Recurrent Infections in Children

Transcription

1 2:00pm - 3:00pm: Breakout 3 - Case Discussions Option B: Recurrent Infections in Children ACPE UAN L01-P Activity Type: Application-Based 0.1 CEU/1.0 Hr Program Objectives for Pharmacists: Upon completion of this program, participants should be able to: 1. Recognize the most common organisms causing recurrent infections. 2. Discuss the most appropriate antibiotics to use in children. 3. Describe common recurrent viral infections in children, treatment options, use of antibiotics, and education for parents regarding referral to a physician. 4. Discuss the FDA guidelines and recommendations on OTC products for pediatrics. 5. List pediatric drug references that may be useful in the community pharmacy setting. Speaker: Kelli DeVore, PharmD, BCPS, has been at Blank Children s Hospital in Des Moines, IA, for the past 4 years as a pediatric clinical pharmacist. She is board certified in pharmacotherapy and has also served as adjunct faculty at Drake University as a pharmacy student preceptor and pharmacy resident preceptor for the past 3 years. Dr. DeVore graduated from Drake University in 2005 and completed a pharmacy practice residency with an emphasis in pediatrics and critical care in 2006 at the University of Iowa. Speaker Disclosure: Kelli DeVore reports she has no actual or potential conflicts of interest in relation to this program. The speaker has indicated that off-label use of medications will be discussed during this presentation.

2 Kelli DeVore, PharmD, BCPS Graduated from Drake in 2005 Completed a PGY1 Residency at the University of Iowa in 2006 Joined the team at Blank Children s Hospital in 2006 as a pediatric clinical pharmacist Adjunct faculty for Drake University, Creighton University, and the University of Iowa Name 1 of the most common bacterial causes of acute otitis media (AOM)? Name 2 antibiotics that would be appropriate for treating community acquired methicillin-resistant staph aureus (MRSA) in children. What antibiotic or antibiotics would you recommend empirically for community acquired pneumonia in a 5 year old? A parent approaches you in the pharmacy and asks for a recommendation for her 6 month old for congestion. Do you recommend: A) Tylenol Cough and Cold with Congestion B) Saline nasal drops and bulb suction C) Advil Cold and Congestion Name 1 pediatric drug reference that would be beneficial to have to double check pediatric medication doses for appropriateness. Otitis Media CA-MRSA Infections CA-Pneumonia Viral Infections - RSV, bronchiolitis, influenza Recognize the most common organisms causing recurrent infections and the most appropriate antibiotics to use in children Gain knowledge about common recurrent viral infections in children, treatment options, and education for parents regarding referral to a physician. Become familiar with the FDA guidelines and recommendations on OTC products for pediatrics. Be familiar with pediatric drug references that may be useful in the retail setting. AOM is the 2 nd most frequent diagnosis made by pediatricians, next to the common cold Most common indication for antibiotics for children in the US accounting for 20 million Rx AAP defines AOM as an infection in the middle ear with acute onset, presence of middle ear effusion, and signs of inflammation Important physicians distinguish AOM from otitis media with effusion 80% of children have had at least one episode of AOM by 3 years of age Viruses have been found in 40-75% of all AOM cases 1) Subcommittee on Management of Acute Otitis Media (2004). Pediatrics 113 (5):

