4/11/2017. A Review of How to Treat Common Infections in a Pediatric Patient. Disclaimer. Objectives for Pharmacists

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1 A Review of How to Treat Common Infections in a Pediatric Patient Tara Bergland, Pharm D. PGY2 Pediatric Pharmacy Resident Tara-bergland@uiowa.edu Disclaimer Tara Bergland reports that she has no actual or potential conflict of interest in relation to this presentation. Off label use of medications will be discussed during this presentation. Objectives for Pharmacists Review treatment options for community acquired pneumonia (CAP) in a pediatric patient Understand the etiology of meningitis in pediatric patients of varying ages Describe the diagnosis of osteomyelitis in a pediatric patient Examine treatment of otitis media based on a clinical case using the current guidelines Summarize treatment of urinary tract infections (UTI) in a pediatric patient 1

2 Objectives for Technicians Recognize classes of antibiotics used for treatment of community acquired pneumonia (CAP), meningitis, osteomyelitis, otitis media and urinary tract infections. Understand the etiology of meningitis in pediatric patients of varying ages Describe the diagnosis of osteomyelitis in a pediatric patient Examine treatment of otitis media based on a clinical case using the current guidelines Recognize when a pediatric patient should be referred to a pharmacist for questions or to a physician for further care. COMMUNITY ACQUIRED PNEUMONIA Epidemiology million cases worldwide Leading to an estimated 2 million deaths per year In developed countries, the annual incidence is less 33 per 10,000 in children younger than 5 years 14.5 per 10,000 in children ages 0-16 years Mortality in developed countries is less than 1 per 1,000 Incidence is increased during colder months in temperate climates 1. Gereige RS. Laufer PM. Pneumonia, Pediatrics In Review 2013; 34 (10);

3 Definitions Walking Pneumonia Clinical and radiological evidence of pneumonia but mild symptoms that do not interfere with normal activity Community-Acquired Pneumonia Acute infection in a previously healthy individual Hospital-Acquired Pneumonia Develops with in 48 hours after admission 1. Gereige RS. Laufer PM. Pneumonia, Pediatrics In Review 2013; 34 (10); Neonates: Group B Strep and Gram negative bacteria Etiology School age and young adults: Atypical 3 months to 5 years: organisms become 50-60% are viral more common, S. pneumoniae most common 1. Gereige RS. Laufer PM. Pneumonia, Pediatrics In Review 2013; 34 (10); Jain S. Williams DJ. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Children, NEJM 2015; 372; Role of Vaccinations H. Influenzae introduced in 1990 Decreased rates of invasive disease and incidence on pneumonia that required hospitalization Pneumococcal 7 valent vaccine led to a shift in serotypes causing disease leading to development of the 13 valent vaccine introduced in Gereige RS. Laufer PM. Pneumonia, Pediatrics In Review 2013; 34 (10);

4 Diagnosis Usually non-specific signs Fever and cough are hallmark Increased work of breathing may proceed the cough Impossible to differentiate between bacterial and viral Lung examination is key X-ray not always necessary 1. Gereige RS. Laufer PM. Pneumonia, Pediatrics In Review 2013; 34 (10); Chest X-rays Pneumococcal pneumonia Normal 1. Bartlett, JG. UpToDate 7/19/16 2. Grad, R. UpToDate 6/29/15 Outpatient Treatment Antimicrobial therapy not recommended for preschool age children S. pneumoniae remains the most common bacteria so amoxicillin or amoxicillin clavulanate are most appropriate May consider atypical coverage with azithromycin for school aged children and teenagers 1. Gereige RS. Laufer PM. Pneumonia, Pediatrics In Review 2013; 34 (10);

