Common Respiratory Tract Infections in Children Pt 1 Flashcards
pathophysiology of acute otitis media
Pathophysiology: mucociliary clearance mechanisms in eustachian tube ventilates and drains fluids away from middle ear. Eustachian tube obstruction can impair the drainage, leading to fluid stasis, which can lead to infection colonization. Children get more AOMs than adults because they are exposed to more viral URTIs and have shorter and more horizontal eustachian tubes.
Risk factors of acute otitis media
Risk factors: exposure to cigarette smoke, pacifier use, bottle feeding while lying down, shorter duration of breastfeeding, lack of immunization. Household crowding, daycare attendance, siblings, syndromes/craniofacial anomalies, immunodeficiency, atopy, male gender, FN/inuit.
Microbiology of acute otitis media
Microbiology of Acute Otitis Media: STREP STREP STREP PNEUMO, Haemophilus influenzae, Moraxella catarrhalis, group A strep.
Clinical Presentation: fever, fussiness, poor feeding, earache, ear discharge (indicates perforation), URTI symptoms are commonly present.
3 criteria for diagnosing AOM
Signs of middle ear effusion: decreased mobility of tympanic membrane, acute otorrhea (™ perf), loss of bony landmarks, air-fluid level
- AND sign of middle ear inflammation(bulging tympanic membrane with marked discoloration)
- AND Acute onset of symptoms: rapid onset of ear pain or unexplained irritability in a preverbal child.
Management of acute otitis media
Management: if left untreated, spontaneous resolution happens in 2/3ds of cases by 72 hours. Perforation with purulent discharge is very indicative of bacterial>viral, and it’s important to target strep pneumo cases.
First line: high dose amox (75-90) OR low dose amox 10 days if <2yo, or 5 days >2yo.
Second line if allergic to penicillin: 2nd or 3rd gen cephalosporin, azithromycin.
If there is a treatment FAILURE or there is also purulent CONJUNCTIVITS: amox-clav, ceftriaxone.
May need TUBES if >3 months with bilateral hearing loss, or recurrent AOM >3 episodes in 6 months.
Complications of acute otitis media
**Distinguish AOM from myringitis: redness of the tympanic membrane seen temporarily in a crying child, OR associated with viral URTI.
Complications of AOM: pus/blood draining from canal (perforation), persistent effusion associated with conductive hearing loss, impacting language development and school performance. Acute mastoiditis (inflammation and potential destruction of the mastoid air spaces leading to abscess formation).
Less common: cranial nerve VII palsy, CN6 palsy, labyrinthitis, Sinus venous thrombosis, meningitis.
Mastoiditis Features: pinnae displaced outward and down. Posterior auricular redness, swelling and tenderness.
Definition of otitis externa
ear canal inflammation and infection from broken skin
symptoms: otalgia, fullness, rapid onset
risk factors and microbiology of otitis externa
Risk factors: swimming, hearing aides, ear tubes, foreign body, trauma, dermatological conditions, AOM.
Microbiology: pseudomonas aeruginosa, staphylococcus Aureus, group A strep.
Diagnostic criteria for otitis externa (3)
treatment of otitis externa
Otitis Externa Treatment; analgesics, antibiotic drops (ciprodex, polysporin)
T/f usually pharyngitis is group A strep
false. >70% of cases are viral. If its bacterial, it’s usually group A strep.
Viral infection likely if: rhinorrhea, hoarseness, cough, and conjunctivitis → if classic viral symptoms predominante, the etiology is likely viral and no tests or antibiotics are needed
clinical presentation of strep pharyngitis,
how do you diagnose?
pharyngeal or tonsillar exudate, fever, tenderness and enlargement of anterior cervical lymph nodes, absence of cough, increased risk if exposure to individual with strep throat in previous 2 weeks
Diagnosis: McIsaac Score– give 1 point for each:
- pharyngeal or tonsillar exudate
- swollen/tender anterior cervical nodes
- a history of a fever greater than 38 C
- absence of cough
- Age < 15 years (-1 point if > 45 years)
Treatment for bacterial (GAS) strep pharyngitis
First line: Penicillin V and Amoxicillin
Second line if allergic to Penicillin: clindamycin and erythromycin
Antibiotics Treatment: Antibiotics will reduce: • Severity of symptoms • Duration of symptoms by ONE day • Risk of transmission (after 24h) • Risk of suppurative complications • Risk for rheumatic fever
Antibiotics will NOT reduce • Risk of non-suppurative complications (PSGN or GAS associated movement disorders)
___ ____ is a complication of bacterial pharyngitis.
RETROPHARYNGIEAL ABSCESS
Pathophysiology: often a complication of bacterial pharyngitis. Abscess formation often arises from lymph tissue
Microbiology: Group A strep, oral anaerobes
Epi: young kids
Clinical Presentation: pain, drooling, fever, tonsils look normal, loss of extension
Diagnosis: lateral neck X-ray and CT if +
Treatment: antibiotics and surgery
differentiating between retropharyngeal abscess and peritonsillar abscess
both can be complications of bacterial pharyngitis.
retropharyngeal: tonsils look normal, loss of extension. drooling
peritonsillar: hot potato voice, fever, unilateral swelling and deviation of the uvual.