3 13 month old F presents to the pediatric clinic in October with a h/o a fever of 38.4 C, pulling on her ears, fussy, and has a persistent cough with congestion. Upon exam, the physician notes a bulging tympanic membrane with inflammation of the middle ear canal. Mom reports she has NKDA and does attend day care. Most common bacterial organisms: S. Pneumoniae, H. influenzae, and Moraxella Catarrhalis Common viral organisms: Rhinovirus and RSV What risk factors does this patient have for AOM? What are the most common organisms associated with AOM? 13 month old F presents to the pediatric clinic in October with a h/o a fever of 38.4 C, pulling on her ears, fussy, and has a persistent cough with congestion. Upon exam, the physician notes a bulging tympanic membrane with inflammation of the middle ear canal. Mom reports she has NKDA and does attend day care. Age URI (frequent) Presents in Fall (Oct) Fall/winter months higher incidence Daycare attendance This is this child s 1 st diagnosed episode of AOM. Based on her symptoms, should this patient be treated with antibiotics? Treatment recommendations: < 6 months of age Treat with antibiotics 6 months 2 years of age Treat IF the diagnosis is certain. If the diagnosis is uncertain and it is nonsevere, a hour observation period can be utilized prior to starting antibiotics > 2 years Highly recommended to observe for hours prior to starting antibiotic therapy if non-severe. Treatment duration: < 5 years of age, treat for 10 days; >6 years of age, 5-7 days is appropriate What antibiotic would you recommend? Amoxicillin (high dose) of 80-90mg/kg/day remains the treatment of choice If there is concern for H. influenza or M. Catarrhalis high dose amoxicillin/clavulanate (Augmentin ) is recommended For PCN allergic patients, 2 nd or 3 rd generation cephalosporins may be considered or azithromycin After 3 days of high dose amoxicillin, she is still fussy and tugging at her ears. She comes back to the pediatrician s office and he determines she does not have a perforated ear drum, but has failed amoxicillin therapy. What would your recommendations be for treatment? A) Change antibiotics to ciprofloxacin/dexamethasone (Ciprodex ) ear drops B) Change antibiotics to amoxicillin/clavulanate (Augmentin ) C) Change antibiotics to cefdinir (Omnicef ) D) Ceftriaxone 75mg/kg IM once daily x 1-3 days

4 Most common organisms: Respiratory bugs (S. pneumoniae (25-50%), H. influenzae (15-30%), M. catarrhalis (3-20%), Rhinovirus, RSV) Most cases of OM are self limited, due to the large number being caused by viral infections Observation period should only last hours before antibiotic therapy is initiated and should only be considered in non-severe cases Patients with persistent pain or fever should be re-seen within 72 hours and re-evaluated Topical antibiotic/steroid combos are more effective in children with tubes than PO antibiotic therapy 1) Subcommittee on Management of Acute Otitis Media (2004). Pediatrics 113 (5): UTI is one of the most common bacterial infections 8% of all girls and 2% of boys will have a UTI during childhood 2 Incidence of recurrent UTI within 12 months of an initial UTI has been cited as high as 30% 3 AAP 1991 guidelines recommend a voiding cystourethrogram (VCUG) for all children with their 1 st febrile UTI between the ages of 2 months and 2 years 2 2) Merguerian PA, Sverrisson EF, et al. Curr Urol Rep (2010). 11: ) Bing Dai, Yawei Liu, et al. Arch Dis Child (2010). 95: mo old F admitted to the hospital with NKDA, a fever of 38.8 C, and not wanting to urinate. The UA showed +nitrites, +leukocyte esterase with WBC. Ceftriaxone 50mg/kg IV was started upon admission. What is the most likely organism causing her infection? a) Proteus b) E. Coli c) Pseudomonas d) Staph Aureus A catheter UA culture was obtained and showed E.Coli 50,000 cfu/ml. Susceptibility results were: Ampicillin Resistant Ampicillin/sulbactam Resistant Amox/clavulanate Cefazolin Ceftriaxone SMX/TMP 1) Is this a true UTI based upon the bacterial count in the UA culture? 2) What oral antibiotic would be most appropriate to send this pediatric patient home on? 8 weeks after finishing her treatment for her UTI, she underwent a VCUG as was recommended by her pediatrician. The study showed she had Grade III reflux. The pediatric nephrologist recommended starting a prophylactic antibiotic. What antibiotic should be started for prophylaxis? a) SMX/TMP (Bactrim ) 2-5mg/kg/day b) Cephalexin 15-20mg/kg/day c) Amoxicillin 20-30mg/kg/day d) No prophylaxis is needed 1 st febrile uncomplicated UTI in children is caused by E. Coli in 70-90% of all cases 4 Use of antimicrobial prophylaxis for patients with recurrent UTIs is controversial 2-4 Increased rate of bacterial resistance, especially when using cephalosporins 4 A recent meta-analysis showed that the use of prophylactic antibiotics did not decrease the rate of recurrent symptomatic UTIs in those with or without VUR or renal scarring. 3 Long term complications: renal scarring, hypertension, and renal failure 2 2) Merguerian PA, Sverrisson EF, et al. Curr Urol Rep (2010). 11: ) Bing Dai, Yawei Liu, et al. Arch Dis Child (2010). 95: ) Cheng C-H, et al. Pediatrics (2008). 122:

