Virus. Bacteria. Otitis, sinusitis, pneumonia in a nutshell. Common organisms for URTI. The respiratory tract is a continuum

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1 The respiratory tract is a continuum Otitis, sinusitis, pneumonia in a nutshell Klara Pósfay Barbe Pediatric Infectious Diseases University Hospitals of Geneva Virus Common organisms for URTI Viruses Bacteria Pneumonia S. pneumoniae; Respiratory viruses, M. pneumoniae, C. pneumoniae But also The Big Three Streptococcus pneumoniae Haemophilus influenzae (non typable) Moraxella catarrhalis

2 Common organisms for community acquired LRTI Respiratory viruses (RSV++) Streptococcus pneumoniae (25 30%) Mycoplasma pneumoniae Chlamydia pneumoniae Moraxella catarrhalis Haemophilus influenzae Staphylococcus aureus Group A Streptococcus Nosocomial LRTI in Pediatrics S. aureus H. influenzae P. aeruginosa Gram negative enteric bacteria Acute external otitis ACUTE OTITIS Risk factors Swimming Trauma (Q tips) Eczema (or other skin diseases) Chronic otorrhea Hearing aid Immunocompromised patient (rare in children) External otitis and otitis media

3 External otitis: mecanisms External otitis: clinical picture Pain++, increased with movement of outer ear 1) Mild Treatment: simple analgesic sufficient Erythema, but little edema 2) Moderate Refusal to let someone introduce something in ear pain sleeping issues Important erythema by hair + desquamation+++ (whitish grey) Canal < 50% usual size Tympanic membrane (if visualises) moves (not with AOM) 3) Severe Terrible pain (needs opiates) Important edema + debris (can t see the tympanic membrane) Edematous and painful ear (not sticking out mastoiditis) DD malignant external otitis or other illness (rhabdomyosarcoma,...) EAO External otitis : etiology 80% Pseudomonas aeruginosa Revue Médicale Suisse 2007 Bizindavyi F et al Otherwise: E.coli, Proteus, S. aureus, S. pyogenes (local extension), Aspergillus niger, Candida spp, VZV Possible as a secondary process after AOM (maceration)

4 External otitis : treatment Treat the pain Take out, if possible, debris (curetage, lavage + gentle aspiration) Mild AEO: topical antibiotics Moderate AEO: daily debridement; dry canal; topical antibiotics + cotton Drops 2 3 x/day for 5 7 days Cultures if no clinical response or risk factors or fungal appearance Topical treatment: Fluoroquinolones or Neomycin/polymyxin B +/ steroids Acute otitis media: definitions Sudden onset of symptoms and signs of inflammation and fluid in middle ear Inflammation of middle ear Fluid in middle ear Obvious erythema of tympanic membrane Undoubted otalgia impact on every day life or sleeping pattern Bulging tympanic membrane Reduced mobility or no mobility of tympanic membrane Air/fluid level behind the membrane Otorrhea

5 When not to treat? Recommandations Different recommandations depend on Age Clinical status Intact tympanic membrane Duration of symptoms Tympanic membrane intact Treatment in child < 2 years Tympanic membrane intact Treatment in child < 2 years Good clinical condition Analgesia Reassess after 24 hours If persistance of symptoms or decreased general condition: antibiotics Poor clinical status Analgesia Antibiotics AAP & AAFP guidelines; Pediatrics, 2004; 113(5): AAP & AAFP guidelines; Pediatrics, 2004; 113(5):

6 Tympanic membrane intact Treatment child > 2 years Analgesia for 48 h, no antibiotics Reassess after 48 hours If persistance or decreased general condition: antibiotics Traitement: only analgesia > 2 yo, eardrum intact Reassessment > 48 h < 2 yo, eardrum intact Reassessment > 24 h Persistance of symptoms or worsening of general condition Antibiotherapy Exceptions Immediate antibiotic treatment (with analgesia) if: Bilateral AOM Ear malformation Perforated tympanic membrane Previous deafness Immunodeficiency Recurrent AOM Rationale for Wait and see 283 patients between 6 mo and 12 yo Received a prescription for antibiotics and analgesia Two groups: 1. Encouraged to use > 48h later 2. Encouraged to use imediately 62% not used versus 13% (P<.001) No difference in fever, ear pain, nb of medical visits between groups JAMA 2006 Spiro et al

