic:Bartonella henselaeMycobacteria

Lymphadenitis
acute lymphadenitis
Acute Lymphadenitis
  • Clindamycin, cephalexin, macrolide
  • US  Aspiration

Gorup A Streptococcus

Staphylococcus aureus

chronic sub acute lymphadenitis
Chronic (sub-acute) lymphadenitis
  • To consider: CBC, EBV, PPD, B. henselae titers, Toxo, others depending on risk factors
  • Can treat as for “acute” first
  • Watch for 2-3 w and re-evaluate
  • If all negative and not any better, consider wait vs re-test vs aspiration/incision/excision

B. henselae

MAIC

M. tuberculosis

ca pneumonia
Etiologies

ViralRSVInfluenza

BacterialStrep pneumoniae

AtypicalMycoplasmaChlamydiaTuberculosis

Treatment

Amoxicillin (2m- 5 yrs)

MacrolideErythromycinAzithromycin

Antivirals(Oseltamivir)

CA Pneumonia
urinary tract infection
Urinary Tract Infection
  • Not difficult to treat, only difficult to diagnose but the implications of a missed diagnosis may be terrible
  • Always suspect in febrile children < 2 yrs of age
  • Dx of UTI requires a UCx (bag-specimen not good)
  • UA (WBC), dipstick OK as a guide, especially in combination
urinary tract infection24
Etiology

Escherichia coli

Enterococcus

Treatment

Amoxicillin

TMP / SMX

Cefixime

Quinolone

Urinary Tract Infection
  • Follow-up
  • US, VCUG
  • DMSA scan
  • Consider prophylaxis
acute gastroenteritis
Acute Gastroenteritis
  • “Always” infectious
  • Viruses: rotavirus, calicivirus, others
  • Bacteria: Campylobacter, Shigella, Salmonella, Yersinia, E. coli
  • Antibiotics usually not required, unless diarrhea is dysenteric TMP/SMX, Azithromycin, Quinolones
  • Clostridium difficile
impetigo cellulitis
Impetigo / cellulitis
  • Etiology:Group A Streptococcus Staphylococcus aureus (MRSA)
  • Treatment:Bacitracin, Mupirocin, RetapaluminCephalexin, clindamycin, TMP/SMX, erytho, linezolid Drain any abscess
puncture wounds foot
Etiology

Staph aureus (~ 3 d)

Pseudom spp (~ 7 d)

Mycobacteria (~ 2-4 w)

Treatment

Wound careTetanus vaccineAnti-Staph antibiotics

If no responseSurgical exploration  cultureCeftazidime  ciprofloxacin (for 2 w)

Puncture wounds (foot)
bites
Etiology

Pasteurella multocida

Eikenella corrodens

Streptococcus spp / Staphylococcus spp

Neisseria spp / Corynebacterium spp

Anaerobes

Polymicrobial

Prophylaxis and Treatment

Wound careTetanus shotRabies prophylaxis (?)

Amoxicillin / clavulanate

clindamycin + TMP/SMX

Bites
fungal infections
Fungal Infections
  • Oral candidiasisoral nystatin or clotrimazolefluconazole 3 mg/kg qd x 7d
  • Tinea corporistopical clotrimazole or terbinafine bid 2-3 w+ fluconazole 3 mg/kg/w x 2-3 w
  • Tinea capitisgriseofulvin 10 mg/kg qd x 4-8 wterbinafine 125 mg qd x 4 w (Lamisil)
parasites
Worms

Enterobius vermicularis(Ascaris)

Scotch tape test

Mebendazole 100 mg Pyrantel pamoate 11 mg/kgAlbendazole 400 mg

All repeat in 1 w

Protozoans

Giardia (Cryptosporidium)

Metronidazole 5 mg/kg q8h x 5-10dFurazolidone 2 mg/kg q6h x 7-10dAlbendazole 400 mg/d x 5d(Nitazoxanide)

Parasites
  • Taeniasis
  • Praziquantel, different doses

Uncertain significance

Entamoeba coli, Endolimax nana, Iodamoeba butschlii

Blastocystis hominis, Dientamoeba fragilis

head lice
Standard:

Permethrin: 1% Nix (Tx of choice)

Pyrethrins: RID, A-200, R&C, Pronto, Clear Lice System

Lindane 1%: Kwell

Upgrade:

Permethrin 5%: Elimite

Malathion 0.5%: Ovide

Crotamiton 10%: Eurax

TMP/SMX PO

Ivermectin PO200 g/kg

Head Lice
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