5 Inpatient Management Empirically covering S. pneumoniae Ampicillin/penicillin Ampicillin Sulbactam Ceftriaxone Cefotaxime Suspected atypical infection Azithromycin Concerned for MRSA Vancomycin Linezolid 1. Gereige RS. Laufer PM. Pneumonia, Pediatrics In Review 2013; 34 (10); You receive a prescription(s) from Dr. Jones office for the treatment of community acquired pneumonia for Jessie a 6 year old who weighs 28 kg. What is the most appropriate antibiotic regimen for Jessie? A. Amoxicillin-Clavulanic Acid 875 mg BID x 10 days plus azithromycin 200 mg x1 day followed by 100 mg daily for 4 days B. Azithromycin 200 mg x1 day followed by 100 mg daily for 4 days C. No antibiotics are necessary this is likely viral D. Amoxicillin-Clavulanic Acid 875 mg BID x 10 days Clinical Pearl: Augmentin liquid needs to be kept in the refrigerator and can cause diarrhea You receive a prescription(s) from Dr. Jones office for the treatment of community acquired pneumonia for Jessie a 6 year old who weighs 28 kg. What is the most appropriate antibiotic regimen for Jessie? A. Amoxicillin-Clavulanic Acid 875 mg BID x 10 days plus azithromycin 200 mg x1 day followed by 100 mg daily for 4 days B. Azithromycin 200 mg x1 day followed by 100 mg daily for 4 days C. No antibiotics are necessary this is likely viral Clinical Pearl: D. Amoxicillin-Clavulanic Acid 875 mg BID x 10 days Amoxicillin liquid doesn t need to be refrigerated but tastes better if it is 5

6 MENINGITIS Epidemiology Highest incidence of bacterial meningitis remains among children younger than 2 months of age Incidence has decreased in developed countries due to development of vaccinations 1. Swanson, D. Meningitis, Pediatrics In Review 2015; 36 (12); Definitions Bacterial Aseptic nonbacterial Enterovirus Arbovirus West Nile Medications Auto-immune Herpes Simplex Virus Chronic 1. Swanson, D. Meningitis, Pediatrics In Review 2015; 36 (12); Gowin, E. Wysocki, J. Usefulness of inflammatory biomarkers in discriminating between bacterial and aseptic meningitis in hospitalized children from a population with low vaccination coverage. Arch Med Sci. 2016; 12, 2:

7 Cerebral Fluid Analysis Normal Bacterial Meningitis Glucose: mg/dl Glucose: <1/2 of serum level Protein: g/l Protein: g/l Neutrophils: none Neutrophils: >85-95% White Blood Cells <6 cells/mm3 White Blood Cells: >1000 cell/mm3 Bacteria: none Bacteria: 60% will be positive 1. Swanson, D. Meningitis, Pediatrics In Review 2015; 36 (12); Gowin, E. Wysocki, J. Usefulness of inflammatory biomarkers in discriminating between bacterial and aseptic meningitis in hospitalized children from a population with low vaccination coverage. Arch Med Sci. 2016; 12, 2: Etiology Most common causes in 1970 s and 1980 s Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae type b (Hib) Group B Streptococcus (GBS) Listeria monocytogenes Streptococcus pneumoniae is most common cause for children older than 1 month 1. Swanson, D. Meningitis, Pediatrics In Review 2015; 36 (12); Role of Vaccines Most common causes in 1970 s and 1980 s Streptococcus pneumoniae (59% reduction) Neisseria meningitidis Haemophilus influenzae type b (Hib) Group B Streptococcus (GBS) (maternal screening has led to a 86% reduction) Listeria monocytogenes 1. Swanson, D. Meningitis, Pediatrics In Review 2015; 36 (12);

8 Diagnosis Neonate/Infant Fever Vomiting/Poor feeding Fussy Sleepy Seizures Bulging fontanelle Older child Fever Headache Lethargy Irritability Photophobia Nausea Vomiting Stiff Neck 1. Swanson, D. Meningitis, Pediatrics In Review 2015; 36 (12); Bulging Fontanelle 1. SearchBox&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjyiLT5543QAhUCWCYKHR1WAPAQ_AUICCgB&biw=1344&bih=746&dpr=1.25#imgrc=jRqU3LV5H0ey-M%3A Empiric Treatment Neonates Ampicillin Gentamicin Everyone else Vancomycin Cefotaxime or Ceftriaxone Clinical Pearl: may also want to consider adding viral coverage 1. Swanson, D. Meningitis, Pediatrics In Review 2015; 36 (12);

9 Which of the following meningitis symptoms is found more commonly in a school age child than an infant? A. Fever B. Vomiting C. Stiff neck D. Lethargy Which of the following meningitis symptoms is found more commonly in a school age child than an infant? A. Fever B. Vomiting C. Stiff neck D. Lethargy OSTEOMYELITIS 9

