INFECTIONS IN KIDS TO TREAT OR NOT TO TREAT?

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1 INFECTIONS IN KIDS TO TREAT OR NOT TO TREAT? I HAVE NOTHING TO DISCLOSE. Andi Marmor, MD, MSED Professor of Pediatrics University of California, San Francisco Zuckerberg San Francisco General Hospital Three Common Presentations Case Presentation: Infant with Fever FEVER DIFFICULTY BREATHING u Fever without a source (SBI) u Pertussis u Urinary Tract Infections u Community Acquired PNA u Pharyngitis RASH u Infections and Mimickers uxanadu is 2 week old girl with a fever uno symptoms to suggest a source on exam/history uvs: T 38.5, P 150, R 40 s, o/w WNL uexam: well-appearing, no focal findings to suggest source for fever 1

The most likely cause of Xanadu s fever is: A. Viral infection B. Urinary tract infection C. Serious bacterial infection (SBI) (bacteremia/meningitis) D.

2 The most likely cause of Xanadu s fever is: A. Viral infection B. Urinary tract infection C. Serious bacterial infection (SBI) (bacteremia/meningitis) D. HSV infection The most likely cause of Xanadu s fever is: A. Viral infection B. Urinary tract infection C. Serious bacterial infection (SBI)(bacteremia/meningitis) D. HSV infection Everything you need to know about SBI in febrile infants - on ONE SLIDE 2-3% THE FEBRILE INFANT 13-18% E. Coli E.Coli>GBS>S. aureus >enterococcus, S pneumo <1% E.Coli/GBSèS. pneumo Greenhow, 2014 Schwartz, 2009, Gomez 2010, Greenhow,

Fever without a source (FWS): Infants <30 days uappearance and lab criteria do not reliably rule out UTI/SBI in this age group u Urine, blood, CSF, empiric abx recommended Amp/gentamicin or

3 Fever without a source (FWS): Infants <30 days uappearance and lab criteria do not reliably rule out UTI/SBI in this age group u Urine, blood, CSF, empiric abx recommended 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 u Urine, blood, CSF, empiric abx recommended Amp/gentamicin or amp/cefotaxime Listeria vanishingly rare some recommend treating with cefotaxime alone DO NOT treat with gentamicin alone FWS: Infants days Approach to Infant with FWS no 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 uinflammatory markers (CBC/CRP/PCT) helpful in select infants Well appearing, neg UA AND no viral source 3

4 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 nitrites unow what do you do? URINARY TRACT INFECTIONS ( PYELONEPHRITIS ) Risk of UTI in Infants with FWS Which infants <3 mo should we test for UTI? Girls Uncirc Boys Circ Boys ALL infants < 3 mo, T>38 Girls Uncirc Boys Circ Boys Testing threshold ~2-3% m 3m 6m 12m 18m m 3m 6m 12m 18m 4

5 Which infants >3 mo* should we test for UTI? *T 39 for 48hrs Who should we test for UTI? Circ boys <6 mo Testing threshold ~5% All Girls Uncirc boys <12 mo 0 1 m 3m 6m 12m 18m Girls Uncirc Boys Circ Boys u All infants with FWS < 3 mo of age u Girls > 3 mo of age FWS (>39) and < 24 months u 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 Treatment 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 n Consider sending for culture in high risk neonate 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) uimaging 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):

6 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 What is Zaffre s modified Centor score? A. 1 B. 2 C. 3 D. 4 E. 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 s þtemp > 38C þcough absent þage 3-14 Score = 4-5 6

7 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% u When 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 7

Pertussis Epidemiology Phases of Pertussis Acellular pertussis Tdap PHASE TIME COURSE DESCRIPTION Catarrhal 1-2 weeks Mild fever, cough, rhinorrhea Paroxysmal

Improvement in severity and frequency of coughing episodes Slide courtesy of Ellen Laves, MD Pertussis: Clinical Diagnosis ucough lasting >2 weeks + 1of the

cough Pertussis: Laboratory Confirmation ulab confirmation ONLY in those with signs/symptoms consistent with pertussis u Posterior NP specimen (not

8 Pertussis Epidemiology Phases of Pertussis Acellular pertussis Tdap PHASE TIME COURSE DESCRIPTION Catarrhal 1-2 weeks Mild fever, cough, rhinorrhea Paroxysmal 1-6 weeks Older infants/children: Paroxysms, whoop, post-tussive emesis 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* Neonates/young Infants Paroxysms of coughing Older children Inspiratory whoop Post-tussive vomiting (least specific) *May occur without cough Pertussis: Laboratory Confirmation ulab confirmation ONLY in those with signs/symptoms consistent with pertussis u Posterior NP specimen (not pharynx/ant NP) u PCR for pertussis False positives may occur uculture + for B. Pertussis Most SPECIFIC test umost sensitive in first 3 weeks cdc.gov/pertussis cdc.gov/pertussis 8

9 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 u Amaranth s vaccination status and nonspecific 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 CXR B. Obtain a blood culture and CBC C. Obtain a sputum culture D. Start PO amoxicillin and discharge with close follow up E. Start IV cefuroxime and admit PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA 9

