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INFECTIONS IN KIDSTO TREAT OR NOT TO TREAT?

Andi Marmor, MD, MSEDProfessor of PediatricsUniversity of California, San FranciscoZuckerberg San Francisco General Hospital

I HAVE NOTHING TO DISCLOSE.

Three Common Presentations

u Fever without a source (SBI)u Urinary Tract Infections

u Pharyngitis

u Pertussisu Community Acquired PNA

FEVER DIFFICULTY BREATHING

RASH

u Infections and Mimickers

Case Presentation: Infant with Fever

uXanadu is 2 week old girl with a feveruNo symptoms to suggest a source on

exam/historyuVS: T 38.5, P 150, R 40’s, o/w WNLuExam: well-appearing, no focal findings

to suggest source for fever

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The most likely cause of Xanadu’sfever is:

A. Viral infectionB. Urinary tract infectionC. Serious bacterial infection (SBI)

(bacteremia/meningitis)D. HSV infection

The most likely cause of Xanadu’sfever is:

A. Viral infectionB. Urinary tract infectionC. Serious bacterial infection

(SBI)(bacteremia/meningitis)D. HSV infection

THE FEBRILE INFANT

Everything you need to know about SBI in febrile infants - on ONE SLIDE

Schwartz, 2009, Gomez 2010, Greenhow, 2014

2-3%

E.Coli>GBS>S. aureus>enterococcus, S pneumo13-18%

<1%

Greenhow, 2014

E. Coli

E.Coli/GBSèS. pneumo

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Fever without a source (FWS): Infants <30 days

uAppearance and lab criteria do not reliably rule out UTI/SBI in this age group

uUrine, blood, CSF, empiric abxrecommended ¤Amp/gentamicin or amp/cefotaxime

Fever without a source (FWS): Infants <30 days

uAppearance and lab criteria do not reliably rule out UTI/SBI in this age group

uUrine, blood, CSF, empiric abxrecommended ¤Amp/gentamicin or amp/cefotaxime¤Listeria vanishingly rare…some recommend

treating with cefotaxime alone¤DO NOT treat with gentamicin alone

FWS: Infants 30-90 days

uUTI still the most common bacterial source, other SBI less likely

uViral source more reliable ¤Named viral syndromes or + rapid viral test

(flu, RSV) èSBI unlikely¤Consider testing for UTI

u Inflammatory markers (CBC/CRP/PCT) helpful in select infants¤Well appearing, neg UA AND no viral source

Approach to Infant with FWSno

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Case Continued

uSince Xanadu is less than 30 days, and has no source for her fever, you obtain a UA/urine cx and blood cultures and perform an LP

uHer UA is positive for LE and nitritesuNow what do you do?

URINARY TRACT INFECTIONS (“PYELONEPHRITIS”)

Risk of UTI in Infants with FWS

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UncircBoysCircBoys

Which infants <3 mo should we test for UTI?

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Testing threshold ~2-3%

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Testing threshold ~5%

All Girls

Circ boys <6 moUncirc boys <12 mo

Which infants >3 mo* should we test for UTI?*T≥39 for ≥48hrs Who should we test for UTI?

u All infants with FWS < 3 mo of ageu Girls > 3 mo of age

¤FWS (>39) and < 24 monthsu Boys > 3 mo of age

¤Circumcised: FWS (>39) and < 6 mo¤Uncircumcised: FWS (>39) and < 12 mo

u Additional Risk Factors:¤Length of fever (> 2 days)¤Race (non-black)

Diagnostic Dilemmas

u Collection of urine¤By catheter for:

n Infants < 3 mo of age (high risk) n Ill-appearing/getting antibiotics

¤Consider bag collection for:n Low-risk infant (circ boy> 3 mo, girl/boy>1 year) n If UA +, consider cath for culture

u Results:¤+ UA: start empiric treatment, send for cx¤Neg UA: UTI very unlikely, even in young infants

nConsider sending for culture in high risk neonate

Treatment

u Empiric treatment based on local E. Coli resistance¤PO cephalexin safe, tasty, narrow spectrum¤IV if <2 mo, toxic or not tolerating PO¤Total course: 7-14 days (for pyelo)

u Imaging after UTI ¤U/S in infants <3 mo, older kids if recurrent¤Voiding Cystourethrogram (VCUG) only if high

grade VUR/obstruction on U/S Roberts 2011;Pediatrics128(3):595–610

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Case Continued

uXanadu’s 6 yo brother Zaffre also has a fever, and is complaining of a sore throat

uHis temp is 38.9, he has tender cervical LAN and no cough or runny nose

www.accesspediatrics.com

What is Zaffre’s “modified Centorscore?”

