Pediatric Serious Infections PDF

‫همة‬$‫حاضرة مختصرة ل*شياء ا‬$‫يقول الدكتور ا‬ What comes to your mind when you hear serious pediatric infections? Meningitis, encephalitis, there is also other bony infections and skin infections....

‫همة‬$‫حاضرة مختصرة ل*شياء ا‬$‫يقول الدكتور ا‬ What comes to your mind when you hear serious pediatric infections? Meningitis, encephalitis, there is also other bony infections and skin infections. Serious Pediatric Infections ! doctor notes ❤ anything important Unfortunately, ! extra reading yes!  ‫همة‬$‫حاضرة مختصرة ل*شياء ا‬$‫يقول الدكتور ا‬ What comes to your mind when you hear serious pediatric infections? Meningitis, encephalitis, there is also other bony infections and skin infections. Csf It gfa p g.gggygid Serious Pediatric Infections extraocular ! doctor notes ❤ anything important Unfortunately, ! extra reading yes! Skittish.frhaexam  What are the keywords here? Highlighted in ❤ Q1 He is a neonate, cuz organisms in neonate ‫ تختلف عن غيرها‬here it is most likely meningitis. A new mother calls her pediatrician panicking because her 3 days old son is inconsolable. The infant has a high fever, is lethargic, and is not nursing well. On evaluation in the ED, the child appears febrile and ill. The physician in the ED performs lumbar puncture, and laboratory findings of cerebrospinal fluid are consistent with bacterial meningitis, whereas Gram stain reports gram-positive cocci organism. The most likely organism is : 1. Streptococcus pneumonae 2. Staphylococcus aureus 3. GBS 4. GAS 5. E.coli 6. Listeria monocytogenus  It is important to always remember if a neonate (in his first Investigations month of age “3 months ! ! Meningitis There is a decrease in Haemophilus influenza at >6 years because at this age they would be vaccinated  What are the clinical manifestations of meningitis? Everyone mentioned what is written in the slides but the doctor noted that: Clinical manifestations -The posterior fontanelle closes by the age 1 or 2 months (2-9months) -the anterior fontanelle closes between the age of 9 and 18 months. (1 year and a half) *in adults, meningitis usually presents with neck stiffness. He mentioned that in neonates, there will be bulging of the anterior fontanelle since it is still open. Fontanelle= ‫النافوخ‬ % These occur more commonly in children older than 12 to 18 months Pain in the back and neck When flexing the head, automatically the knees will flex Risk of bleeding If the patient is hemodynamically unstable, he is very sick, do NOT do the LP because there is no time… the patient is very sick and might die on the table while you do the puncture! In this case we start the antibiotic immediately.  Q2 A 2.5-month-old boy is brought to wbc ‫ركزو على‬ the emergency department for Bacterial infection, the WBC is evaluation of fever. Two days prior to sky high & (neutrophils) admission the patient developed a fever to 39.1°C and became irritable, with nasal discharge and decreased oral intake. Neurologic examination is remarkable for a lethargic-appearing child who is responsive to stimulation. His anterior fontanel is open and bulging. LP was done Which of the following cerebrospinal fluid results from the lumbar puncture would be most consistent with acute bacterial meningitis?  ' ‫وية‬$‫مثل ا‬ Getting CSF with turbid consistency, you will know right away its bacterial No significant change viral‫مشابه لل‬  Management Listeria is present so we should use Ampicillin to cover it Ceftriaxone will have a risk of Jaundice if it is given in the first 3 months so it is only given beyond 3 months of age Complications Hearing impairment is Very common Hearing impairment – inflammatory damage to the cochlear hair cells may lead to deafness. All children who have had meningitis should have an audiological assessment done promptly Some kids will come with severe consequences: global developmental delay, handicap, hydrocephalus, Neurological lesions , Hydrocephalus ventriculoperitoneal shunt, and seizure disorders. Meningitis is a very nasty disease so it has to be treated well from the beginning. local cerebral infarction –result in epilepsy  What is the difference between encephalitis and meningitis? Encephalitis affects the brain itself. Encephalitis Encephalitis is defined by the presence of an inflammatory process of the brain in association with clinical evidence of neurologic dysfunction.  