5 The first report of CA-MRSA in children without any risk factors appeared in 1998 By 2004, the incidence in children reported at Texas Children s Hospitals was 76.4% Susceptibility to SMX/TMP is very good across the nation, however resistance to clindamycin is increasing Resistance to erythromycin may induce clindamycin resistance Treatment failure is often the result of an undrained abcess 5) Odell, CA. Curr Opin Pediatr (2010). 22: A 3 y/o M is admitted to the hospital for cellulitis around the site of a bug bite. He has been treated outpatient with SMX/TMP 10mg/kg/day for 3 days and the cellulitis has continued to spread up his leg. Upon further exam, it appears he does have a loculated abcess around the site of infection. NKDA. What antibiotic would you recommend for empiric treatment? A) SMX/TMP (Bactrim ) 10mg/kg/day IV divided q12h B) Vancomycin 15mg/kg/dose IV q6h C) Clindamycin 40mg/kg/day divided q6h D) Ampicillin/sulbactam (Unasyn ) 300mg/kg/day divided q6h 2 month old M admitted to the hospital with a buttock abcess. The abcess was drained by surgery and the culture grew out MRSA with the following susceptibility pattern: Clindamycin Intermediate Erythromycin Resistant Oxacillin Resitant Vancomycin SMX/TMP The pediatric intern asks you for recommendations on which antibiotic to start on this patient. A) Vancomycin 15mg/kg IV q8h B) SMX/TMP (Bactrim ) 10mg/kg IV divided q12h C) Clindamycin 40mg/kg IV divided q8h Due to the rising resistance rate of CA-MRSA among children, empiric antibiotic therapy for cellulitis should cover CA-MRSA Outpatient treatment failures are often a result of an undrained or inadequately drained abcess. (Abcesses >5cm have a higher failure rate) Compliance with outpatient PO antibiotics is challenging and can result in treatment failure Multiple recurrent infections require decontamination Mupricin (Bactroban ) Nasal minimal success Bleach Baths ½ cup of bleach in ¼ filled bathtub Dog decontamination 5) Odell, CA. Curr Opin Pediatr (2010). 22: One of the main causes of death in young children Determination of causative agent of pneumonia is difficult diagnostically In a recent study, bacterial etiology was found in 60% of cases S. pneumoniae was causative agent in 73% Viruses in 45% of cases Causative agent differs according to the age of the child 2 month old is admitted to the hospital with tachypnea (RR = 80), hypoxemia (O2 sats 85% on RA) with no evidence of wheezing, and a temp of 39.5 C. A CXR is obtained and shows a RML consolidation. You know the most likely organism causing infection in this patient is S. pneumoniae. 6) Sinaniotis CA & Sinaniotis AC. Curr Opin Pulm Med (2005). 11:

6 What empiric antibiotic would you recommend starting in this 2 month old? A) Ceftriaxone 75mg/kg/day IV + Azithromycin 10mg/kg day 1, then 5mg/kg days 2-5 PO B) Ampicillin 200mg/kg/day IV divided q6h C) Levofloxacin 10mg/kg IV q12h D) Ceftriaxone 75mg/kg/day IV q24h 10 month old with a history of Down Syndrome is admitted in January with tachypnea (RR = 72), hypoxemia (O2 Sat = 83% on RA), fever of 40.1 C, and significant inspiratory wheeze. A CXR is obtained and does not reveal a consolidation, but does show interstitial infiltrates. Who thinks this is a bacterial infection? A viral infection? Most likely causative organism? What is the best treatment option for RSV pneumonia? A) Supportive care O 2, albuterol nebs if beneficial B) Ceftriaxone 75mg/kg/day + Supportive Care 8 y/o presents to the clinic with an URI for 7 days. Mom reports a fever of 39.1 C at home and the child has a headache, cough, rhinorrhea, and a mild wheeze can be heard upon auscultation. She is diagnosed with mycoplasma pneumonia. C) Pavlizumab (Synagis ) 15mg/kg IM x 1 The physician asks for your recommendations on which antibiotic to start this patient on for Mycoplasma Pneumoniae. A)No Antibiotic is Necessary B) Levofloxacin 10mg/kg PO q24h C)Cefdinir 14mg/kg PO q24h D)Azithromycin 10mg/kg PO Day 1, followed by 5mg/kg Days 2-5 Neonates: Bacterial: Group B Streptococcus, gramnegative bacteria 3 weeks 3 mo: Bacterial - S. pneumoniae, H. influenzae, pertussis Viral - para-influenza, RSV 4 mo 4 years: Viral - RSV, Parainfluenza, influenza, adenovirus, rhinovirus Bacterial S. pneumoniae 5-10 years: Bacterial M. pneumoniae, C. pneumoniae; Coinfections with S. Pneumoniae 6) Sinaniotis CA & Sinaniotis AC. Curr Opin Pulm Med (2005). 11:

