Sample Case Presentation- Occult Bacteremia

8/13/2019 Sample Case Presentation- Occult Bacteremia

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Infectious DiseaseOccult Bacteremia

5CLPH SG1

Armes, Janella V.

Bagazin, Precious G.


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Bacteremia s the presence of viable bacteria in

the circulating blood.

Most episodes of occult bacteremiaspontaneously resolve.

Streptococcus pneumoniaeand Salmonella, andserious sequelae are increasingly uncommon.

Occult Bacteremia


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Patients with occult bacteremia by definition do

not have clinical evidence other than fev

Occult bacteremia has been defined asbacteremia not associated with clinical evidence

of sepsis or toxic appearance, underlying

significant chronic medical conditions, or clear

foci of infection upon examination in a patient.

Occult Bacteremia


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Much of the pathophysiology of occult bacteremia is not fully understood.

bacterial colonization of the respiratory passages

bacteria may egress into the bloodstream of somechildren

Bacteria may be spontaneously cleared, they may

establish a focal infection, or progress to septicemia

possible sequelae of septicemia include shock,disseminated intravascular coagulation, multiple

organ failure, and death.

Pathophysiology


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Signs and Symptoms

The condition is not manifested by any

clinical signs.

Duration of fever (fever is the only

manifestation)

History that indicates a specific illness

History that indicates risk for occult

bacteremia

History of an underlying medical condition

History of prematurity


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Signs and Symptoms

History of another reason for an increased

temperature

History of gastroenteritis


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Risk Factors

Studies of the prevalence of bacteremia in

children in diverse settings have identified no

racial, geographic, or socioeconomic

predisposition.

No sex-based difference in the prevalence or

course of bacteremia is known.

Studies of occult bacteremia focus on children

younger than 3 years.


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Patient Demographics

PtCJS

Age

4 y/o

SexFemale

Allergy

NKA

Admitted

Jan 1,2014

Height103 cm

Weight13.5kg

FEVER

Final

Diagnosis

Occult

Bacteremia


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History of Present Illness

One day prior to admission

Pt experienced intermittent

fever with Tmax of 38C.Patient was given

Paracetamol (125mg/5mL) 5

mL every 4 hours which

provided temporary relief of

fever. This was accompanied

by 2 episodes of vomiting- 3tablespoons of previously

ingested food. No other

symptoms noted.

Interval History

persistence of fever

with no dyspnea, hematuria,

dysuria, abdominal pain and

diarrhea noted.


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History of Present Illness

Few hours prior to admission

due to persistence of fever

patient sought consult to a

local clinic . CBC andurinalysis were done advised

admission. Due to financial

constraints patient

transferred to our institution.

HgB 111Hct 0.33

WBC 17.08

N 0.81

L 0.18

E 0.01

platelet 378yellow cloudy, pH 6.0

SG 1.020,

Protein 0.3 g/dL

Sugar (-)

WBC 12-15/hpf

RBC 1-3/ hpf

Epithelial cell: few

bacteria: moderate

mucus threads:

moderate


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PMH Hospitalizations: none

Operations: none

Accidents: none

Blood Transfusion: none Allergies/Drug Reactions: none

Patient Histories


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Family History

(-) DM, HTN,Asthma, Allergies,Cancer, TB

Social History

patient lives withparents

not exposed to

cigar and airpollution

Patient Histories


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Medication History

Paracetamol (125mg/5mL) 5 mL every

4 hours


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VitalSigns

Temp38.3 C

PR

120 bpm

RR

24

bpm

BP

100/60mmHg

Vital Signs


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(-) wt loss, (-) diaphoresis, (-)anorexia

GeneralAppearance

(-) blurring of vision, (-) deafness, (-) epistaxis, (-) bleeding gums, (-)sores

HEENT

(-) itchiness, (-) color change, (-)pigmentation, (-) rashSkin

Review of Systems


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(-) colds, (-) dyspneaLungs

(-) easy fatigability, nopalpitations, (-) chestpain

Cardio-Vascular

Review of Systems


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(-) constipation, (-)

diarrhea, (-) incontinenceAbdomen

(-) joint pain/effusion, (-) jointstiffnessExtremities

Review of Systems


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Conscious , coherent, carriedby mother, ill-looking, not incardiorespiratory distress

General

Survey hair evenly distributed, no scalp lesions

pink palpebral conjunctivae, anicteric

sclera impacted cerumen AU

(+) nasal dischargeHEENT

Physical Examination


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Warm, dry skin, with goodturgor, no jaundice, no cyanosisSkin