Infectious etiology Viruses: Very common Enteroviruses, respiratory viruses (influenza viruses), and herpesviruses [e.g. HSV, varicella zoster virus (VZV), and human herpesvirus 6 (HHV-6)] and arboviruses Very common and has to be treated. Therefore, any CSF sample we do, we have to ask for PCR. Bacteria: Why PCR? To check for HSV and then treat it with acyclovir for 21 days. Mycoplasma,,Mycobacterium Clinical manifestations Fever, headache and lethargy Seizures are common in children. In severe encephalitis, lethargy rapidly progresses to coma and, in some cases, death Diagnosis CSF: viral meningitis‫ﻪ ﻟﻞ‬0‫ﻣﺸﺎ‬ Cell count and protein value are frequently normal or slightly elevated Glucose level is often normal High number of lymphocyte. ( PCR) of body fluids and CSF Neuroimaging  HSV encephalitis Herpes simplex PCR should be performed on all CSF specimens High dose Acyclovir should be initiated in all patients with suspected encephalitis, pending results of diagnostic studies. If CSF HSV PCR is positive , Acyclovir I.V for 21 days Example: Girl asked: do we use acyclovir only for You are not sure about your patients diagnosis (is it encephalitis or HSV? meningitis?) and the PCR result is not out yet, what do you do? Doctor: yes if there is HSV use acyclovir, in this situation, you add the treatment of both encephalitis and but the viral itself is self limited. meningitis (vancomycin, ceftriaxone, and acyclovir) till the results of the Antirovirus presented with meningitis: PCR are out. you can stop the treatment and release If the PCR is positive, keep treating with acyclovir. the patient If the PCR is negative, stop the acyclovir. Osteomyelitis Osteomyelitis is an Infection of the bones What is the most common organism that causes osteomyelitis?( S. Aureus  Note that staph still has a risk even in sickle cell but the risk of salmonella in sickle is more Q3 A 13-year-old boy with sickle cell disease is brought to the emergency department for evaluation of fever and leg pain approximately 2 days. the area of pain is now showing redness of the skin with some mild swelling. temperature is 38.5°C. Physical examination is normal except for a painful right tibia with mild edema and erythema of the overlying skin. He is sent for an MRI and is found to have lytic lesions and blood C/S turn +ve for gram –ve rodes after 10 hour. The most likely causative organism is : 1. E.coli S.aureus is a gram positive rod. In this question they specifically 2. Salmonella species Lytic bone lesion mentioned gram negative so we should 3. Enterobacter species rule out S.aureus. Also the patient is ‫ﻠﺔ‬hi‫ﺗﺤﺲ اﻧﻬﺎ ﻣﺘ‬ 4. Klebseilla pneumonae present with sickle cell disease which 5. Staphylococcus aurues increases the risk of salmonella species 6. GAS What is the imagining of choice? MRI shows up in an acute phase= imaging of choice. X-ray can be used but it takes around 2-4 weeks to show The most common cause of osteomyelitis, in general is Staphylococcus aureus. However, in patients with sickle cell disease (SCD), Salmonella is the most common cause of osteomyelitis in the United States and Europe, while S. aureus is the most common in Africa and the Middle East. Lytic bone lesions do not commonly manifest on plain films until 30%-50% of the bone matrix is destroyed, often taking more than 2 weeks to become apparent. If osteomyelitis is suspected, MRI may be helpful as further imaging. Empiric treatment in this pt should cover for Salmonella as well as S. aureus Clinical Characteristics The most common manifestations are Fever Pain at the site of infection, Reluctance to use an affected extremity. Less common complaints are anorexia, malaise, and vomiting. Sometimes generalized symptoms appear.  