7 Antibiotics for AOM Other treatments of AOM Amoxicilline 50 mg/kg/d in 2 doses (up to 80 mg/kg/d in Suisse Romande) If failure: amoxicilline ac. clavulanique à80 mg/kg/d Alternative if allergies (type I reaction): cephalosporins, or macrolide Length of treatment: < 2 yo or perforated ear drum: 10 days > 2 yo: 5 days Alternative treatments No proven efficacy Decongestionants Anti histaminics Cochrane review 2008 No cotton in ear if possible Myth n 1 AOM: etiologies Frequ. Spontaneous healing A viral otitis can cure by itself, a bacterial no. S. pneumoniae 30 35% 69% H. influenzae non typable 20 25% 90% Moraxella catarrhalis 10 15% 97% Strepto A 6% 96% S. aureus 5% Resp viruses 30% 100%

8 Myth n 2 Effect on AOM The anti pneumo vaccine is useful to decrease invasive pneumococcal disease (meningitis, pneumonia, bacteremia), but has no effect on AOM. Efficacy of vaccine Antigen linked to diphtheria To meningococcus Risk= remplacement Vaccine 2008: Dagan R Metanalysis on effectiveness of pneumococcal vaccines in children Myth n 3 If there is liquid behind the ear drum at the end of the treatement, you have to continue the antibiotics Overall efficacy ~56% for VT; 29% all serotypes Pavia et al Pediatrics 2009

9 Persistance of fluid after AOM with and without antimicrobial treatment Length of follow up % with retrotympanic fluid 2 weeks 70% SINUSITIS 4 weeks 50% 2 months 20% 3 months 10% SSP Sinusitis Inflammation of the paranasal cavities Bacterial complication of viral URI Normal physiology Patency of the ostia Function of the ciliary apparatus Quality of the secretions In children: ethmoid & maxillary Sphenoid and posterior ethmoid sinuses drain to superior meatus All other drain to the middle meatus CHILDREN

10 Clinical manifestations Clinical severity score for sinusitis Persistent symptoms Nasal discharge, cough or both > 10 days and not improving Severe symptoms High fever [>39 C] and purulent discharge together > 3 days Wald ER; Pediatrics 2009 When to treat Usefulness of treatment of acute sinusitis Infection of upper airways + 1.Symptoms > 10 days 2.Bimodal course 3.Fever > 39 + purulent rhinitis > 3 days Randomized, double blind, children 1 10 yo with mild to severe symptoms Amoxi clav (90/6.4mg) vs placebo Survey Days 0,1,2,3,5,7,10,20 Clinical exam D14 Wald ER; Pediatrics 2009

11 Results Treatment sinusitis Spontaneous cure rate 30 40% Prevention of complications Antibiotics (amoxicillin, amoxicillin clavulanic acid, cefuroxime, etc. ; same as AOM) Wald ER; Pediatrics 2009 Duration of treatment 10 days or symptom free + 7 days Wald ER et al 1986 Sinusitis: usefulness of adjuvant therapy Saline nasal irrigation (yes) Antihistamines (no) Decongestants (no) Topical intranasal steroids (if allergy) Mucolytic agents (no studies) Berlan IB et al 1997 Wald ER in Sarah Long 2 nd ed.p When to investigate further Periorbital or facial swelling Eye mobility impaired Signs of intracranial high pressure CT= best choice

12 Diagnostic methods: Radiology Sinusitis: When to do an X ray? (or a CT) 88% children < 6 years old with persistent respiratory symptoms have abnormal X ray Wald ER 1984 CT scan abnormal in adults with common cold (inflammation not infection) Gwaltney JM et al NEJM 1994 Complicated sinus disease orbital or CNS complication Numerous recurrences Protracted child Symptoms nonresponsive to treatment Indication for sinus aspiration Lack of response to multiple courses of antibiotics (sampling) Severe facial pain Orbital or intracranial complications Evaluation of immunocompromised host (sampling) Send for Gram stain and quantitative aerobic + anaerobic cultures : >10 4 CFU= infection If one organism seen on Gram stain = 10 5 CFU Sinus surgery Recurrent or non reponsive chronic infection Nasoantral window Improvement of 27% after 6 months Adeno tonsillectomy may have benefit Ostiomeatal complex surgery: 2 mucosal area in contact ciliary clearance impaired No randomized trial Muntz HR, Laryngoscope 1990 Chan KH Otolaryngo Head Neck Surg 1999

