3/18/2015 Overview of Infectious Diseases I have nothing to disclose. in Children Eliza Hayes Bakken, MD Assistant Clinical Professor of Pediatrics University of California, San Francisco Primary Care Coordinator Children’s Health Center San Francisco General Hospital Overview • Prevention and Screening • Vaccine- Preventable Illnesses Vaccines • Important Guidelines and Updates • Visual Diagnosis “An ounce of prevention is worth a pound of cure.”- Benjamin Franklin 1
3/18/2015 Standard Schedule Primary Series Boosters Live Attenuated Vaccines 2
3/18/2015 Hepatitis B Influenza Teen Vaccines Hot off the Presses… • HPV-9 – New 9-valent HPV vaccine newly approved – Adds 4 strains implicated in 20% of cervical - TdaP at 11yo cancers (required for 7 th grade entrance in – Same protection against previous strains CA) • Serotype B Meningococcus - HPV is 3 doses (min 6 months – 2 serotype B vaccines are now approved between 1 st and – This type implicated in recent college outbreaks 3 rd ) - MCV4 given at – No current universal vaccination 11yo and 16yo recommendation, but can be used in outbreaks 3
3/18/2015 Vaccine Contraindications Invalid Contraindications • Serious reaction to any previous dose • Mild illness – Anaphylaxis, encephalopathy w/in 7 days (DTaP) • Antimicrobial therapy • Life threatening allergy to a component (e.g. anaphylaxis) • Pregnant or immunosuppressed – Neomycin: IPV, MMR, VZV – Gelatin: MMR, VZV household contact – Egg: Influenza (both IIV and LAIV) • Preterm birth – Yeast: Hep B, HPV • Specific to Live Vaccines (RV5, MMR, VZV, LAIV) • Erythema/induration with past vaccine – Severe immunodeficiency: SCID, HIV with AIDS – Pregnancy • Non-life threatening allergy to ingredient – LAIV only (based on ACIP recommendations): chronic medical conditions including asthma, CKD, heart disease cdc.gov/vaccines/recs/vac-admin/contraindicatons Vaccination Precautions • Weigh risk, benefits, alternatives with family • Include: – Moderate/severe illness without fever Screening – History of Guillain-Barre within 6 weeks of previous vaccine (flu) – Progressive Arthus-type reaction after previous dose of tetanus or diptheria containing vaccine – Unstable neurological condition (pertussis) – Recent receipt of blood product (MMR, VZV) – History of thrombocytopenia (MMR) – DTaP: fever >105 or hypotonic hyporesponsive episode or crying >3 hrs within 48 hours of previous dose 4
3/18/2015 Tuberculosis Screening Latent TB Treatment • Universal Screening NOT recommended • Individual more likely to progress to active disease: – Screen those with a positive close contact, HIV disease, – Recent converters immigration from or travel to an endemic country, a stay in – Young children jail/homeless shelter, or symptoms of disease – HIV infected – PPD recommended for first line screening – IV Drug Users • If BCG vaccinated, can use Interferon-gamma release assay ( – Those on certain immunosuppressants e.g. Quantiferon) • Regimen options: • OR for confirmation if PPD positive • Threshold for positive PPD – INH 10-15mg/kg/day x 9 months – 5 mm if HIV +, abnormal CXR, contact w/ case – Rifampin 10-20mg/kg/day x 6 months – 10 mm if <4yo, birth/resident of high risk location, medical – INH + rifapentine x 3 months (dosing being studied) conditions (diabetes, renal failure), IV drug users, child • Screening labs (i.e. LFTs) are not needed in normal contact with adult with these risk factors healthy children taking INH unless symptomatic – 15 mm all others Pertussis: Microbiology • damaged • Gram negative coccobacillus • Toxin mediated disease Vaccine Preventable Diseases effecting cilia – Interferes with clearance of pulmonary secretions • Cough of 100 days that can continue for weeks after the organism is gone Slide courtesy of Ellen Laves, MD 5
3/18/2015 Pertussis in the US Pertussis in Children Phases of Pertussis Pertussis Case Definition PHASE TIME COURSE DESCRIPTION • Clinical: In the absence of a more likely diagnosis a cough 1-2 weeks Mild fever, cough, Catarrhal illness lasting at least 2 weeks with one of the following: rhinorrhea – Paroxysms of coughing 1-6 weeks Older infants/children: Paroxysmal – Inspiratory “whoop” Paroxysms of cough, – Post-tussive vomiting post-tussive emesis, Young infants: apnea, – Apnea (with or without cyanosis) cyanosis, bradycardia, • Infants less than 1 year old poor feeding • Laboratory Confirmation: Convalescent Weeks-Months Improvement in – Isolation of B. Pertussis from clinical specimen severity and frequency of coughing episodes – Positive PCR for pertussis cdc.gov/pertussis Slide courtesy of Ellen Laves, MD 6