10 Pathophysiology Preceding bacteremia commonly leads to osteomyelitis Asymptomatic May also see trauma as cause Most commonly seen in the appendicular skeleton Femur Humerus In neonate infection can spread through growth plates Common to see with septic arthritis 1. Conrad, DA. Osteomyelitis, Pediatrics In Review 2011; 31 (11); Etiology Staphylococcus aureus most common in all age groups Less common Streptococcus pyogenes Kingella kingae Salmonella (important for sickle cell) Neonates Streptococcus agalactiae, Enterobacteriaceae Pseudomonas aeruginosa if preceding penetrating injury is known 1. Conrad, DA. Osteomyelitis, Pediatrics In Review 2011; 31 (11); Role of vaccinations Historically common causes now decreased in incidence Haemophilus influenza Streptococcus pneumoniae 1. Conrad, DA. Osteomyelitis, Pediatrics In Review 2011; 31 (11);

11 Diagnosis Septic clinically ill child with focal findings of skeletal infections Patient who looks clinically well but has progressive pain at the site of infection with loss of function Serum markers of inflammation are elevated Elevated white blood cells MRI helps to distinguish soft tissue versus bony disease 1. Conrad, DA. Osteomyelitis, Pediatrics In Review 2011; 31 (11); Treatment Empirically cover Staph aureus Nasal swab for MRSA Vancomycin, nafcillin, cefazolin Clindamycin, cefuroxime Follow blood cultures for organism 1. Conrad, DA. Osteomyelitis, Pediatrics In Review 2011; 31 (11); Bubnov-Raz, G, Ephros M. Invasive Pediatric Kingella kingae Infections. Pediatr Infec Dis 2010;29: OTITIS MEDIA 11

12 Epidemiology Accounts for more than 30 million clinic visits per year Approximately 13% of all emergency department visits in any given year Most commonly occurs in children between 6 and 24 months of age with a peak incidence between 9 and 15 months 62% of children have otitis media by their first birthday 1. Rosa-Olivares, J, Porro, A, Rodrigues-Varela M, et al. Otitis Media, Pediatrics In Review 2015; 36 (11); Pathophysiology Viral process increases mucus production Eustachian tube gets closed leading to build up of fluid behind the tympanic membrane Fluids starts sterile but secretions from the nasopharynx reflux in to the this middle ear space This can lead to bacterial colonization 1. Rosa-Olivares, J, Porro, A, Rodrigues-Varela M, et al. Otitis Media, Pediatrics In Review 2015; 36 (11); Etiology Streptococcus pneumoniae H. influenzae Moraxella catarrhalis 1. Rosa-Olivares, J, Porro, A, Rodrigues-Varela M, et al. Otitis Media, Pediatrics In Review 2015; 36 (11);

13 Role of Vaccines Incidence of S. pneumoniae related infections has significantly decreased since the PCV 7 vaccine Expected to further decrease with PCV 13 H. Influenzae becoming the primary pathogen 1. Rosa-Olivares, J, Porro, A, Rodrigues-Varela M, et al. Otitis Media, Pediatrics In Review 2015; 36 (11); Diagnosis Rapid onset fever and ear pain Ear pulling, irritability, decreased sleep Bulging of tympanic membrane Otorrhea 1. Rosa-Olivares, J, Porro, A, Rodrigues-Varela M, et al. Otitis Media, Pediatrics In Review 2015; 36 (11); Klein JO, Pelton S. UpToDate 11/8/16 13

14 Treatment Watchful Waiting Patients aged 6-24 months with unilateral non-severe symptoms Amoxicillin More than 30 days since last infection and no purulent conjunctivitis Amoxicillin-Clavulanate Less than 30 days since last infection or purulent conjunctivitis 1. Rosa-Olivares, J, Porro, A, Rodrigues-Varela M, et al. Otitis Media, Pediatrics In Review 2015; 36 (11); SS is an 18 month old 15 kg female who presents to her pediatrician with mom reporting complaints of fever, lethargy and tugging at her right ear. Upon examination the physician finds a bulging membrane in the right ear. First line treatment is: A. Amoxicillin 675 mg twice a day B. Watchful waiting C. Augmentin 675 mg twice a day D. None of the above SS is an 18 month old 15 kg female who presents to her pediatrician with mom reporting complaints of fever, lethargy and tugging at her right ear. Upon examination the physician finds a bulging membrane in the right ear. First line treatment is: A. Amoxicillin 675 mg twice a day B. Watchful waiting C. Augmentin 675 mg twice a day D. None of the above 14

