Ch 42 Bacterial & spirochetal: Bacterial infections: Pneumoncoccal, H flu & pertussis, Chlamydia trachomatis Flashcards by Michele Burr

How does pneumococcal bacteremia present?

age, finding, lab finding

6 - 24 months
high fever > 39.4C
Leukocytosis > 15000

all three of these findings should arouse suspicion

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What findings are specific to bacterial pneumococcal pneumonia?

beaver, Tac-P, Luke-Side-Toe,

Fever, leukocytosis, tachypnea
localized chest pain
localized or diffuse rales
XRAY may show lobar infiltrate (with effusion)

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What findings are specific to bacterial pneumococcal meningitis?

beaver, Luke-side-toe,

Fever, Leukocytosis
Infants: Bulging fontanelle, neck stiffness
irritability and lethargy

Older children: nuchal rigidity, positive Brudzinski and Kernig signs

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What are essential diagnostic tools for all bacterial pneumococcal infections?

cultures - blood, CSF, pleural fluid, or other bodily fluid

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What vaccine has decreased the incidence of bacterial meningitis?

pneumococcal conjugate vaccine

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What comorbidities in children increases the susceptibility to pneumococcal sepsis and meningitis?

What catastrophic findings will present in these children?

Sickle cell disease and other hemoglobinopathies
Congential or Acquired Asplenia
Immunoglobin and complement deficiencies

shock and DIC often occurs in these children

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What organ is important in the control of pneumococcal infection?

spleen

this is why sickle cell disease children are at an increased risk for pneumococcal infections

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Children with _______________ are at higher risk for pneumococcal meningitis.

cochlear implants

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T/F Neonates with serious disease is caused by S Pneumoniae

FALSE! - rarely S pneumoniae causes serious disease in children. However, pneumonia, sepsis, or meningitis is clinically similar to GBS infection

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T/F The drug of choice for pneumococcal infections is penicillin

FALSE! - Pneumococcal infections are likely to be resistant to penicillin (use to be the agent of choice and not all strands are resistant)

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Pneumococcal infections:
WBC may show?
Other lab findings will show?
What is present on CSF?

WBC - leukocytosis (20-45k) with left shift (elevated poly. neutrophils)
Elevated CRP and procalcitonin
CSF: elevated WBC with neutrophils, low glucose, elevated protein

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What is the diagnostic tool that will diagnose pneumococcal meningitis?

Lumbar puncture - gram-stained smear and culture is necessary to distinguish pneumococcal from bacterial meningitis

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What are differential diagnosis fora young infant with high fever and leukocytosis, when pneumococcal infection is suspected?

Viral infection
UTI
Salmonellosis
early acute shigellosis
infection else where in the body

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Children that are severely ill or immunocompromised with invasive infection with suspected S Pneumoniae, should be treated with what specific medication?
If meningitis is also suspected, what should be given in addition to this medication?

bacteremia treatment:
IV Vancomycin (GLYCOPEPTIDE)

meningitis - IV Vancomycin and Ceftriaxone (CEPHALOSPORIN)

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A infant over 1 month old with known susceptible organisms of pneumonia, what medication is given? What is another choice of medication?

Pneumonia treatment in infant > 1 month
IV Ampicillin (PENICILLIN)
or
IV Ceftriaxone

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What is the medication of choice for mild pneumonia?

What class of medication (and name) can be given as an alternative for mild pneumonia?

Amoxicillin for 7-10 days

Oral cephalosporin (Cefdinir) is an alternative for penicillin allergic patients

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What two medications are the choice for severely ill or immunocompromised children with pneumonia if susceptibilities are NOT known?

IV Vancomycin
or
IV Cephalosporin-resistant pneumococcus

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What alternative regimens can be given to a child with pneumonia that is allergic to penicillin and cephalosporin?

Fluoroquinolones (Ciprofloxacin, Levofloxacin, Ofloxacin)

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You are awaiting results of bacteriologic confirmation and susceptibility testing on a child you presume has meningitis. What medication should you prescribe this child?

IV Vancomycin
AND
IV Ceftriaxone

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The child you suspect has meningitis, you are awaiting for bacteriologic results, is allergic to beta-lactam antibiotics. What medication should you treat this child with?

IV Vancomycin and Levofloxacin (FLUOROQUINOLONE)
or
IV Vancomycin and Meropenem (CARBOPENUM)

Beta-lactam antibiotics include penicillins and cephalosporins

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What adjunctive therapy is recommended for pneumococcal meningitis?