Long bones are at Common Location ? higher risk than short bones Investigations Partial septic work up CBC , Diff CRP ESR Blood c/s Synovial fluid PLAIN X-RAY Bone scan MRI  Q4 Septic arthritis in the joint=accumulation of fluid in site. -WBC is high An 8-year-old girl is brought to the emergency department by -Gram positive culture her parents after complaining of severe pain in her right groin and knee for 1 day. Her T is 39.0°C.Physical examination reveals that the patient has severe pain with both active and passive range of motion, and she refuses to bear weight on her right leg. Laboratory values show a WBC count of 13,000/mm³ and an (ESR) of 41 mm/hr. Synovial fluid analysis shows a WBC count of 68,000/mm³, a glucose level of 32 mg/dL, and gram-positive cocci in clusters. Cultures are pending. S.aureus most common organism What is the best next step in management? 1. Immediate intravenous antibiotics, then observation and monitoring of ESR and WBC count for improvement 2. Immediate oral antibiotics, then switch to intravenous antibiotics if methicillin-resistant Staphylococcus aureus infection grows 3. Immediate surgical irrigation and debridement, then observation and monitoring of ESR and WBC count for improvement 4. MRI of affected hip 5. Take patient to OR for surgical irrigation and debridement Antibiotics alone is never enough and start empiric antibiotic therapy antibiotics ‫ﻪ‬7‫ﻌﺪﻳﻦ ﻧﻌﻄ‬0 ‫ ﻧﻔﺘﺢ و ﻧﻨﻈﻒ و‬OR‫ﺾ ال‬JK‫ﻻزم ﻧﺎﺧﺪ اﻟﻤ‬  ) Remember: -Take the patient to the OR -irrigation -drainage -start antibiotic Septic arthritis classically presents as acute onset of fever, joint pain, swelling of the affected joint, and pain with active and passive range of motion. When the hip is involved, the pain is often referred to adjacent joints including the knee as in this case. Evaluation of infants and children with suspected bacterial arthritis of the joint must occur promptly so diagnostic joint aspiration, appropriate empiric antimicrobial therapy, and formal irrigation and debridement (if necessary) can be instituted. Delayed therapy has been associated with long-term sequelae; therefore, surgical intervention must be performed first and antibiotic treatment of children with suspected bacterial arthritis should begin immediately after blood and synovial fluid cultures are obtained. Synovial fluid WBC counts >50,000 cells/ microL, with a predominance (>90%) of neutrophils ‫ﺎ‬Q‫ﻏﺎﻟ‬ suggest bacterial arthritis. The higher the synovial fluid WBC count, the greater the likelihood of bacterial arthritis. Additional laboratory findings include an elevated ESR >20 mm/hr and WBC count >10,000/mm³.  Pathogenesis Most of the cases in childhood follow the hematogenous spread of organisms to the vascular synovium of the joint space. Bacteria can spread to joints from contiguous osteomyelitis. Joints also can be infected from penetrating wounds, intra-articular injections of medications, arthroscopy, and prosthetic joint surgery  ‫اﻟﻌﻴﻦ‬ ‫ﺣﻮل اﻟﻌﻴﻦ‬ Orbital and periorbital cellulitis Cellulitis=Infection of the skin -which is more dangerous? ( Orbital !  Q5 A 6-year-old boy is brought to the emergency department with a painful, swollen eye. He has been having some upper respiratory symptoms for the past 2 weeks, including headache and sinus pain. Two days ago, he developed pain in his left eye and he is "seeing double." His temperature is 39.4°C. His left conjunctiva and lids are erythematous and swollen. Movement of the eye is painful, limiting examination of extraocular movements. Proptosis is observed. Most likely diagnosis is : The eye itself is affected. 