15 SS returns 9 months later and is now 20 kg. She has similar symptoms including fever, lethargy and tugging at her ears. Upon examination the physician finds red bulging membranes. Treatment at this time should include: A. Amoxicillin 900 mg twice a day B. Watchful waiting C. Augmentin 900 mg twice a day D. None of the above SS returns 9 months later and is now 20 kg. She has similar symptoms including fever, lethargy and tugging at her ears. Upon examination the physician finds red bulging membranes. Treatment at this time should include: A. Amoxicillin 900 mg twice a day B. Watchful waiting C. Augmentin 900 mg twice a day D. None of the above URINARY TRACT INFECTIONS 15

16 Epidemiology 0.7% of ambulatory visits for children were for UTI in % of emergency department visits Prevalence of 7% in infants Circumcised males 2.4% versus 20.1% in uncircumcised males Spike during toilet training 1. Jackson, EC. Urinary Tract Infections, Pediatrics In Review 2015; 36 (4); Etiology E coli Klebsiella Proteus Enterococcus Pseudomonas 1. Jackson, EC. Urinary Tract Infections, Pediatrics In Review 2015; 36 (4); Diagnosis Infants-high temperature without another source Irritability, lethargy, vomiting or poor feeding Suprapubic tenderness, abdominal pain, new onset incontinence, dysuria Urine culture harder to get, commonly requires catheterization 1. Jackson, EC. Urinary Tract Infections, Pediatrics In Review 2015; 36 (4);

17 Urinalysis Normal Nitrite- Negative Leukocyte esterase- Negative Bacteria- None UTI Nitrites can be positive Leukocyte esterase can be positive Bacteria positive White Blood Cells- None White blood cellspositive 1. Simerville JA, Maxted WC, Pahirs JJ. Urinalysis: A Comprehensive Review, American Family Physician 2005; 71 (6); Treatment Severe symptom empirically treat, mild symptoms wait for culture E coli-bactrim resistance is commonly high First line empiric treatment usually cephalosporin or nitrofurantoin 1. Jackson, EC. Urinary Tract Infections, Pediatrics In Review 2015; 36 (4); VS is a two year old with known urogenital abnormalities including dilating vesicoureteral reflux. She presented to your ED with high fever, fussiness and poor feeding, after completing 3 days of IV ceftriaxone for an Ecoli UTI the team would like to transition her to oral cefdinir to complete her course and then transition to prophylaxis. What is an import counseling point to tell mom? A. Cefdinir has to be refrigerated B. It should be taken on an empty stomach C. Cefdinir causes some children s stool to turn and orange/red color D. Discard this medication 14 days after reconstitution 17

18 VS is a two year old with known urogenital abnormalities including dilating vesicoureteral reflux. She presented to your ED with high fever, fussiness and poor feeding, after completing 3 days of IV ceftriaxone for an Ecoli UTI the team would like to transition her to oral cefdinir to complete her course and then transition to prophylaxis. What is an import counseling point to tell mom? A. Cefdinir has to be refrigerated B. It should be taken on an empty stomach C. Cefdinir causes some children s stool to turn and orange/red color D. Discard this medication 14 days after reconstitution VS is readmitted to your floor 24 hours later with a returning high fever. Mom states she has not missed any doses of antibiotics and the culture comes back positive for Pseudomonas. VS is started on IV cefepime. The medical team asks you what oral therapy would be appropriate for home going after completing hours of IV antibiotics. VS weighs 19 kg. Your recommendation is: A. Amoxicillin-Clavulanic Acid 250 mg TID B. Ciprofloxacin 200 mg BID C. Cefdinir 120 mg BID D. VS must complete a course of IV antibiotics VS is readmitted to your floor 24 hours later with a returning high fever. Mom states she has not missed any doses of antibiotics and the culture comes back positive for Pseudomonas. VS is started on IV cefepime. The medical team asks you what oral therapy would be appropriate for home going after completing hours of IV antibiotics. VS weighs 19 kg. Your recommendation is: A. Amoxicillin-Clavulanic Acid 250 mg TID B. Ciprofloxacin 200 mg BID C. Cefdinir 120 mg BID D. VS must complete a course of IV antibiotics 18

19 Questions A Review of How to Treat Common Infections in a Pediatric Patient Tara Bergland, Pharm D. PGY2 Pediatric Pharmacy Resident Tara-bergland@uiowa.edu 19