10 Pediatric CAP: Diagnosis Bradley JS, et al. Clin Infect Dis Pediatric CAP: Labs Bradley JS, et al. Clin Infect Dis uclinical Symptoms of acute illness (ie: fever) + resp distress (tachypnea*, retractions, hypoxia) AND Focal lung findings on exam OR on CXR uimaging Chest x-ray NOT recommended routinely in outpatients Does not distinguish between pathogens (viral, atypical, etc) *MOST SENSITIVE sign u Routine lab testing NOT recommended u Blood cultures: Clinically worsening or hosp with mod/severe disease u Viral testing (flu, RSV) IF no evidence of bacterial co-infection u CBC/CRP Not recommended u Testing for Mycoplasma pneumoniae, S. pneumo If available, may guide antibiotic selection Pediatric CAP: Causes Viral is most common < 2 yrs: S. pneumoniae, C. Trachomatis 2-5 yrs S. pneumoniae > M. pneumoniae, H influenzae, C. pneumoniae Bradley JS, et al. Clin Infect Dis u Based on age, severity, local resistance 2 MO TO 5 YRS: OVER 5 YEARS: u M. pneumoniae> C. pneumoniae, S. pneumoniae Community Acquired Pneumonia: Treatment Bradley JS, et al. Clin Infect Dis u Inpatient or Outpatient 1 st line treatment: Amoxicillin/ampicillin in infants and young children Consider Macrolide (azithro) in kids > 5 u Ill patent or high-level PCN resistance: 3 rd generation cephalosporin if suspect S. pneumo Vancomycin if suspicion for MRSA +Macrolides if suspicion high for M. pneumoniae and C. pneumoniae 10

3/14/18 What is the RECOMMENDED next step?

cefuroxime and admit Toddler with fever,

disease (coxsackie virus) NAME THAT RASH

11 3/14/18 What is the RECOMMENDED next step? A. B. C. D. E. Obtain a PA and lateral CXR Obtain a blood culture and CBC Obtain a sputum culture Start PO amoxicillin and discharge with close follow up Start IV cefuroxime and admit Toddler with fever, refusing po s drooling Hand- foot-mouth disease (coxsackie virus) NAME THAT RASH Examples of atypical coxsackie Pediatrics.aapublications.org Eurosurveillance.org 11

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

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

u 2 doses of vaccine = 97% effective u Dx by serology (IgM or rise in IgG) or PCR u High risk = <5yo or >20yo,

1-2/1000 Subacute sclerosing panencephalitis (SSPE): rare u No specific treatment (vit A for severe illness) 9

12 5 yo comes back from camp with fever, cough and runny nose, then develops rash proceeding head to toe Measles 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 Fast Facts u Droplet/airborne spread, ~90% u 2 doses of vaccine = 97% effective u Dx by serology (IgM or rise in IgG) or PCR u High risk = <5yo or >20yo, pregnant, immunocompromised u 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 infantum Typically caused by Human Herpes Virus (HHV) 6 or 7 12

Delayed hypersensitivity (T-cell mediated, Type

and soles, day 5-10 of treatment u NOT a drug

anaphylaxis Allergy Rash started on day 6 of

extremities, including palms and soles Not

within hours, may progress May affect up to 10%

with dry, diffuse rash most pronounced on trunk

13 3/14/18 10 mo old with rash on day 7 of amoxicillin for AOM Amoxicillin Drug Eruption u Delayed hypersensitivity (T-cell mediated, Type IV) reaction Morbilliform, often includes palms and soles, day 5-10 of treatment u NOT a drug allergy, and not associated with advancement to anaphylaxis Allergy Rash started on day 6 of treatment Started truncally, spread to head and extremities, including palms and soles Not itchy, otherwise well = itchy, urticarial, within hours, may progress May affect up to 10% of pedi pts treated with amox or PCN u Future use of amox NOT contraindicated u From: Consultant yo with fever, sore throat now with dry, diffuse rash most pronounced on trunk and face 5 yo with temp of 39 for 5 days Group A Streptococcal Scarlet Fever 13

Kawasaki Disease Unusual color names u Unknown etiology (?ID?

aneurysms u Treatment: IVIG Xanadu Amaranth C (conjunctivitis) R (rash) A (adenopathy) S

The changing epidemiology of serious bacterial infections in young infants.

Roberts KB and the Subcommittee on Urinary Tract Infection, Steering Committee on Quality

Urinary tract infection: clinical practice guideline for the diagnosis and management of the

2011;128(3): 595 610 3. Lieberthal, A et al.

14 Kawasaki Disease Unusual color names u Unknown etiology (?ID?) uclinical diagnosis: Fever x5d = 4/5 clinical criteria u Significance: coronary artery aneurysms u Treatment: IVIG Xanadu Amaranth C (conjunctivitis) R (rash) A (adenopathy) S (strawberry tongue) H (hands and feet) Zaffre References 1. Greenhow TL, et al. The changing epidemiology of serious bacterial infections in young infants. Pediatr Infect Dis Journal 2014; 33(6): 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): Lieberthal, A et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics 2012; 131(3): e964-e 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 14

INFECTIOUS DISEASES IN CHILDREN

INFECTIOUS DISEASES IN CHILDREN Acknowledgement: Hayes Bakken, MD Andi Marmor, MD, MSED Professor of Pediatrics University of California, San Francisco Zuckerberg San Francisco General Hospital I HAVE