INFECTIONS IN KIDS TO TREAT OR NOT TO TREAT? I HAVE NOTHING TO - PDF document

3/14/18 INFECTIONS IN KIDS TO TREAT OR NOT TO TREAT? I HAVE NOTHING TO DISCLOSE. Andi Marmor, MD, MSED Professor of Pediatrics University of California, San Francisco Zuckerberg San Francisco General Hospital Three Common Presentations Case Presentation: Infant with Fever FEVER DIFFICULTY BREATHING u Xanadu is 2 week old girl with a fever u Fever without a source (SBI) u Pertussis u No symptoms to suggest a source on u Urinary Tract Infections u Community Acquired PNA exam/history u Pharyngitis u VS: T 38.5, P 150, R 40’s, o/w WNL u Exam: well-appearing, no focal findings RASH to suggest source for fever u Infections and Mimickers 1

3/14/18 The most likely cause of Xanadu’s The most likely cause of Xanadu’s fever is: fever is: Viral infection Viral infection A. A. Urinary tract infection Urinary tract infection B. B. Serious bacterial infection (SBI) Serious bacterial infection C. C. (bacteremia/meningitis) (SBI)(bacteremia/meningitis) HSV infection HSV infection D. D. Everything you need to know about SBI in febrile infants - on ONE SLIDE 2-3% E.Coli>GBS>S. aureus >enterococcus, S pneumo 13-18% E. Coli THE FEBRILE INFANT <1% E.Coli/GBS è S. pneumo Greenhow, 2014 Schwartz, 2009, Gomez 2010, Greenhow, 2014 2

3/14/18 Fever without a source (FWS): Fever without a source (FWS): Infants <30 days Infants <30 days u Appearance and lab criteria do not reliably u Appearance and lab criteria do not reliably rule out UTI/SBI in this age group rule out UTI/SBI in this age group u Urine, blood, CSF, empiric abx u Urine, blood, CSF, empiric abx recommended recommended ¤ Amp/gentamicin or amp/cefotaxime ¤ Amp/gentamicin or amp/cefotaxime ¤ Listeria vanishingly rare…some recommend treating with cefotaxime alone ¤ DO NOT treat with gentamicin alone Approach to Infant with FWS FWS: Infants 30-90 days no u UTI still the most common bacterial source, other SBI less likely u Viral source more reliable ¤ Named viral syndromes or + rapid viral test (flu, RSV) è SBI unlikely ¤ Consider testing for UTI u Inflammatory markers (CBC/CRP/PCT) helpful in select infants ¤ Well appearing, neg UA AND no viral source 3

3/14/18 Case Continued u Since Xanadu is less than 30 days, and has no source for her fever, you obtain a UA/urine cx and blood cultures and URINARY TRACT INFECTIONS perform an LP (“PYELONEPHRITIS”) u Her UA is positive for LE and nitrites u Now what do you do? Risk of UTI in Infants with FWS Which infants <3 mo should we test for UTI? 20 20 Girls Girls 18 18 Uncirc Uncirc 16 16 Boys Boys 14 14 Circ Circ ALL infants < 3 mo, T>38 12 12 Boys Boys 10 10 8 8 Testing threshold ~2- 6 6 3% 4 4 2 2 0 0 0 1 m 3m 6m 12m 18m 0 1 m 3m 6m 12m 18m 4

3/14/18 Which infants >3 mo* should we test for UTI? Who should we test for UTI? *T ≥ 39 for ≥ 48hrs 20 Girls u All infants with FWS < 3 mo of age 18 u Girls > 3 mo of age Uncirc 16 Boys ¤ FWS (>39) and < 24 months 14 Circ All Girls u Boys > 3 mo of age 12 Boys 10 ¤ Circumcised: FWS (>39) and < 6 mo Circ boys <6 mo 8 ¤ Uncircumcised: FWS (>39) and < 12 mo Uncirc boys <12 mo 6 u Additional Risk Factors: 4 ¤ Length of fever (> 2 days) 2 Testing threshold ~5% ¤ Race (non-black) 0 0 1 m 3m 6m 12m 18m Diagnostic Dilemmas Treatment u Collection of urine u Empiric treatment based on local E. Coli resistance ¤ By c atheter for: ¤ PO cephalexin safe, tasty, narrow spectrum n Infants < 3 mo of age (high risk) ¤ IV if <2 mo, toxic or not tolerating PO n Ill-appearing/getting antibiotics ¤ Consider bag collection for: ¤ Total course: 7-14 days (for pyelo) n Low-risk infant (circ boy> 3 mo, girl/boy>1 year) u Imaging after UTI n If UA +, consider cath for culture u Results: ¤ U/S in infants <3 mo, older kids if recurrent ¤ + UA: start empiric treatment, send for cx ¤ Voiding Cystourethrogram (VCUG) only if high ¤ Neg UA: UTI very unlikely, even in young infants grade VUR/obstruction on U/S n Consider sending for culture in high risk neonate Roberts 2011; Pediatrics 128(3):595–610 5

3/14/18 What is Zaffre’s “modified Centor Case Continued score?” u Xanadu’s 6 yo brother Zaffre also has a 1 A. fever, and is complaining of a sore throat 2 B. u His temp is 38.9, he has tender cervical 3 C. LAN and no cough or runny nose 4 D. 5 E. www.accesspediatrics.com Modified Centor Score Modified Centor Score u 1 point each: u 1 point each: ¤ Exudate or swelling on tonsils q Exudate or swelling on tonsils?? ¤ Tender/swollen ant cervical LN’s þ Tender/swollen ant cervical LN’s ¤ Temp > 38C þ Temp > 38C ¤ Cough absent þ Cough absent ¤ Age 3-14 þ Age 3-14 ____________ ____________ Max score = 5 Score = 4-5 6