13 Complications of sinusitis Intracranial Epidural abscess Subdural abscess Cavernous or sagittal sinus thrombosis Meningitis Brain abscess Orbital Orbital abscess, cellulitis Optic neuritis Subperiosteal abscess Inflammatory edema Osteitis (Pott puffy tumor) Epidural abscess Complications of sinusitis Pneumonia Definition and epidemiology «Inflammation of the lungs» Estimated annual incidence in the USA + Europe cases/1000 children < 5 yo cases/1000 children 5 14 yo Developing countries: yearly 1.9 Mio deaths (3rd cause death in children)

14 Up to date: from Feigin Up to date: from Feigin When to treat pneumonia? WHO criteria Clinical signs Diagnosis Antibiotic Cough Tachypnea Retractions Up to date: from Feigin Present Absent Absent Upper resp infection Present Present Absent Mild pneumonia Present Present Present Severe pneumonia No Yes Yes

15 Treatment Compatible clinical exam and history Fever > 38.5, cough, tachypnea, retractions, nasal flaring, poor general status If > 1 yo: typical auscultation Asymetry, unilateral decrease breath sounds Against antibiotics: no tachypnea, wheezing CXR: alveolar infiltrate Yes: probably antibiotics useful No: reassess, no antibiotics Amoxicillin 80 mg/kg/d for 7 days Fig. 1: PA CXR R middle lobe pneumonia with effusion Pleural effusion Pleural effusion: prevalence Not well known 0.6 2% of all bacterial pneumonia Admission for empyema: 3.7 per children Increased rates reported France: 1995: 0.5 / : 13 / Spain: 1999: 1.7 / : 8.5 /

16 Pathogenesis Replication of microorganisms Inflammatory response in sub pleural alveola Endothelial destruction Increase in capillary leak Extravasation of intertitial pulm. Fluid Migration of neutrophils Fibrin deposition following inflammation: purulent collection Decreased drainage + limitation of lung expansion Pneumonia with pleural effusion Secondary to: Desequilibrium between intrapleural pressures (increase in capillary permeability, decrease in the hydrostatic pressure of the interstitial space or the oncotic plasmatic pressure, etc ) Inappropriate flux of the lymphatic fluid Modified vascular permeability Bacteria classically linked with pleural effusion Pneumococcus ( ) Staphylococcus aureus ( ) Haemophilus influenzae type b ( ) Group A Streptococcus Anaerobes Parapneumonic effusion Pleural inflammation or empyema Ultrasound: quantity, site, organized appearance or not Pediatrics 1998; 101: CT scan (with contrast) Drainage for diagnostic purpose Exsudate/ transsudate Etiology No response to treatment (afer 24 48h, CRP still high) Drainage for therapeutic purpose Respiratory failure > 1cm effusion on CxR Thorax 2001; 56(11): Quintero DR Pediatr Resp Rev 2004

17 Pneumonia with effusion Treatment Transsudate < 30 g/l Exsudate= infection Concentration pleural fluid Ratio pleural fluid/serum Prot LDH Prot LDH ph Gluc 30 g/l < 2/3 < 0.5 < 0.6 >7.45 >3.3 > 2/ <7.30 Empye ma <2.2 Prolonged antibiotics (minimum 4 weeks): 2 nd generation cephalosporine (?) If walled in pleural effusion: urokinase UI in ml NaCl 0.9% over 1 h, 2 h clamp, aspiration at 15cm H 2 O Repeat if necessary 1x/d for 5 days Urokinase= only fibrinolytic used in children in RCT Thoracoscopy or visually assisted thoracoscopy (VAT) In general followed by urokinase Balfour Lynn IM Thorax 2005: BTS guidelines Wells RG Radiology 2003 Thomson AH Thorax 2002 Barbato A Pediatr Pulmonol 2003 What to do after the treatment for pleural effusion? CXR at the end of treatment and 6 months later to show normalization of lung parenchyma No other work up necessary if first episode Pneumonia with severe underlying disease/immunosuppressed patients Risk of poor outcome Sampling! Treatment options Antipseudomonal beta lactam and aminoglycoside or meropenem. Add vancomycin?

18 THANKS