1. Acute angel glaucoma 2. Bacterial conjunctivitis 3. Orbital cellulitis ‫ﺎرزة ﺷﻮي‬0 ‫اﻟﻌﻴﻦ ﺗﺤﺴﻬﺎ‬ 4. Periorbital cellulitis 5. Subconjunctival hemorrage The infection could be Either local infection on the skin and penetrates ‫ ﻋﻠﻰ ﺟﻮا‬or hematogenous from the blood or sinusitis. Organism travels to the globe ! or skin around it. *treatment differs according to orbital or periorbital. -periorbital=oral antibiotics, in severe cases give IV antibiotics. -orbital= more aggressive management than peri. you have to admit the patient ‫ ﺗﻨﻮﻣﻪ‬and do CT , then refer to a specialist. Orbital cellulitis is mostly associated with preexisting sinusitis,. It is usually caused by streptococci (Pneumococcus), staphylococci (including MRSA), and H. influenzae. It often presents with acute-onset fever, proptosis, decreased extraocular muscle movement, ocular pain, and decreased visual acuity. Broad-spectrum antibiotic therapy for both aerobic and anaerobic organisms should be initiated, and CT scan of the orbit is necessary to determine the degree of orbital involvement. It is important to note that each patient with orbital cellulitis needs to be evaluated by an ophthalmologist and an ENT specialist; IV antibiotic therapy should be initiated immediately. Note that: periorbital can turn into orbital. Pathogenesis of preseptal cellulitis (1) secondary to a localized infection or inflammation (2) secondary to hematogenous dissemination of nasopharyngeal pathogens to the periorbital tissue (3) as a manifestation of inflammatory edema in patients with acute sinusitis Clinical manifestations Orbital Preseptal(periorbital) Fever Yes Yes Erythema, tenderness, and Yes Yes edema of the eyelid or other skin adjacent to the eye Proptosis YES No Painful or limited ocular YES No movement Reduced visual acuity YES No  Etiology and management anaerobes ‫ﻒ‬7‫ﻣﻤﻜﻦ ﻧﻀ‬ In orbital cellulitis URGENT ophthalmological consultation is required to preserve the eye and prevent the complications ( Intracranial extension , sinus venous thrombosis) Skin and soft tissue infections Erysipelas Epidermis is affected. It is a superficial skin infection affecting the upper dermis and the lymphatic system. In most cases, GAS is causative, but group B, C, and G streptococci occasionally cause the infection Treatment of erysipelas consists of oral anti-streptococcal agent for 10-14 days  If it is more DEEP than it is cellulitis. Cellulitis It is an acute infection of the skin involving the dermis and subcutaneous tissues that manifests as edema, warmth, erythema, and tenderness of the skin. Uncomplicated cellulitis in treated with antimicrobial therapy targeting streptococci and staphylococci. Oral antibiotics circular ‫ﺳﻄﺤﻲ و‬ Involves all the skin Ecthyma A rare, deep ulcerative infection of the skin that penetrates down to the dermis Most commonly caused by S. pyogenes. Ulcerative Systemic antibiotic therapy with an agent effective against ‫ﻘﺔ‬7‫ﻋﻤ‬ streptococci is recommended Ecthyma gangrenosum It is serious and characteristic skin lesion associated with gram- negative organisms, especially Pseudomonas aeruginosa. Effective treatment requires prompt initiation of an antibiotic effective against P. aeruginosa or other likely causative organisms. Gram negative pseudomonas—> always think of it when you see ‫ﻨﺔ‬áà‫ﻏﺮﻏ‬ ‫ﻨﺔ‬áà‫ﻣﺜﻞ اﻟﻐﺮﻏ‬  Any Questions? Student questions and answers: 1)do we give vancomycin in cellulitis? Only in MRSA, otherwise no. 2)how would we know if the neonate has a headache or pain from meningitis? First, neonate will not have pain in the neck. Again we look at the anterior fontanelle, it will be bulging. Another point, neonate will be irritable * , moaning, ‫ ﻃﺎﻓﻲ‬، + ‫ﺎن‬î‫ﺗﻌ‬, crying ,. In the late stages he will be inactive. *if you test neonate with the tests we discussed it will be negative because he has an open fontanelle..‫ﻜﻲ‬Q‫ﺪ اﻻﻟﻢ ﻓﻲ ﻃﻔﻞ ﻳ‬l‫ ﺳﺆال ﻋﻦ ﺗﺤﺪ‬- this is a common case and you have to examine the child from head to toe ‫ﺎن اﻻﻟﻢ‬s‫ ﻣﺎرح ﺗﻘﺪر ﺗﺤﺪد ﻣ‬- ‫ﻪ‬7‫ﻜﻮن ﻗﺎرﺻﻪ ﺷﻲ او ﺷﻌﺮ اﻣﻪ ﻻف ﻋﻠ‬l ‫ ﻣﻤﻜﻦ‬- Make sure no fracture or bony tenderness, examine ENT, abdomen, make sure baby is not hungry. - If everything is normal and the child is from weeks to 3 months usually it’s an infantile colic - !