Pediatric Infectious Disease

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Common Cold causes

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caused by >100 viruses including rhinovirus, parainfluenza v, coronavirus, and RSV

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Common Cold sx and tx

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low grade fever, rhinorrhea, cough, and sore throat for 7-10 days. if >10 days, think superinfection. Tx is adequate hydration and exclusion of more serious causes.

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Sinusitis Causes and Tx

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If acute (10-30) days or subacute (30-90 days)-S pneumoniae, H influenza, M catarrhalis.
Tx-->Amoxicillin or amoxicillin-clavulanate

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Pharyngitis causes

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Viral -coxsackievirus, EBV, CMV
Bacterial- Streptococcus pyogenes-GABHS; C diptheriae; Arcanobacterium hemolyticum

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Pharyngitis Sx and Tx

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Viral-simple URI sx +/- tonsilar exudates. EBV-may have enlarged cervical LN + hepatosplenomegaly. Coxsackie-may have painful vesicles or ulcers on posterior pharynx or hand-food-mouth disease (palms/soles).
Bacterial-GABHS-strep throat-school aged kids-see fever, scarlatiniform rash in some, lack of other URI sx; and exudates on tonsils, petechiae on soft palate, strawberry tongue, and enlarged anterior cervical LN

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Pharyngitis Management

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Viral-supportive
Bacterial-oral PCN or erythromycin if allergic
Diptheria-oral erythromycin or parenteral PCN and antitoxin

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Otitis Media Causes

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Acute infection of middle ear sapce
caused by S pneumo, H influenza, and Moraxella catarrhalis.

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Otitis Media Dx

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Proper diagnosis depends on ID of fluid in middle ear space in presence of symptoms. Pneumatic otoscopy is most reliable. Erythema and loss of tympanic membrane landmarks-less reliable.

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Otitis Media Tx

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Tx includes (1) amoxicillin; or if B-lactamase resistant (2) Augmentin; or if really resistant (3) ceftriaxone

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Epiglottis Etiology

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Acute inflammation and edema of supraglottic area

Caused by H influenza type B, and Group A b-hemolytic strep (GABHS)

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Epiglottis Clinical Features

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Abrupt onset of rapidly progressive upper airway obstruction-high fever, toxic appearance, muffled speech, dysphagia with drooling, and sitting forward in tripod position. Complete airway obstruction can happen at any time.

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Epiglottis Dx and Management

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CBC-shows inc WBC with left shift; 90% of patients have + blood cultures if due to HIB. See cherry red epiglottis on exam-be careful not to irritate throat.
Management-this is a medical emergency, controlled nasotrachael intubation with minimal stimulation; Abx therapy-2nd or 3rd gen cephalosporin IV-ceftriaxone or
cefuroxime ; and rifampin prophylaxis to household if HIB

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Croup (Laryngotracheobronchitis) -
What is it

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Inflammation of larynx and upper airway, mainly subglottic space => narrowing of airway
kids 3 mos. - 3 yrs.
Viral croup is most common cause of stridor-see parainfluenza (most common) and RSV, rhinovirus, adenovirus, influenza A/B, and Mycoplasma.

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Croup (Laryngotracheobronchitis) -
Hx/PE and DX

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Prodrome - URI Sxs 1-7 days
stridor - worse by agitation
fever - low grade
hoarseness
barking cough

Dx is clinical. Steeple sign on CXR

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Croup TX

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Mild - cool mist and fluids.

moderate -oral corticosteroids

severe -(resp. distress at rest)
admit + racemin epinephrine aerosols-vasoconstricts subglottic tissues.

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Bronchiolitis Causes

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It is inflammation of the bronchioles. Most common lower respiratory tract infection in first 2 years of life-occurs from Nov to April.

Etiology-RSV is most common

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Bronchiolitis DX

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Dx is clinical
See gradual onset with URI that progresses to tachypnea, fine rales, wheezing with lung hyperinflation. hyperresonance to percussion Hypoxemia may occur.

CXR-hyperinflation, patchy infiltrates, and atelectasis. Improvements in 2 weeks.

ELISA of nasal washings for RSV -
hi sens & spec

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Bronchiolitis Tx

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Tx is primarily supportive-nasal bulb suctioning, hydration, and O2 as needed.

admit if -
marked resp distress
O2 saturation < 95%
toxic appearance
dehydration/poor oral feeding
premie (< 34 wks)
< 3 mos. old
underlying cardiopulmon dis.
unreliable parents

Ribavarin may be helpful for very ill infants.