Corticosteriods - Dexamethasone

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The lumbar puncture shows CSF pneumococcal meningitis that is susceptible to penicillin. What medication can be given? What can be used alternatively based on susceptibility findings?

Aqueous Penicillin G IV
or
Ceftriaxone (isolate must be cephalosporin susceptible)

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When should the NP reorder a lumbar puncture after CSF proves patient has resistant pneumococci?

24 - 48 hours to ensure sterility of CSF collection

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What specific serious neurologic sequelae may be present following pneumococcal or H. Influenzae meningitis?

Hearing loss - check hearing throughout course of illness and shortly after recovery. Child may need cochlear implants (sensorineural loss)

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What medical illnesses present although uncommon due to vaccination of Haemophilus influenzae type B? (MACE PP)

``` Meningitis Arthritis - septic Cellulitis Epiglottis Pneumonia Pericarditis ```

Unencapsulated, nontypeable H. Influenzae frequently colonizes what?

mucous membranes

What does unecapsulated, nontypeable H. Influenzae cause in adults and children?

``` Otitis media Sinusitis Bronchitis Pneumonia *invasive disease* ```

What medication is resisted by nontypeable H. Influenzae?

Ampicillin *low BLNAR strains in US*

What treatment is necessary for people that are unimmunized, or partially immunized, household contacts of a Hib patient? Any contraindications to this treatment?

Rifampin chemoprophylaxis of all household contacts (except pregnant women) to eradicate potential nasopharyngeal colonization with Hib and limit risk of invasive disease Contraindications: pregnant women

What are three examples of when Rifampin chemoprophylaxis should be given to all household contacts?

1. families where at least 1 household contact is < 4 yr old and unimmunized/partially immunized against Hib. 2. Immunocompromised child of any age or immunization status resides in the household 3. a child younger than 12 months resides in the home and has not received the primary series of the Hib vaccine

What symptoms are specific to Hib and non-type B invasive disease with suspected meningitis?

Infants: fever, irritability, lethargy, poor feeding with or without vomiting high-pitched cry

What symptoms are specific to Hib and non-type B invasive disease with suspected acute epiglottitis?

``` evidence of *dysphagia* is most useful early sign with s/s of refusal to eat/swallow saliva, and drooling high Fever (toxic child) ```

What symptom may not always present in Hib and non-type B invasive disease with suspected acute epiglottis?

cherry-red epiglottis on direct examination - INTUBATE IMMEDIATELY

What symptom is a late sign specific to Hib and non-type B invasive disease with suspected acute epiglottis?

stridor

What symptoms are specific to Hib and non-type B invasive disease with suspected septic arthritis?

Unimmunized < 4 years old with fever and refuses to move involved joint and limb swelling, warmth, redness, tenderness on palpitation, and severe pain on physical exam

What symptoms are specific to Hib and non-type B invasive disease with suspected cellulitis?

3 months - 4 years old unimmunized child | cheek or preorbital (preseptal) area is often involved

What will the CBC reveal in a child with suspected Hib infection?

high or normal with a shift to the left

What other diagnostic tools are utilized in the suspicion of Hib infection?

positive blood culture CSF - meningitis pleomorphic gram-negative rods aspirated pus or fluid from site FDA approved PCR test for CSF

What XRAY is best for a child with suspected Hib infection?

lateral neck - epiglottits (can be misinterpreted)

T/F All patients with bacteremic or potentially bacteremic H. Influenzae diseases require hospitalization for treatment

TRUE! - hospitalized and third generation cephalosporins

What treatment should be selected for the child with suspected H. Influenzae meningitis infection? Duration of therapy?

IV Vancomycin and Ceftriaxone (IM if IV access lost) | 10 days

What class of medications is best for Hib infections?

3rd generation cephalosporins (cefotaxime or cefttriaxone

Once the organism has been identified as H influenzae in a child with meningitis, what treatment should be given before antibiotics? What will this treatment prevent?

6 hours before antibiotics give Dexamethasone for up to 4 days prevents hearing loss

Why would a NP order a follow-up lumbar puncture for Hib meningitis?

``` *the NP would not usually order this unless* questionable clinical response seizure after several days of treatment abnormal neurological exam recurrent fever ```

What is the initial treatment for a patient with septic arthritis with suspected H. Influenzae organism?