A. 1B. 2C. 3D. 4E. 5

Modified Centor Score

u1 point each:¤Exudate or swelling on tonsils¤Tender/swollen ant cervical LN’s¤Temp > 38C¤Cough absent¤Age 3-14

____________Max score = 5

Modified Centor Score

u1 point each:qExudate or swelling on tonsils??þTender/swollen ant cervical LN’sþTemp > 38CþCough absentþAge 3-14____________Score = 4-5

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What does this mean?

uWhat is Zaffre’s prior probability of a + GAS culture?

A. ~25%B. ~50%C. ~75%D. ~90%

What does this mean?

uWhat is Zaffre’s prior probability of a + GAS culture?

A. ~25%B. ~50% - this is why we test, don’t treat!C. ~75%D. ~90%uWhen should you treat empirically?

¤Scarlet fever, cx + sibling, etc

Case Presentation: 3 yo with cough

uAmaranth is a 3 yo who presents with 2 weeks of cough, keeps her awake, and occasional post-tussive vomiting

uShe has a PMH of bronchiolitis (6 mo) and is up to date for age on vaccinations

uVS: T 38.2, P 130, RR 42, O2 sat 95%uHer mother wants to know if this could be

“the whooping cough”

PERTUSSIS

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Pertussis Epidemiology

Tdap

Acellular pertussis

Phases of Pertussis

PHASE TIME COURSE DESCRIPTION

Catarrhal 1-2 weeks Mild fever, cough, rhinorrhea

Paroxysmal 1-6 weeks Older infants/children:Paroxysms, whoop, post-tussiveemesis 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

uCough lasting >2 weeks + 1of the following:¤Apnea* ¤Paroxysms of coughing¤Inspiratory “whoop”¤Post-tussive vomiting (least specific)

cdc.gov/pertussis

Older children

*May occur without cough

Neonates/young Infants

Pertussis: Laboratory Confirmation

u Lab confirmation ONLY in those with signs/symptoms consistent with pertussis

uPosterior NP specimen (not pharynx/ant NP)uPCR for pertussis

¤False positives may occuruCulture + for B. Pertussis

¤Most SPECIFIC testuMost sensitive in first 3 weeks

cdc.gov/pertussis

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Pertussis: Treatment

u Major benefits:¤Prevent severe disease* in those at risk¤Prevent spread to high risk (HR) patient

u Empiric treatment: high suspicion and/or HR ¤ Infants <1 year (< 3mo, preemie at highest risk)¤Pregnant women near term¤Unimmunized or underimmunized

u Test and treat if +:¤HR but low clinical suspicion¤Patient LR but has HR contacts

*Only treatment BEFORE paroxyms may shorten course

Case Continued

uAmaranth’s vaccination status and non-specific clinical symptoms make pertussis less likely

uHowever, her RR (42) and O2 sat (95%) make you concerned for pneumonia¤Well-appearing, in minimal resp distress

aside from tachypnea¤Decreased breath sounds with crackles over

the LLL

What is the RECOMMENDED next step?

A. Obtain a PA and lateral CXRB. Obtain a blood culture and CBCC. Obtain a sputum cultureD. Start PO amoxicillin and discharge with

close follow upE. Start IV cefuroxime and admit

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

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Pediatric CAP: Diagnosis

uClinical¤Symptoms of acute illness (ie: fever) + resp

distress (tachypnea*, retractions, hypoxia) AND¤Focal lung findings on exam OR on CXR

u Imaging¤Chest x-ray NOT recommended routinely in

outpatients¤Does not distinguish between pathogens (viral,

atypical, etc)

Bradley JS, et al. Clin Infect Dis. 2011

*MOST SENSITIVE sign

Pediatric CAP: Labs

u Routine lab testing NOT recommendedu Blood cultures:

¤ Clinically worsening or hosp with mod/severe diseaseu Viral testing (flu, RSV)

¤ IF no evidence of bacterial co-infectionu CBC/CRP

¤ Not recommendedu Testing for Mycoplasma pneumoniae, S. pneumo

¤ If available, may guide antibiotic selection

Bradley JS, et al. Clin Infect Dis. 2011

Pediatric CAP: Causes

¤ Viral is most common¤ < 2 yrs: S. pneumoniae, C.

