Common Pediatric Infections Blaise L. Congeni M.D. Akron Childrens - - PowerPoint PPT Presentation

Appropriate Management of Common Pediatric Infections

Blaise L. Congeni M.D. Akron Children’s Hospital Division of Pediatric Infectious Diseases

It’s all about the microorganism

The common pathogens

 Viruses  Pneumococcus  Haemophilus influenzae  Moraxella catarrhalis  Group A Strep  S. aureus  E. coli

Changes in bacterial flora

 Rapidly adjust to selective pressures

 Antimicrobials  Vaccines  Population dynamics

 Enhanced understanding of pathogenesis

 Virulence mechanisms

Sinusitis

The common pathogens

 Pneumococcus  Haemophilus influenzae  Moraxella catarrhalis  S. aureus

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

Respiratory Pathogens from Sinus Aspirates

Viral Upper Respiratory Infection

 Children develop on average 6 episodes/

year

 Infection type

 90% of episodes due to virus  10% due bacteria

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

Wald et al. Pediatrics. 1991, 87(2): 129

Duration of Simple URI in Children <1 yr of age

Clin Infect Dis. (2012) 54 (8): e72-e112.

www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

IDSA ABRS Guideline

limits

 Use of antimicrobials limited by few studies

with varying diagnostic criteria

 Clinical diagnosis remains problematic  Radiographic imaging of limited value  Nasal swabs not helpful

IDSA Guideline for ABRS

diagnosis

 Onset with persistent s/sx ≥ 10 days  Onset with severe symptoms or signs of

 high fever (≥ 39⁰C) AND  purulent nasal discharge OR facial pain  lasting 3-4 consecutive days

 Onset with worsening symptoms or signs

 new onset fever, headache OR  worsening nasal discharge (after initial

improvement of typical viral URI)

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

IDSA Guideline for ABRS

approach

 Recommended that empiric antimicrobial

treatment be promptly initiated when ABRS is indicated

 Delaying or withholding antimicrobial therapy

for ABS is not recommended.

 “Watchful waiting” is not thought to have a

role when more rigorous diagnostic criteria are applied.

IDSA Guideline for ABRS

empiric antimicrobial choice

 Amoxicillin/clavulanate is recommended over

amoxicillin alone

 High dose amoxicillin/clavulanate is

recommended for

 areas with high rates of invasive PNS

pneumococcus

 severe infection  attendance at daycare  age < 2 years,  antibiotic use in the past month  immunocompromised.

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

IDSA Guideline for ABRS

role for other antimicrobials

 2nd and 3rd generation cephalosporins no

longer recommended for empiric therapy of ABRS

 Macrolides are not recommended  TMP/SMX is not recommended  Doxycycline may be used in children >7 yrs of

age

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

IDSA Guideline for ABRS

β lactam allergy Clindamycin with cephalosporin for

PCN allergic pts (non-type 1)

 Clinda use limited in areas of high resistance

Pts with type 1 hypersensitivity

 Levofloxacin recommended  Doxycycline for children > 7 yrs of age

Chow et al. Clin Infect Dis. (2012) 54 (8): e72-e112. www.idsociety.org/Organ_System/#Lower/Upper%20Respiratory

Community Acquired Pneumonia

The common pathogens

 Pneumococcus  Mycoplasma pneumoniae  S. aureus

Clinical Infectious Diseases Advance Access published August 30, 2011

PIDS/IDSA CAP Guideline

Outpatient management

 Clinical

 Evaluate tachypnea, hypoxemia, toxicity

 Laboratory

 Blood culture not indicated in mild CAP  Consider viral testing (e.g. influenza)  Sputum culture in moderate CAP

 Chest x-ray

 Consider with moderate CAP  pts not improving or worsening

PIDS/IDSA CAP Guideline

Outpatient management

• Children <5 years with likely viral CAP

 Observation

• Suspect mild to moderate bacterial CAP

 High dose amoxicillin  No benefit of cephalosporins over high-dose

amoxicllin

 azithromycin not reliable in areas of high PRP

 Suspect atypical pneumonia

 azithromycin

PIDS/IDSA CAP Guideline

Inpatient management

 Ceftriaxone is preferred over ampicillin in

areas of increased high level PRP

 Consider combination with azithromycin for

school age and above

 Consider vancomycin

 Worsening clinical course  Imaging studies suggestive of CA-MRSA

Pharyngitis

The common pathogens

pharyngitis

 Group A streptococci  Group C, G streptococci  Neisseria gonorrheae  Archanobacterium haemolyticum  Fusobacterium necrophorum  Mycoplasma pneumoniae  EBV, HSV

McIsaac et al. Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults. JAMA, 2004, 291(131):1587

Management of Pharyngitis

 Pen VK, benzathine PCN, and amoxicillin

remain the drugs of choice

 For penicillin allergic patients:

 Cephalosporin (cephalexin) for non type 1  Macrolide, clindamycin for type 1

 Empiric treatment recommendations vary with

Centor score of 3 or 4

 ACH, AAFP, CDC: can treat empirically  IDSA, AHA: should not treat empirically

Urinary Tract Infections

Urinary Tract Infections

 Common antimicrobial resistance concerns

 Amoxicillin - >50% resistance  TMP/SMX – 20-30% resistance

 Emerging antimicrobial concerns

 Amp C β-lactamase

(Enterobacter, Serratia, Citrobater)

 Extended spectrum β-lactamase

(Klebsiella, E. coli)

Extended Spectrum β lactamase producers (ESBLs)

 Found most often in Klebsiella and E. coli  Confers resistance to most β lactams (except for

carbapenems)

 In the U.K. rates of resistance to 3rd generation

cephalosporins has increased from 2% (2000) to 14% (2011)

 Spain, Italy, Turkey – rates 25-50%  Asia, South America - higher

Urinary Tract Infection AAP Guidelines

 Apply to children ≤ 24 months of age  Catheterized specimen recommended  5x104 cfu considered positive  No indication for prophylaxis  No indication for VCUG with 1st UTI

 In absence of sepsis  Abnormal renal US

Skin Infections

Antimicrobial management of skin infections

 Consider pathogens

 S. aureus, MRSA  S. pyogenes  Other β hemolytic streps  Pseudomonas  Pasteurella, Aeromonas

 Consider host

 Immunosuppression

 Consider location

Skin Infection antimicrobials

 S. aureus

 clindamycin  TMP/SMX  doxycycline (> 7yrs of age)  β lactams

 Empiric skin infection

 clindamycin  TMP/SMX plus β lactam  mupirocin 2% topical ointment

MRSA Skin Infection

 Epidemic of MRSA skin infection continues  Incision and drainage has a clear role in

management

 The role of antimicrobial therapy is less clear

after I&D

 Studies comparing placebo to antibiotic

suggest non-inferiority

Skin Infection antimicrobials

 Recent study suggests inferiority of

TMP/SMX to clindamycin for purulent skin infections likely due to S. aureus

 Data suggests that use of an antimicrobial

after I&D may provide benefit in preventing relapse or reoccurrence.

Antimicrobials New and changing

 Vancomycin  Linezolid  Cefepime  Ceftaroline  Daptomycin  Telavancin