Symmetrical chest expansion,

no retractions, equal vocal andtactile fremiti, resonant, normalbreath soundsLungs



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Adynamic precordium, (-)heaves, thrills, lifts, S1>S2 atapex, S2>S1 at base, Apex beat

at 5th

LICS MCL

Cardio-

Vascular

Soft and flabby abdomen,

normoactive bowel sounds,tympanic, non-tender, nomasses palpated

Abdomen



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(-) Edema, (-) Cyanosis, nodeformities, pulses full and

equal

Extremities



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Cerebrum: conscious, coherent

Cranial Nerves:

CN I

not assessedCN II pupils 2-3mm ERTL

CN III, IV, VI full and equal

extraocular movementCN V1-V3 no sensory deficits

Neurological Exam


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CN VII can raise eyebrows, puff cheeks,smile, nonshallow nasolabial fold,

symmetrical

CN VIII gross hearing intact CN IX, X can swallow, intact gag reflex

CN XI can shrug shoulders and turn

head against resistance

CN XII tongue midline in protrusion

Neurological Exam


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Neurological Exam

Motor: 5/5 bilateral upper extremities

Cerebellum: no ataxia, no

dysdiadochokinesia

Sensory: no deficits

Reflexes: +2DTR on all extremities

Meningeal Irritation: (-) Babinski, (-) nuchalrigidity


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LABORATORY AND ANCILLARYSERVICES


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PATIENT MLA NORMAL VALUES

Hemoglobin 111g/L 120- 160 g/L LOW

RBC 4.29x 106/L 3.6-5.2 x 106/L NORMAL

Hematocrit 0.34 0.28-0.46 NORMAL

MCV 78.20 76-100 fL NORMAL

MCH 26 23-34 pg/cell NORMAL

MCHC 33.20 31.5 36.3 g/dL NORMAL

RDW 12.50 IU/L < 35 IU/L NORMAL

MPV 6.10 6.4-10.4 fL NORMAL

PT 371 150-400 x 109/L NORMAL

WBC 29.10 4.0-10.0 x 109/L HIGH

CBCwith Plt

Laboratory and Ancillary Services


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PATIENT MLA NORMAL VALUES

Neutrophils 0.86 0.54-0.62 HIGH

Lymphocytes 0.14 0.25-30 LOW



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UA Color Light YellowTransparency Slightly turbid

pH 6.0

SG 1.020

Protein ++

Sugar (-)

Ketone (+)

Urobilinogen Normal

Bilirubin (-)

Nitrite (-)

Erythrocytes (+)


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UALeukocytes (+)

RBC 0-1/hpf

Pus cells 2-3 hpfMucus threads None

Bacteria Few

Renal Cells None

Amorphous Urates FewCasts None


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COURSE IN THE WARDS


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Course in the Wards

Day 1(January 1, 2014)

Meds

IVF: D5 0.3% NaCl 500 mL torun at 16-17 gtts/min (100%)

Ampicillin-Sulbactam 500mg/SIV infusion over 30 mins

based on Ampicillin content(q6 hrs) (-) ANST;

148mg/kg/day

Labs

-blood C/S

-CBC withplatelet

-urinalysis

-peripheralblood smear

Others

Diet for AGEMonitor vital signsevery 4 hours and

record

Monitor input and

output every shiftWatch out for

vomiting, abdominalpain, and diarrhea


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Course in the Wards

Day 2

(January 2, 2014) 1:35AM

Meds

Continue standing meds

Paracetamol 120mg/5mL,give 6mL every 4 hours

For temp > 38.3 degreesCelsius or as needed

Labs Others:


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Course in the Wards

Day 2

(January 2, 2014) 4AM

Meds

Continue standing meds

IVF to follow: D5 0.3% NaCl500mL to run at 16-17

gtts/min

Labs

blood CS with ARD

Facilitate Peripheral

Blood Smear

Others:

Measure input, outputaccurately


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Course in the Wards

Day 2

(January 2, 2014) 9:30AM

Meds

Hydrogen peroxide, instill 2-3drops each 3x/day for 5 days

D5 IMB 500mL to run at 12-

13gtts/min

LabsOthers:

Increase oral fluidintake


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Course in the Wards

Day 3

(January 3, 2014)

Meds

D5 IMB 500mL to run atsame rate (12-13gtts/min)