Trachomatis¤ 2-5 yrs S. pneumoniae >

M. pneumoniae, H influenzae, C. pneumoniae

u M. pneumoniae> C. pneumoniae, S. pneumoniae

2 MO TO 5 YRS: OVER 5 YEARS:

Bradley JS, et al. Clin Infect Dis. 2011

uBased on age, severity, local resistance

Community Acquired Pneumonia: Treatment

u Inpatient or Outpatient 1st line treatment:¤Amoxicillin/ampicillin in infants and young children ¤Consider Macrolide (azithro) in kids > 5

u Ill patent or high-level PCN resistance: ¤3rd generation cephalosporin if suspect S. pneumo¤Vancomycin if suspicion for MRSA¤+Macrolides if suspicion high for M. pneumoniae

and C. pneumoniae

Bradley JS, et al. Clin Infect Dis. 2011

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What is the RECOMMENDED next step?

A. Obtain a PA and lateral CXRB. Obtain a blood culture and CBCC. Obtain a sputum cultureD. Start PO amoxicillin and discharge with

close follow upE. Start IV cefuroxime and admit

NAME THAT RASH

Toddler with fever, refusing po’sdrooling…

Hand- foot-mouth disease(coxsackie virus)

Examples of “atypical coxsackie”

Eurosurveillance.orgPediatrics.aapublications.org

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5 yo comes back from camp with fever, cough and runny nose, then develops rash proceeding head to toe

PHASE TIME COURSE DESCRIPTION

Prodromal 2-3 days Fever + 3 C’s: cough, coryza (runny nose), conjunctivitis

Exanthem 3-5 days Erythematous macules proceed cranial -> caudal. May become confluent. Koplik spots

Recovery 5+ days Fever subsides and rash fades

Measles

Measles Fast Facts

u Droplet/airborne spread, ~90% u 2 doses of vaccine = 97% effectiveu Dx by serology (IgM or rise in IgG) or PCRu High risk = <5yo or >20yo, pregnant,

immunocompromisedu Severe/fatal complications:

¤Encephalitis: 1/1000 ¤Resp/neurologic complication: 1-2/1000 ¤Subacute sclerosing panencephalitis (SSPE): rare

u No specific treatment (vit A for severe illness)

9 mo old with high fever for 3 d, fever gone then w/rash on chest èhead

Roseola infantumTypically caused by Human Herpes Virus (HHV) 6 or 7

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10 mo old with rash on day 7 of amoxicillin for AOM

From: Consultant 360

• Rash started on day 6 of treatment• Started truncally, spread to head and

extremities, including palms and soles• Not itchy, otherwise well

Amoxicillin Drug Eruption

u Delayed hypersensitivity (T-cell mediated, Type IV) reaction ¤Morbilliform, often includes palms and soles,

day 5-10 of treatmentu NOT a drug allergy, and not associated with

advancement to anaphylaxis¤Allergy = itchy, urticarial, within hours, may

progress u May affect up to 10% of pedi pts treated

with amox or PCNu Future use of amox NOT contraindicated

7 yo with fever, sore throat now with dry, diffuse rash most pronounced on trunk and face

Group A Streptococcal “Scarlet Fever”

5 yo with temp of 39 for 5 days

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Kawasaki Disease

uUnknown etiology (?ID?)uClinical diagnosis: Fever x5d = 4/5

clinical criteriauSignificance: coronary artery aneurysmsuTreatment: IVIG

C (conjunctivitis) R (rash) A (adenopathy) S (strawberry tongue)

H (hands and feet)

Unusual color names…

Xanadu

Zaffre

Amaranth

References

1. Greenhow TL, et al. The changing epidemiology of serious bacterial infections in young infants. Pediatr Infect Dis Journal 2014; 33(6): 595-599

2. Roberts KB and the Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.” Pediatrics. 2011;128(3): 595–610

3. Lieberthal, A et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics 2012; 131(3): e964-e999

4. Bradley, J. et al. The Management of Community- Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Disease Society of America. Clin Inf Dis. 2011; 53(7): e25-e76