Antistaphylococcal antibiotic and Cefotaxime or Ceftriaxone (CEPHALOSPORIN)

How long is the duration of therapy to treat H. Influenzae septic arthritis?

2 - 4 week course of antibiotics (longer if complications or s/s are unresolved)

Besides antistaphylococcoal and cephalosporin antibiotics for H. Influenzae septic arthritis, what else is an essential part of treatment?

Drainage of infected fluid - surgical drainage if in the hip, if treatment is delayed, or clinical response is slow

What is the initial treatment for a patient with cellulitis with suspected H. Influenzae organism?

broad spectrum antibiotics | Amoxicillin - PENICILLINS or Clindamycin/Azithromycin (MACROLIDE) if penicillin allergy

If a patient with cellulitis has positive results of H. Influenzae organism, what will be the medication of choice?

CEPHALOSPORIN - Cefotaxime or Ceftriazone or CARBAPENEM - Meropenem

How long is the duration of therapy to treat H. Influenzae cellulitis?

3 - 7 days parenterally followed by PO therapy **minimum course of 21 days in uncomplicated cases without abscess*

T/F A fever above 38C is a typical finding of pertussis infection

FALSE! - a fever > 38.3 C is unusual and suggests an alternative diagnosis

What are the three stages of Pertussis?

1. Catarrhal: 7 - 10 days 2. Paroxysmal: 1 - 6 weeks - high-pitched "whoop" at end of cough 3. Convalescent: 7 - 10 days gradual recovery

What clinical findings may follow coughing found in pertussis?

cyanosis sweating prostration (action of lying stretched out on the ground) exhaustion *coughing fits are more frequent at night*

T/F It is best practice to wait for pending results of a potential pertussis organism before treatment

FALSE! - early treatment for suspected pertussis is best practice

Pertussis WBC: Severe disease findings in young children:

WBC 20-30k with lymphocytes typically near the end of the catarrhal stage **the degree of lymphocytosis correlates with the severity of disease** Severe: Pulmonary HTN and Hyperleukocytosis

T/F Older children with mild pertussis infection never demonstrate lymphocytosis

TRUE! - mild infections in older children and adults will never have lymphocytosis

What finding may present on chest XRAY on a child that has a pertussis infection?

thickened bronchi and "shaggy" heart border

What diagnostic test is only best for pertussis identification in the first 3 weeks of cough?

rapid antigen test (PCR) of nasal cavity

What medications are best for treatment before the paroxysmal stage of pertussis infection?

Antibiotics in the catarrhal phase - no effect on clinical symptoms in the paroxysmal stage. Initiate as quickly as possible.

What antibiotics are best for treatment of the catarrhal phase of pertussis infection?

**Azithromycin (MACROLIDE)** drug of choice Erythormycin (MACROLIDE) is not preferred but acceptable Clarithryomycin (MACROLIDE) must be > 1 month old

What is a contraindication of erythromycin treatment for pertussis?

Infants < 1 month old erythromycin can cause pyloric stenosis; azithromycin is least likely to cause this but inform parents of potential risk and signs of pyloric stenosis

What therapy is most important during the paroxysmal phase of pertussis?

Nutrition - small frequent feedings, tube feeding, or parental fluid supplemenation Minimize stimuli that trigger coughing

What infection typically presents within a few days after birth until 16 weeks of life with watery, mucopurulent, to blood discharge and conjunctival injection?

Neonatal Chlamydia conjunctivitis

What preventive measures are best to reduce the rate of chlamydia conjunctivitis?

diagnosis and treatment of pregnant women and their partners oculcar prophylactic antibiotic after birth is only for gonococcal infection, NOT C. Trachomatis

What specific chlamydia infection is the leading cause of acquired blindness worldwide?

C trachomatis trachoma - 4-6 years old and in poor hygienic countries often

What findings are most present in infants with C trachomatis pneumonia?

afebrile tachypneic staccato cough

What medication treatment is best for chlamydophila pneumonia?

Azithromycin or doxycycline (MARCOLIDE)

What medications are most effective for neonatal conjunctivitis or pneumonia? What is a potential complication from these medications?

10-day course of Erythromycin base or Ethylsuccinate Azithromycin - increased compliance **both are associated with pyloric stenosis**

What medication is recommended for children with trachoma?

single dose Azithromycin | **consider treating the community/regional mass if population is > 10 % of trachoma cases**