3/18/2015 Pertussis Treatment Pertussis Treatment: • Important to consider whether patient is high risk • Azithromycin: most commonly used (HR) for complications – If < 6 months: 10mg/kg daily x 5 days – CDC definition: Infants under 1 year old – If ≥ 6 months: 10mg/kg/day on day 1, then – Also consider: < 3mo highest risk of hospitalization, 5mg/kg daily x 4 days pregnant women near term, prematurity, unimmunized or underimmunized • Erythromycin • Consider treating before testing is resulted in – risk of hypertrophic pyloric stenosis outweighs patients who are high risk use if <1 month old • Treat HR patients within 6 weeks of cough onset • Clarithromycin and others within 3 weeks • Have a lower threshold for testing in patients with • TMP/SMX HR contacts – If >2 months old Measles Microbiology Measles in the US • Single- stranded, enveloped RNA virus with 1 serotype • Humans are the only host • Transmission is from direct contact with droplets or airborne for up to 2 hours • 9/10 people who are exposed and susceptible will contract the disease Photo credit: http://www.nature.com/news/2008/0806 www.cdc.gov/vaccines/pubs/pinkbook.meas.html 20/full/news.2008.907.html 7
3/18/2015 Measles in the US Phases of Measles PHASE TIME COURSE DESCRIPTION Prodromal 2-3 days High fever (>103), cough, runny nose (coryza), conjunctivitis (fever + 3 C’s) 3-5 days Erythematous Exanthem maculess that proceed cranial -> caudal. May become confluent. Koplik spots may also be seen. Recovery After a few days Fever subsides and rash fade http://www.cdc.gov/measles/cases-outbreaks.html Measles Diagnosis Measles Complications • Clinical case definition: • 1 in 1000 cases will develop acute encephalitis – Generalized rash lasting > 3 days – Temperature > 101 • 1-2 in a 1000 children will die from respiratory – Cough, coryza, and conjunctivitis or neurologic complications • Laboratory definition: • Subacute sclerosing panencephalitis (SSPE) – Isolation of the virus (respiratory or urine) is a rare, fatal degenerative disease that – Positive RT-PCR (throat swab) occurs 7-10 years after infection – Positive serologic test for specific IgM • Those at highest risk: <5yo and >20yo, – Rise in specific IgG titers pregnant women, immunocompromised 8
3/18/2015 Current Recommendations and Updates • Serious Bacterial Infections Current Recommendations • Urinary Tract Infections • Community Acquired Pneumonia and Updates • Bronchiolitis • Acute Otitis Media • Influenza Infants <30 days • Multiple studies show clinically significant rates of serious bacterial infections (SBI) Serious Bacterial Infections even in neonates with viral illnesses – Recommended to obtain full set of cultures • Some studies support a staged approach to decision about LP – Infants should be admitted and placed on emipiric antibiotics 9
3/18/2015 Work-up for Febrile Infants 30-90 days • Is the infant well-appearing? – Toxic infants -> full work-up and empiric antibiotics • Is there a source? – Non-specific symptoms do NOT rule out SBI – Named viral syndromes or focal bacterial infections generally do • Stepwise Approach – UTI is most common � all require urine testing – Rapid viral testing should be done – If viral testing + UA are NEGATIVE then a staged approach can be used: • Inflammatory markers (CBC/CRP/Procalcitonin) • If abnormal then proceed with blood cx and empiric antibiotics • Consider LP if toxic/irritable or giving antibiotics Evaluation and Management of Fever in Infants and Young Children” Summary Courtesy of Marmor 2014 Hamilton, Jennifer and John, S. Am Fam Physician. 2013 Feb 15; 87(4):254-206. Current Guidelines: Urinary Tract Infections • Who should have a specimen collected? • Children 2- 24 months with fever without a source requiring antibiotics Urinary Tract Infections – Should have urine obtained by catheterization (cath) or suprapubic aspiration (SPA) • Children 2- 24 months with fever without a source NOT requiring antibiotics – If low risk then no further assessment needed – If high risk then can follow 2 pathways • Obtain urine for UA/Cx by Cath or SPA • Obtain urine for UA/Udip ONLY by any method (includes bag) THEN do a cath or SPA if nitrite or LE positive Roberts 2011; Pediatrics 128(3):595–610 10
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