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Pneumonia Causes

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Infection and inflammation of lung parenchyma.
Etiology
0-3 months: congenital infections like CMV, syphilis, HSV; intrapartum infections-like GBS

3 months-5 years-viruses like adenovirus, influenza A/B, parainfluenza, and RSV; or bacteria like Strep pneumo, S aureus, HIB

Age 6 or older-Mycoplasma, Chlamydia, adenovirus, influenzas, and S pneumo

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Pneumonia Dx and Tx

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*Viral-PE of URI, tachypnea, wheezing, rales, etc. DX by interstitial infiltrates on CXR and WBC > 20,000. Tx is supportive
*Bacterial-sx have rapid onset with greater severity. See decreased breath sounds, rales, tachypnea on exam. Dx by WBC >20,000 wiht lobar consolidation. Management-Abx and supportive care
*Chlamydia -afebrile pneumonia at 1-3 monts of age. See staccato-type cough and +/- hx of conjunctivitis. Dx by eosinophilia and CXR with interstital infiltrates. Tx with erythromycin or azithroymycin
*Mycoplasma pneumonia-most common causes in adolescnet. May see widespread rales on exam. Dx by positive cold agglutinins, CXR findings of bilateral diffuse infiltrates, and by inc IgM titesr for Mycoplasma. Tx-erythromycin or azithromycin.

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Chlid with fever at 0-1 month

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Group B Strep, E coli, LIsteria
Prophylatic-Ampicillin + cefotaxime

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Child with fever at 1-3 months

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GBS, Strep pneumo, Listeria
Prophylatic-Ampicillin + cefotaxime and + vanc if suspect menigitis (high resistnace of pneumo)

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Child with fever 3 months-3 years

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Strep Pneumo, H influenza type B, Neisseria meningitidis
Prophylatic-Cefotaxime + vanc if suspect meningitis

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Child with fever > 3

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Strep pneumo, Neisseria
Prophylatic-Cefotaxime + vanc if suspect meningitis.

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FUO

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Fever that lasts longer than 8 days-3 weeks with no diagnostic findings.

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Meningitis-Acute Bacterial

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CSF: WBC >50,000 + PMNs, High protein, and low glucose, + gram stain

Sx-infants may present with nonspecific findings; in older kids-may see nuchal rigidity, seizures, photophobia, emesis, HA

Tx-Newborn (amp + 3rd gen cephalosporin like cefotaxime)
Infants (amp +3rd gen +/-vanc)
Children (third gen cephalo +/-vanc)
+/- corticosteroids

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Meningitis-Viral

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CSF-WBC 10-1,000-lymphocytes, normal to high protein and normla glucose. Enterovirus and HSV can be identified by PCR

Etiology-Enterovirus (summer, fall), mumps, HSV, arbovirus-encephalitis. lymphocytis choriomeningitis.

Tx-most are self limited. HSV tx with acyclovir.

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Infectious Mononucleosis Causes and Symptoms

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EBV is major cause. Transmitted primarily by saliva. Other agents can also cause it including toxoplasmosis, CMV, and HIV.

Symptoms: young kids may be asymptomatic. fever, malaise, fatigue, pharyngitis (exudative-resembles GABHS), posterior cervical lymphadenopathy, hepatosplenomegaly, +/- macular of scarlatiniform rash. Lasts weeks to months.

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Infectious Mono Diagnosis

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-CBC-atypical lymphocytes
-Monospot-Diagnosis EBV-sensitivity of 85% but less so if <4 yrs.
-EBV antibody titers for <4 yrs: acute infection dx by finding elevated levels of IgM-VCA

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Mono Treatment and complications

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Therapy is mostly supportive, corticosteroids sometimes used for severe pharyngitis.

Complications: neurological (CN palsies, etc), upper airway obstruction, amoxicillin associated rash, splenic rupture, malignancy (Burkitt's Lymphoma)

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Measles

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-Caused by RNA virus of Paramyxoviridae family.
-Is highly infectious.
-8-12 day incubation period
-Classic prodrome: cough, conjunctivitis, and coryza, low grade fever
-Enanthem (rash on skin) see Koplik spots (pathognomonic-gray papules on red base on buccal mucosaz)-->generalized enanthem
-generalized rash-starts on neck and ears and spreads down
-tx is supportive, vitamin A

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Rubella-German Measles

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-RNA virus-togavirus family
-Highly infectious
-incubation period of 14-21 days
-Is mild and often asymptomatic
-Prodrome-mild URI sx
-Painful lymphadenopathy
-See exanthem after adenopathy is nonpruritic, maculopapular and confluent. begins on face and spreads down.
-complications: meningoencephalitis, polyarteritis, congenital rubella sx

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Congenital Rubella Syndrome/CRS

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Occurs after primary maternal infection during the first trimester. Fetal anomalies occur in 30-50% of infected fetusus.
Presenting features include "blueberry muffin" purpura, jaundice, thrombocytopenia, hepatosplenomegaly.
-structural abnormalities include congenital cataracts and PDA, and sensorineural hearing loss.