3/14/18 What does this mean? What does this mean? u What is Zaffre’s prior probability of a + u What is Zaffre’s prior probability of a + GAS culture? GAS culture? ~25% ~25% A. A. ~50% - this is why we test, don ’ t treat! ~50% B. B. ~75% ~75% C. C. ~90% ~90% D. D. u When should you treat empirically? ¤ Scarlet fever, cx + sibling, etc Case Presentation: 3 yo with cough u Amaranth is a 3 yo who presents with 2 weeks of cough, keeps her awake, and occasional post-tussive vomiting u She has a PMH of bronchiolitis (6 mo) and PERTUSSIS is up to date for age on vaccinations u VS: T 38.2, P 130, RR 42, O2 sat 95% u Her mother wants to know if this could be “the whooping cough” 7

3/14/18 Pertussis Epidemiology Phases of Pertussis PHASE TIME COURSE DESCRIPTION Tdap Catarrhal 1-2 weeks Mild fever, cough, rhinorrhea Paroxysmal 1-6 weeks Older infants/children: Paroxysms, whoop, post-tussive Acellular pertussis emesis Young infants: apnea, cyanosis, bradycardia, poor feeding Convalescent Weeks-Months Improvement in severity and frequency of coughing episodes Slide courtesy of Ellen Laves, MD Pertussis: Clinical Diagnosis Pertussis: Laboratory Confirmation u Lab confirmation ONLY in those with u Cough lasting >2 weeks + 1of the following: signs/symptoms consistent with pertussis ¤ Apnea* Neonates/young Infants u Posterior NP specimen (not pharynx/ant NP) ¤ Paroxysms of coughing Older children u PCR for pertussis ¤ Inspiratory “whoop” ¤ False positives may occur ¤ Post-tussive vomiting ( least specific ) u Culture + for B. Pertussis ¤ Most SPECIFIC test *May occur without cough u Most sensitive in first 3 weeks cdc.gov/pertussis cdc.gov/pertussis 8

3/14/18 Pertussis: Treatment Case Continued u Major benefits: u Amaranth’s vaccination status and non- specific clinical symptoms make pertussis ¤ Prevent severe disease* in those at risk less likely ¤ Prevent spread to high risk (HR) patient u Empiric treatment: high suspicion and/or HR u However, her RR (42) and O2 sat (95%) ¤ Infants <1 year (< 3mo, preemie at highest risk) make you concerned for pneumonia ¤ Pregnant women near term ¤ Well-appearing, in minimal resp distress ¤ Unimmunized or underimmunized aside from tachypnea u Test and treat if +: ¤ Decreased breath sounds with crackles over the LLL ¤ HR but low clinical suspicion ¤ Patient LR but has HR contacts *Only treatment BEFORE paroxyms may shorten course What is the RECOMMENDED next step? Obtain a PA and lateral CXR A. Obtain a blood culture and CBC B. Obtain a sputum culture C. PEDIATRIC COMMUNITY Start PO amoxicillin and discharge with D. ACQUIRED PNEUMONIA close follow up Start IV cefuroxime and admit E. 9

3/14/18 Pediatric CAP: Diagnosis Pediatric CAP: Labs Bradley JS, et al. Clin Infect Dis. 2011 Bradley JS, et al. Clin Infect Dis. 2011 u Clinical u Routine lab testing NOT recommended u Blood cultures: ¤ Symptoms of acute illness (ie: fever) + resp distress (tachypnea*, retractions, hypoxia) AND ¤ Clinically worsening or hosp with mod/severe disease u Viral testing (flu, RSV) ¤ Focal lung findings on exam OR on CXR ¤ IF no evidence of bacterial co-infection u Imaging u CBC/CRP ¤ Chest x-ray NOT recommended routinely in ¤ Not recommended outpatients u Testing for Mycoplasma pneumoniae, S. pneumo ¤ Does not distinguish between pathogens (viral, ¤ If available, may guide antibiotic selection atypical, etc) *MOST SENSITIVE sign Community Acquired Pneumonia: Pediatric CAP: Causes Treatment Bradley JS, et al. Clin Infect Dis. 2011 Bradley JS, et al. Clin Infect Dis. 2011 u Inpatient or Outpatient 1 st line treatment: u Based on age, severity, local resistance ¤ Amoxicillin/ampicillin in infants and young children 2 MO TO 5 YRS: OVER 5 YEARS: ¤ Consider Macrolide (azithro) in kids > 5 ¤ Viral is most common u M. pneumoniae > C. u Ill patent or high-level PCN resistance: pneumoniae, S. ¤ < 2 yrs: S. pneumoniae , C. ¤ 3 rd generation cephalosporin if suspect S. pneumo pneumoniae Trachomatis ¤ Vancomycin if suspicion for MRSA ¤ 2-5 yrs S. pneumoniae > ¤ +Macrolides if suspicion high for M. pneumoniae M. pneumoniae , H and C. pneumoniae influenzae, C. pneumoniae 10

3/14/18 What is the RECOMMENDED next step? Obtain a PA and lateral CXR A. Obtain a blood culture and CBC B. Obtain a sputum culture C. Start PO amoxicillin and discharge with D. NAME THAT RASH close follow up Start IV cefuroxime and admit E. Toddler with fever, refusing po’s Examples of “atypical coxsackie” drooling… Hand- foot-mouth disease (coxsackie virus) Eurosurveillance.org Pediatrics.aapublications.org 11