7 Common symptoms for bacterial and viral: Fever, tachypnea, headache, dyspnea, cough, rhinorrhea, abdominal pain Differentiating symptoms/diagnostics CXR Bacterial: Lobar consolidation Viral: Interstitial infiltrates, however this can still be seen in certain bacterial pneumonias or mixed infections Wheezing more often viral, however can occur with M. pneumoniae Most common among young children aged 4 months 4 years RSV is the most common viral organism during RSV season (October March) Other viral infections commonly seen: influenza, adenovirus, para-influenza, rhinovirus Croup, bronchiolitis caused by other viral infections not identified 6) Sinaniotis CA & Sinaniotis AC. Curr Opin Pulm Med (2005). 11: ) Sinaniotis CA & Sinaniotis AC. Curr Opin Pulm Med (2005). 11: Treatment is supportive O 2, suctioning of secretions, +/- albuterol or 3% saline Outpatient Treatment 60% of OTC recommendations sought by the public involve cough and cold medications 7 New labeling from the FDA in 2007 regarding children 7 No proof of efficacy in children <12 years of age Increased side effects and deaths reported among children More than 120 deaths arising from OD of antihistamines or decongestants in children More than 1500 ED visits in kids <2 years of age with severe side effects between ) Aguilera L. US Pharmacist (2009). 34(7): Result: Do NOT give to kids < 2years of age and many products have changed labeling to not give to children <6 years of age What do I recommend to parents? Room humidifier or vaporizer Saline nasal drops Bulb suction/saline Maintain hydration status APAP/IBU (if >6 months of age) Know when to refer to a HCP 7) Aguilera L. US Pharmacist (2009). 34(7): Vaccinations for bacterial pneumonia S. pneumoniae Prevnar 13, Pneumovax 23 H. influenza Vaccinations/Prevention for Viral Illness Influenza Live Flu Mist, Inactivated Injection Highest Risk Groups: 6 months 5 years of age, aspirin therapy, lung disease, cardiac disease, immunocompromised, neurological disease RSV Synagis Not a true vaccine Monoclonal Ab to boost immunity against RSV Cost $$$$ High risk groups only Prematurity GA < 32 weeks Chronic lung disease, Congenital cardiac disease Pediatric Dosage Handbook (Lexi-Comp) The Red Book (AAP) Harriet Lane (Mosby) - contains more diagnostic information for physicians Other Hospital Must Haves: Pediatric Injectable Drugs (Teddy Bear Book) (ASHP) Neofax (Thomson Reuters) NICU Centers Trissels compatibility information

8 Name 1 of the most common bacterial causes of acute otitis media (AOM)? Name 2 antibiotics that would be appropriate for treating community acquired methicillin-resistant staph aureus (MRSA) in children. What antibiotic or antibiotics would you recommend empirically for community acquired pneumonia in a 5 year old? A parent approaches you in the pharmacy and asks for a recommendation for her 6 month old for congestion. Do you recommend: A) Tylenol Cough and Cold with Congestion B) Saline nasal drops and bulb suction C) Advil Cold and Congestion Name 1 pediatric drug reference that would be beneficial to have to double check pediatric medication doses for appropriateness.