Pediatric Infection in the Vaccinated Era: Should We Be Concerned? - PowerPoint PPT Presentation

Pediatric Infection in the Vaccinated Era: Should We Be Concerned? Dr Bashir Youssef

DISCLOSURE I do not have any relevant financial relationship with commercial interest to disclose.

Learning Objectives • Distinguish life threatening from simple pediatric infection • Discuss the effect of vaccination on the prevalence of bacterial and viral infection • Evaluate and apply the available management guidelines.

Background • Infection/sepsis is one of the leading causes of morbidity/mortality among children worldwide In USA: • >42,000 cases of severe sepsis in children <18rs old annually • 1/2 of children with severe sepsis are infants • Hospital mortality in children with severe sepsis:10.3% Pediatr Crit Care Med.2005 May;6(3 Suppl):S3-5

Category of Patients Jan 2018 – Nov 2018 PEC Al Saad 4500 4117 3853 4000 Number of Patients 3500 3000 2500 2000 1500 1000 411 500 146 69 17 17 8 0 Urinary tract Pneumonia Sepsis Bacteremia Meningitis Septic arthritis Osteomyelitis Septic shock infection Total Patient Visited (PEC Al Saad) Jan 2018 – Nov 2018 : 322569

How to Differentiate Between Simple and Serious Infection? “Searching for a needle in haystack” • Clinical assessment Ø Detailed history Ø Thorough clinical examination; ?focus on features consistent with diagnosis Ø Screening system, (Yale observing scale score, traffic light system) • Investigation: Ø CBC(WBCs, ANC…) Ø CRP Ø PCT Ø Urine, CXR, others as indicated

Observation Scales to Identify Serious Illness in Febrile Children “YOS” 320 Febrile children, ED/ primary care; 37 SBI Score ≤ 10: 2.7% had serious illness Score ≥ l6 : 92.3% had serious illness Specificity:88%; sensitivity:77% NB: not applicable to <60days old infant. Pediatric July 2017 PEDIATRICS Vol. 70 No. 5 November 1982

Traffic light system for identifying risk of serious illness in under 5yrs: NICE NICE, 2013

Management of Children 3 months to 5 years Assess: look for life-threatening, traffic light and specific diseases symptoms and signs Perform: Perform (unless deemed unnecessary) • Perform test for urinary tract • blood culture • urine test for urinary tract infection infection. • full blood count • full blood count • Assess for pneumonia. • urine test for urinary tract infection • blood culture • Do not perform routine blood • C-reactive protein. tests or chest X-ray. • C-reactive protein. Consider the following, as guided by clinical Perform chest x-ray if fever higher than 39 ° C and assessment: white blood cell count greater than 20 x 10 9 /litre. • lumbar puncture in children of all ages • chest X-ray Consider lumbar puncture if child is younger than 1- • serum electrolytes year old . • blood gas. If no diagnosis is reached, manage the child at home with appropriate care advice. Consider admission. If admission is not necessary but no MICE, 2013 diagnosis has been reached, provide a safety net for the parents/carers.

The Predictive Value of the NICE "Red Traffic Lights" in Acutely Ill Children • 6260 pts • Nearly all red features had rule-in value for SI • only 4 red features significantly raised the probability of SI: v ‘‘ does not wake/stay awake’’, v ‘‘reduced skin turgor’’, v ‘‘non-blanching rash’’, and v ‘‘focal neurological signs ’’. • Combined 3 red features improved prediction of SI . LH 5

Can inflammatory markers help to predict serious infection?

CRP in Febrile Children 1 to 36 Ms With Clinically Undetectable Serious Bacterial Infection •To find how helpful CRP to predict the risk of SBI •Prospective cohort study •77 children, T >39°C. •WBCs, ANC, CRP, Urine analysis, BC, …… •14 (18%) had a SBI : 6 UTI; 4 pneumonia, 4 bacteremia… Pulliam et al (2001) Pediatrics. 2001 Dec;108(6):1275-9

C-Reactive Protein in Febrile Children 1 to 36 Months of Age With Clinically Undetectable Serious Bacterial Infection Sensitivity (95% Specificity (95% Likelihood Ratio Variable Cutoff Point CI) CI) (95% CI) PPV (95% CI) NPV (95% CI) B 15.0 64 (35.8, 85.9) 67 (53.6, 77.7) 1.9 (1.1, 3.1) 30 (14.7, 49.4) 89 (76.9, 96.5) WBC (thousand/mm 3 ) E T 10.2 71 (42.2, 90.3) 76 (63.6, 85.6) 3.0 (1.7, 5.1) 40 (21.1, 61.3) 92 (81.5, 97.9) ANC (thousand/mm 3 ) T E 7.0 79 (49.0, 94.2) 91 (79.8, 96.0) CRP 8.3 (3.8, 27.3) 65 (38.3, 95 (86.1, R concentration 85.8) 99.0) (mg/dL)

