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

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

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

Duration of Simple URI in Children <1 yr of age Wald et al. Pediatrics. 1991, 87(2): 129

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 (≥ 39 ⁰ C) 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  2 nd and 3 rd 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 3 rd 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  5x10 4 cfu considered positive  No indication for prophylaxis  No indication for VCUG with 1 st 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