Clinical Presentation: painful mass in cervical area, URTI symptoms, erythematous phaynx and tonsils, facial swelling, torticolllis
Diagnosis? treatment?
sounds like cervical lymphadnitis.
Ddx: VERY BROAD-
- Diffuse – infectious (reactive), inflammatory/rheumatological, malignant, drug
- Localized – Infectious (Bacterial), inflammatory/rheumatological
Generally, cervical lymphadenitis refers to acute bacterial infection of single, or a group of lymph nodes
Microbiology: staph A, group A strep, cat scratch disease, mycobacterium, HIB
Treament: Cefazolin IV or keflex PO
most common cause of cough
viral URTI
Most common cause of cough
Clinical presentation: runny nose, eyes, sore throat, fever, decreased energy and appetite, vomiting with cough is common
Natural history: in kids, might get URTI q3 weeks, especially if in daycare. Usually lasts 5-7 days
Management: conservative, antipyretics, encourage fluids, encourage hand washing, no cough medicine
cough red flags
worsening fever
chest pain
immunocompromised
noenate
FTT
prev history of pneumonia
choking episode
tachypnea
hypoxia
resp distress
focal findings on auscultation (pneumonia)
toxic appearance
is pneumonia an upper or lower airway disease
Pathophysiology: lower airway infection, causing pus and inflammation in small airways and alveoli
How does etiology of pneumonias differ depedning on age of child?
Etiology: Viral if <2, bacterial if older than 2• ***Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Moraxella catarrhalis
• Mycoplasma pneumoniae and Chlamydophila pneumoniae are more common in school aged children (ask about siblings in school usually greater than 5 years of age)
• __ pneumoniae and __ pneumoniae are more common in school aged children (ask about siblings in school usually greater than 5 years of age)
• Mycoplasma pneumoniae and Chlamydophila pneumoniae are more common in school aged children (ask about siblings in school usually greater than 5 years of age)
Diagnostic crtieria of pneumonia in children
Diagnosis: Fever and Cough, AND ONE OF:
- tachypnea,
- increased work of breathing,
- crackles,
- hypoxia,
- chest/abdo pain.
Pneumonia Investigations:
• Can be challenging to distinguish viral from bacterial
- High white count with left shift → more likely ___
- High CRP → more likely ___
- Suspect bacterial if:
- • Airspace __/consolidations
- • Lobar ___/distribution
- • Round opacities
- • Pleural ___
- Normal total WBC with lymphopenia → more likely ___
- Bloodwork: Consider only in patients being admitted for IV treatment or suspected sepsis
- CBC, blood culture (only 10% will be positive with pneumonia but will allow you to identify pathogen)
- CRP
- Consider electrolytes, renal function (at risk of SIADH)
- Nasopharyngeal aspirate if viral suspected
Pneumonia Investigations:
- Can be challenging to distinguish viral from bacterial
- High white count with left shift → more likely bacteria
- High CRP → more likely bacteria
- Suspect bacterial if:
- • Airspace opacities/consolidations
- • Lobar consolidation/distribution
- • Round opacities
- • Pleural effusion
- Normal total WBC with lymphopenia → more likely viral
- Bloodwork: Consider only in patients being admitted for IV treatment or suspected sepsis
- CBC, blood culture (only 10% will be positive with pneumonia but will allow you to identify pathogen)
- CRP
- Consider electrolytes, renal function (at risk of SIADH)
- Nasopharyngeal aspirate if viral suspected
first line antibiotic for pneumonia treatment
- First line Antibiotics: Oral: Amoxicillin, IV: Ampicillin
- Will not cover B-lactamase producing strains of H. influenzae and M. catarrhalis. Will not cover S. aureus.–> WOULD NEED A 3rd GENERATION CEPHALOSPORIN +/- MACROLIDE FOR MYCOPLASMA PNEUMONIA (severe pneumonia)
- Pen. allergy:
- 2nd generation Cephalosporin (Cefazolin, Cefuroxime)
- Macrolide (Azithromycin)
- If influenza precedes the pneumonia, consider Staphylococcus aureus
- Amoxicillin-clavulanate (will also cover B. lactamase producing H. influenzae and M. catarrhalis)
- If MRSA is suspected: Septra or Clindamycin
• If influenza precedes the pneumonia, consider Staphylococcus aureus and treat with ____.
- if MRSA is suspected cause of pneumonia, treat with:
staph A. treat with amox-clav
if MRSA suspected: septra or clinda
treatment for atypical pneumonia (chlam, mycoplasma)
clarithomycin or azithromycin
• CXR generally show bilateral interstitial markings, non- segmental patchy lung opacities
• Subacute onset, prominent cough, minimal leukocytosis, non-lobar opacity, typically school-aged – suspect Mycoplasma pneumoniae