CRP Likelihood Posttest Concentration Ratio (95% Probability of (mg/dL) CI) SBI I >9 9.0 (3.2, 25) 67% N C 7–9 6.8 (1.4, 31) 60% R E A 5–7 1.8 (0.42, 7.0) 29% S E <5 0.087 (0.02, 1.9% 0.38) Pre test probability: 18% Area under the curve for CRP 0.905; for ANC 0.805 and for WBC 0.761 Pulliam P N et al. Pediatrics 2001;108:1275-1279

Bedside procalcitonin and C-reactive protein tests in children with fever without localizing signs of infection seen in a referral center • Prospective study, 99 children, 7 days to 36 ms, with fever >38 • PCT, CRP, and IL-6 values compared with the total WBCs and clinical score • SBI in 29 pts(29%): Ø 4 occult bacteremia, Ø 21 pyelonephritis, Ø 2 lobar pneumonia, Ø 1 mastoiditis, Ø 1 retropharyngeal abscess Galetto-Lacour A et al. Pediatrics 2003;112:1054-1060

Sensitivity, Specificity, and Predictive Values of Markers of SBI Sensitivity (% [95% CI]) Specificity (% [95% CI]) NPV (%) PPV (%) PCT (0.5 ng/mL) 93 (77–99) 74 (62–84) 96 60 B CRP (40 mg/L) 79 (60–92) 79 (67–88) 90 61 Leukocytes ≥ 15 G/L 52 (33–71) 74 (62–84) 78 45 E T Band ≥ 1.5 G/L 11 (2–28) 93 (84–98) 72 38 38 T Leukocytes ≥ 15 G/L or band 55 (36–74) 72 (61–83) 80 46 ≥ 1.5 G/L E R IL-6 (100 pg/L) 36 (13–65) 80 (64–91) 77 38 YOS score >10 23 (5–54) 82 (67–92) 76 30 Galetto-Lacour A et al. Pediatrics 2003;112:1054-1060

• Children with SBI more likely to have high inflammatory markers • PCT and CRP performed better than IL-6, WBC, ANC in predicting SBI • Using inflammatory markers improve clinicians' abilities in the early recognition of clinically undetectable SBI. • A single value gives a probability but never a certainty of presence or absence of SBI

Learning Objectives • Distinguish life threatening from simple pediatric infection • Discuss the Impact of vaccination on the prevalence of bacterial and viral infection • Evaluate and Apply the available management guidelines

Bacteremia in Children 3 to 36 Months Old After Introduction of Conjugated Pneumococcal Vaccines PEDIATRICS Volume 139 , number 4 , April 2017

Rate of all bacteremia by organism per 100 000 children per year between 1998 and 2014. Tara L. Greenhow et al. Pediatrics doi:10.1542/peds.2016-2098

Post PCV13 • Pneumococcal bacteremia in healthy children become rare • E coli; salmonella ; staph aureus become more common. • Bacteremia more likely to occur with a source. • focused examination should be performed and appropriate studies should be obtained

Impact of meningococcal C conjugate vaccine in the UK J. Med. Microbiol. — Vol. 51 (2002), 717–722 - - - -, age <20 1999 2001 Laboratory-confirmed cases J Med Microbiol. 2002 Sep;51(9):717-22.

Impact of Hib vaccination on Haemophilus Influenzae Disease in France Epidemiol. Infect. (2013), 141, 1787–1796

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Pediatric Infection in the Vaccinated Era: Should We Be Concerned? • Distinguish life threatening from simple pediatric infection • Discuss the effect of vaccination on the prevalence of bacterial and viral infection • Evaluate and Apply the available guidelines Ø Septic shock management Ø Bacterial meningitis Ø Urinary tract infection Ø Pneumonia

Septic Shock Optimization Care • Recognition Bundle • Trigger tool • Rapid clinical assessment • Activation of sepsis resuscitation bundle • Resuscitation/stabilization bundle • Securing venous access • Fluid resuscitation • Blood culture • Antibiotics • Inotropic support • Monitoring the response • Performance Bundle Critical Care Medicine, June 2017 • Volume 45 • Number 6

American Academy of Pediatrics trigger tool for early septic shock recognition, Crit Care Medicine 2017;45:1061 .

American College of Critical Care Medicine algorithm for time-sensitive, goal- directed stepwise management of hemodynamic support in infants and children. Critical Care Medicine, June 2017 • Volume 45 • Number 6

Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis OR 3.52 130 pts, Initial management in ED/Inpatient before transfer to PICU PICU mortality 16 (12%) OR 2.43 Increased risk of mortality with each hour delay OR 1.67 but did not reach significance till 3hrs delay OR 3.92 3hrs delay is independent risk factor Crit Care Med. 2014;42(11):2409–17

Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome • Whether early septic shock reversal and use of 96% resuscitation as (ACCM-PALS Guidelines) associated with improved outcome? 63% • A 9-year (Jan 1993–Dec 2001) retrospective study P<.001 • 91 patients: 26 died(29%) 92% 62% Conclusion: Early recognition and aggressive resuscitation of septic shock can save lives P<.001 PEDIATRICS Vol. 112 No. 4 October 2003