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Vomiting/Diarrhea Differential Diagnosis

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Gastroenteritis (viral vs bacterial vs parasitic)
Toxin Ingestion
GI obstruction (congenital vs acquired)

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Viral Gastroenteritis

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(1) Rotavirus most common in winter months-incubation periods for 1-3 days, diarrhea is usually self limited and lasts 4-7 days. ELISA of stool is used to make the diagnosis. Treatment is supportive-hydration.
(2) Norwalk virus: RNA virus spread by fecal-oral route-common in daycare groups, usually seen in outbreaks, management is supportive
(3) Enteric Adenovirus

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Bacterial Gastroenteritis

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(1) Enterotoxigenic E coli (ETEC): major cause of traveler's diarrhea-watery diarrhea
(2) Enteropathogenic E Colic (EPEC) noninvasive watery diarrhea seen in preschoolers, tx w/oral sulfas
(3) Enterhemorrhagic E coli (EHEC) Bloody diarrhea with endotoxin release causing HUS, see WBCs in stool
(4) Shigella sonneiL bloody diarrhea, + stool WBCs; third generation cephalosporins
(5) C jejuni: bloody diarrhea; stool WBCs, self resolving
(6) Yersinia:
(7) C diff: common after Abx use
(8) Vibrio Cholera: seen in developing countries, watery diarrhea with massive water loss
(9) Salmonella bloody diarrhea, fever; headaches, myalgias, and arthralgias; contact of lizards, turtles; outbreaks

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Gastroenteritis Parasitic

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(1) Giardiasis-common in day cares, infection occurs by ingestion of cyst, usually occurs as endemic, diarrhea is voluminous, watery, and foul-smelling; also see bloating, flatulence and weight loss. Tx is metronidazole

(2)Amebiasis-ingestion of cyst in food or water. May see cramping abdominal pain and diarrhea with blood or mucus.

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Gram Positive Bacteria

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- a lot of peptidogylcan in cell wall
-Bacillus, Listeria, Staphylococcus, Streptococcus, Enterococcus, and Clostridium

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Gram Negative Bacteria

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-thin peptidoglycan wall
-outter membrane containing LPS

* Cocci: gonorrhoeae, neisseria, Moraxella catarrhalis

*Bacilli: Hemophilus influenzae, Klebsiella pneumoniae, Legionella pneumophila, Pseudomonas aeruginosa; Escherichia coli, Proteus mirabilis, Enterobacter; H pylori, Salmonella.

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Penicillin

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*Classic-used now mainly for GABHS, syphillus, Neisseria M, susceptible pneumo, and enterococcus

*Newest PCN: Augmentin (po) vs Unasyn (IV)-contains PCN + B-lactamase inhibitor-used for MSSA, Strep, Enterococcus, and Anaerobes. Use for BITES.

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Ampicillin
Amoxicillin

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Good for H flu, GABHS, Listeria and enterics (E coli, Salmonella, Klebsiella). Can also use for syphillus and enterococcus (but PCN is first line).
Clinically use for (1) sinusitis (amox); (2) meningitis in newborn and infants (amp); otitis media (amox-then augmentin if resistance).

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1st generation cephalosporins-cefazolin, cephalexin

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(1) Good for gram positive cocci. (2) PEK-Proteus, E Coli, Klebsiella.
Uses include (1) MSSA-susceptible bone/joint infection; (2) UTIs (3) GABHS alternative.

Does not cross CSF

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2nd generation cephalosporins-cefoxitin, cefaclor, cefuroxime

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Created for H flu. Has really been displaced by 3rd generation cephalosporins.

Good for gram positive cocci-H influenza, Enterobacter, Neisseria, Proteus mirabilis, E Coli, Klebsiella pneumonia

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3rd generation cephalosporins-ceftriaxone, cefotaxime, ceftazidime

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Uses (1) resistant gram negative enterics (E Coli, Klebsiella, Salmonella); (2) Meningitis-great CSF penetration + covers Strep pneumo, H flu, Neisseria; (3) PCN resistant gonorrhea, (4) epiglottis, (5) number one choice for salmonella

Don't use for CAPES (citrobacter, acetobacter, pseudomonas, enterbacter, serratio) secondary to inducible resistance-->use cefepime

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Vancomycin

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Used for serious gram positive multidrug resistant organisms-including S aureus and C diff. Use in meningitis if suspect Strep Pneumo which has high PCN resistance.