CLIPP 10 Flashcards
adverse rxn w rotavirus vaccine
happens typically within first several days and most commonly with the first dose of it
-is a live virus vaccine, can cause fever
MMR and varicella adverse rxns
are live virus vaccines and can cause fever in some infants 7-10d after administration
FWS vs FUO
FWS - complete hx and Pex done and no identified source of fever
FUO - fever >38.3 (101) for at least 2 weeks with failure to reach dx after 1 week of eval
sepsis dx
typically requires +BC? card 6 case 10
occult bacteremia
applied to child with bacteremia who looks well or is a little fussy (compared to toxic or ill appearing child with bacteremia is more likely to be septic)
SBI - and most common cause
serious bacterial illness - kids with occult bacteremia will likely not get this while kids with sepsis are a medical emergency.
-most common cause is a UTI
organisms responsible for a lot of the occult bacteremia we see, if we see it
strep pneumo, hib, NM, salmonella enteritidis
a wbc count of <15000
excellent at ruling out bacteremia
will most young children presenting w/ fever w/o focus be bactremic?
no - thus empiric tx not always indicated
kernigs and brudzinski signs
kernig - flex at hip and knee, then extend at knee: positive result of pain w/ ext of knee
brudzinski - positive result is flexion of hip and knee in response to flexion of neck by examiner
*note that most kids under 1 yo will not demo a kerning or brudzinski sign even if they do have bacterial meningitis i.e. the absence of meningismus cannooottt rule meningitis out. but if theo do demo a + or both + sign, then do LP
one of the things on ddx of bulging fontanelle
meningitis
paroxsymal criyng is __ and could indicate __
for example, crying when picked up, meningitis
opisthotonos
hyperextension (severe) , almost in bridge form. In severe cases of meningitis, increased extensor tone of neck and spine leads to hyperextension of the entire spine or “opisthotonos.”
nuchal rigidity
involuntary reisstance to neck flexion
UTI presentation
commonly presents as fever and no focus on physical examination and a relatively unremarkable review of systems.
Fussiness and lack of appetite are common associated symptoms.
UTI gender and age RF
females =39 (102.2) or more than 24 h of FWS
in what case is a cxr in an immunized kid w/o resp sx indicated
if WBC>=20,000 x 10^3
how could young infants in sepsis present
hypothermia rather than fever
most common cause of bacterial meningitis in kids is
SP, NM (conjug pneumococcal vaccine only projects against 13 serotypes)
common culprit in viral meningitis and sx
enterovirus
in kids, presents w/ fever and can also have diarrhea, rash, or URI sx
roseola - age, virus type, sx, tx
Common viral illness in children under 2 years of age.
Caused by human herpes virus 6 (HHV-6).
A high fever is often the only symptom in the first few days of illness and typically lasts for 3 to 5 days.
Some patients develop a rash as the fever resolves; the rash can persist from 1 to 4 days.
Appropriate management for a child with roseola is to reassure the family that no other therapy is indicated
occult bacteremia vs sepsis
by definition, it may be found in a child with high fever with no other symptoms and no source of infection on physical examination who appears well (as opposed to children with sepsis who also have bacteria in their blood).
hsv gingivostomatitis
often in 10 month to 3 yo kids, starts as irritability and fever but then oral lesions / vesicles form around mouth
PPV of red tM
essentially none.
to dx OM, should see
poor mobility and bulging at least mildly - without either of these, hard to dx om
viral uri sx
cough, coryza, conjuncitva, fever , rhinorrhea
when to obtain cxr
if sx of lower resp tract dz or if wbc>=20k, or if ill appearing
if kid has diarrhea, do these testing steps
stol guaicia and fecal leukocytes and if positive, get stool and blood cultures
in what age group is acute rheumatic fever rare and implication of this?
kids less than 3yo - implication is no need to do rapid or strep culture in kids <2 yo
which age group should not get strep rapid or culture
kids <2yo
general rule in approaching if an LP is needed
General Rule
If you are going to treat any febrile, ill-appearing, young infant (especially an infant less than 3 months of age) with parenteral antibiotics that will cross the blood-brain barrier (ceftriaxone is probably the most commonly used antibiotic in this setting), an LP to rule out meningitis should be performed:
Parenteral antibiotics will affect the CSF culture results, and
The antibiotic treatment of bacterial meningitis requires higher doses.
On the other hand, if the infant is not toxic, or has another obvious focus of infection, a lumbar puncture may not be necessary.
can bagged specimens be used for culture
no - high contamination rate
interp of high wbc (22k) on cbc in terms of ddx
If Holly was a low-risk child (immunized and looked well), given the low prevalence of bacteremia in that setting the positive predictive value of WBC’s would be very low. Almost all patients with a positive WBC would be false positives.
It is a piece of the puzzle, however, and in the setting of a child with an increased likelihood of SBI (Holly appears ill) the elevated WBC and bands increase the likelihood of a SBI.
+nitrites and +leuk est strongly suggests:
UTI
when does +nitrite test occur and what is its sensitivity and specificity
gram- bacteria reduce nitrAte to nitrite thus nitrIte happen when these specific bacteria are present in the urine for 3-4h
*a positive nitrite is highly specific (few false positivties) but negative nitrite has poor sensitivity ( lots o false neg) esp in young infants who urinate a lot
nitite producing bacteria especially incldue
protues, kleb, e coli
+ leuk est
detects esterase from broken down leukocytes and indicates presence of WBC in urien but pyuria can be seen in things other than UTI
can +leuk est dx a UTI?
not alone
what is +pyuria defined as in cetringed vs uncentrofiuged urine
> 5 WBCs per high-power field (hpf) in a centrifuged urine considered positive. If a counting chamber is used, then > 10 WBCs per microliter in uncentrifuged urine is considered positive.
route of UTI abx administration
most can be oral unless too sick to take PO, lack of compliance
most common cause of UTI in kids not recently on abc
ecoli, then other gram- like proteus, kleb, or by enterococus
good pyelo med
ampicillin/gent
enteroccoi tx
amp
ceftriaxone covers, does not cover, contraindic
most gram- bacilli EXCEPT pseudomonas, not enterococci, don’t give calcium thru same line otherwise it forms precipitates
ceftriaxone does not cover , among other, these things…
pseudomonas, enteroccci
pip tazo does and does not
gram - bacili and psuedomonas, less optimal for enterocci
pip tazo vs ceftr
pip tazo and cent both do gram-bacili but ceft does NOT do psuedomas
in whom is cipro approved and the exception to cipro tx
kids> 1 yo w complicated UTI resistant to other things, but quinolines in general not to be used w/ kids under 16. cipro exception is in CF Kids to tx their pseudomonas
nitrofurantoin tx
cysitis not pyelo - and in fever + high wbc w +UA, consider pyelo as possibility.
renal techniticum scan
used for providing evidence of pyelo but not needed in pt who responds well to abx/tx
vcug
not routinely done after first febrile uti unless renal/bladder US demonstrate reflux - but IS done after 2nd febrile uti.
f/u to do after 1st pyelo episode
US renal and bladder, gives info about collecting ducts and renal structure. can be done at completion of abx tx unless kid has severe case or not resolvign
grading of VUR and implications
1-5, 5 is most severe. 1 and 2 tend to resolve spontaouelsy and grade 4-5 tend to need surgery. grade 3 might need surgery.
g1-2 can be followed by pcp but g3-5 need urolo referral
reflux implication on further UA
do UA if pt is febrile illness w/o clearly defined focus.
RF for recurrent UTI
VUR
role of prophylactic abx in VUR
reduces UTI recurrence but no change in renal scaring
most common bacterial illness in female infant
uti