Labs

Request CBC with pltOthers:


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Course in the Wards

Day 4

(January 4, 2014)

Meds

Ampicillin-Sulbactam 500mg/SIVP

shifted

Co-amoxiclav 457mg/ 5mL,3mL every 12 hours

Labs Others:


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Course in the Wards

Day 5

(January 5, 2014)

Take Home Meds

Co-amoxiclav 457mg/5mL,3mL every 12 hours

Hydrogen peroxide 2-3 drops

each ear 3x a day for 7 days

Labs Others:


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1. Fever

2. Occult Bacteremia

3. Impacted Cerumen

List of Problems


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Medications

Standing Meds Indication/ Problem treated

Ampicillin-Sulbtactam 500mg/ SIV q6h Empiric treatment; antibacterial

Hydrogen Peroxide 2-3 drops each

3x/day for 5 days

Impacted Cerumen

Co-Amoxiclav 457mg/ 5mL, 3mL every

12 hours

antibacterial

PRN Meds Indication/ Problem Treated

Paracetamol 120mg/5mL, give 6mL every 4

hours

PRN if Temp > 37.5

Fever


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Ampicillin Sulbactam-

Recommended Dose- Computation

>1 year old: 100-200 mg/kg/day IV/IM Q6

hrWeight 13.5kg

13.5kg x 100mg/1kg= 1350mg13.5kg x 200mg/1kg=2700mg

=1350-2700mg/day IV/IM Q6

=patient was given 2000mg/day Q6


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Paracetamol Recommended Dose-

Computation

10-15 mg/kg PO q6-8 hr not to exceed

2.6g/day

Weight 13.5kg13.5kg x 10mg/1kg= 135.0mg

13.5kg x 15mg/1kg=202.50mg

=135-202.50mg/day PO

=patient was given 144mg of Paracetamol as needed for

fever relief


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Pharmacotherapeutic Goals

Restore

NormalBodyFunction

Treatmentof occultbacteremia

Normalizebody

temperature

Removal ofimpactedcerumen


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Guidelines VS Actual Management

Guidelines/Algorithm Actual Management

Children who are afebrile and well

appearing can be treated on an

ambulatory basis with a 10-day course

of oral penicillin

Reference: Practice Guideline for the Management of Infants

and Children 0 to 36 Months of Age With Fever Without

Source

Co-amoxiclav 457mg/5mL, 3mL every

12 hours


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S N/A

O Co-amoxiclav 457mg/5mL, 3mL every 12 hours

A

Unclear dosing regimen/duration. Children and who are afebrile and wellappearing can be treated on an ambulatory basis with a 10-day course of oralpenicillin.

P Suggest to physician the duration of Co-amoxiclav therapy is 10 days.

Recommendations/

Intervention

Reference: NICE clinical guidelines


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Guidelines VS Actual Management

Guidelines/Algorithm Actual Management

The recommended dose for co-

amoxiclav >3months is 25mg/kg/day

q12h

Reference: Lexicomp

Co-amoxiclav 457mg/5mL, 3mL every

12 hours

d /


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S N/A

O Co-amoxiclav 457mg/5mL, 3mL every 12 hours

A Underdosing. The recommended dose for co-amoxiclav >3months is

25mg/kg/day q12h .

P Suggest to physician to increase the dose of Co-amoxiclav therapy up to 4.2 mL

or 4mL.

Recommendations/

Intervention



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Co-Amoxiclav Recommended Dose-

Computation

25 mg/kg/day PO divided q12hr

Weight 13.5kg

13.5kg x 25mg/1kg= 337.5mg/kg

400mg/5mL=X/3mL mg=240mg

patient was given 240 mg of Co-Amoxiclav

337.5mg/x=400mg/5mL

x=4.2mL

R d i /


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Recommendations/

Intervention


Based on amoxicillin content

13.5kgx25mg/kg= 337.5mg

400mg/5mL=x/3mL x=240 mg

337.5mg/x=400mg/5mL

x=4.2mL


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Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline forthe management of infants and children 0 to 36 months of

age with fever without source. Agency for Health Care

Policy and Research. Ann Emerg Med. Jul

1993;22(7):1198-210 Kramer MS, Shapiro ED. Management of the young febrile

child: a commentary on recent practice guidelines.

Pediatrics. Jul 1997;100(1):128-34 Medscape.com

Medline.com Lexicomp

MIMS

References:


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Thank you!

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Sample Case Presentation- Occult Bacteremia