Exam 3 lecture 4 Flashcards
What is the most common indication for antibiotics in children
AOM (acute otitis media)
Risk factors that cause AOM
Smoke exposure
forumla feeding (breast milk is protective)\
Immunization
Atopy
Daycare attendance
Male gender
FH
Onset of 1st episode before 6-12 months of age
Lower socioeconomic status
Immune deficiency
non hispanic white
compare acute otitis media (AOM) and otitis media with effusion (OME) (when are antibiotics indicated? What tyoe of infection is seen)
Antibiotics not indicated and not beneficial in OME
Antibiotics indicated if symptomatic in AOM
Middle ear is sterile in OME, no signs of acute infection
Bacterual infection likely in AOM
What is a major reason children are more at risk for acute otitis media
Infant eustachian tube is shorter, more flexible and more horizontal vs adult (harder to drain)
Explain pathogenesis of acute otitis media? What percent of AOM are pathogenic bacteria isolated from?
Ineffective aeration of middle ear space-> Eustachian tube dysfuncion.
This leads to inflammation and edema of mucosal linings and narrowing of eustachian tube lumen.
Trapped air creates vacuum reversing flow of secretions drawing fluid into middle ear
Bacteria mutiply in fluid and stimulate inflammation
Pathogenic bacteria isolated from 65-75% of AOM cases
What are more common microorganisms seen with AOM? What are the big 3
strep pneumo, haemophilus influenza, mraxella catarrhalis (big 3)
Strep pyo and no pathogen is also common
What is the timeline of pneumococcal vaccination in children
Usually given 2, 4, 6 and 12-15 months
clinical manifestations of AOM in children
Otalgia (ear pan)
Holding or tugging at ear
Fever
irritability
poor feeding/anorexia
Malaise
otorrhea
How to diagnose AOM
- Visualize tympanic membrane
Compare normal TM and TM in AOM
- Normal TM
slightly concave
Pearly gray in collor
Translucent
Moves in response to pressure - TM in AOM
-bulging
-cloudy or purulent effusion
Immobile
2 important things to note about diagnosis of AOM
- acute onset (onset needs to be acute)
- ## Middle ear effusion
What are criteria that we use to determine if a patient has severe or non severe disease
non severe- Mild otalgia AND Fever <39 C in past 24 hrs
Severe- Moderate to severe otalgi or Fever > 39
What does effusion mean
Fluid collection
What are the criteria for observation Vs treatment of AOM
If <6 months- treat in every situation (otorrhea, severe uni &bi, Non severe uni & bi)
For 6 months-2 yrs- Treat in otorrhea, severe uni & bi, Bilateral non severe, but OBSERVE unilateral non severe
For > or = 2 yrs- Treat in severe bi anduni and otorrhea, But not in non severe at ALL
What does observation option look like in AOT
Deferment of antibiotics for 48-72 hrs
Watch for resolution of symptoms.
provide symptomatic relief
What to do in case observation fails
Communicate with physician
Begin antimicrobial therapy
Continue symptomatic therapy
What are SNAPs
Safety net antibiotic prescription?
Parents will allow 1-2 days for infection to resolve. If baby not better they can fill it
Describe strep pneumo resistance ( How common, Why, How to overcome)
50% of strains are penicillin resistant
Due to alterations in penicillin binding proteins
Overcome by higher concentrations of antibiotic at site (high dose amox
Describe H influenzae & moraxella catarrhalis resistance (how common and how to overcome)
40-50% of H flu strains and almost all M cattarhalis strains produce B lactamase (lead to amox resistance)
Overcome by addition of B lactamase inhibitor (such as amox/clav)
What is 1st line for AOM? Dose? (exam)
Amoxicillin is 1st line
80-90 mg/kg/day divided Q12H X 5-10 days
What are some advantages of using amoxicillin for AOM
In middle ear, high dose amox concentrations exceeds MIC of S. pneumo strains resistant to penicillin
Safe effective inexpensive
Half life 4-6 hrs in middle ear
When do we NOT use amoxicillin (exam)
Known resistance
tx failure
AMox in last 30 days
Allergy
Concurrent conjuctivitis
2nd line after amox failure in AOM?
Amox clav (augmentin)
1st line if amox in last 30 days or had conjuctivitis
Dose of amox clav? advantage/disadvantage?
90 mg/kg/day amox divided Q12H?
Advantage- additional coverage for B lactamase producing organisms
Disadvantages- may be more expensive
Diarrhea associated with clavulanate
Which augmentin to use for AOM
600 mg amox/42.9 mg clav/ 5 ml
ES- 600
What is the goal clavulanate for AOM
under 10 mg/kg/day
What would we use as 2nd-3rd line tx against AOM? What soecific drugs?
Oralcephalosporins
Cefpodoxime
(3rd gen cephalosporin)
Cefdinir
(3rd gen cephalosporin)
Describe allergies and cross reactivity when treating AOM
Cross reactivity highest between penicillins and 1st gen cephalopsorins
Much lower with 2nd and 3rd gen cephalosporins (cefdinir, cefuroxime, cefpodixime, ceftriaxone
What is the use of ceftriaxone in AOM? ROA?
Used as 3rd line. Used if initial oral tx fails or is not an option.
IM injection
advantages/disadvantages of ceftriaxone
advantage- broad spectrum, as effective as 10 days of amoxicillin
Disadvantages- Inj site pain, cost, avoid in < 1 month of age
What are some cautions with ceftriaxone
Calcium co administration
C diff
duration for children under 2 years old? Over 2 years old?
Under- 10 day duration
Over- 10 days if severe or recurrent, shorter courses (5-7) days may be used if >2 years
Adjunctive therapy for AOM (drugs, dose and age)
- Analgesics
- APAP PO
10-15 mg/kg/dose Q4-6H
- ibuprofen PO
5-10 mg/kg/dose Q 6-8H if older than 6 months ONLY
- Lidocaine otic drops
May consider in children 2 and up, do not use in ruptured TM or tubs, 2-4 drops in affected ear TID-QID
What does follow up look like for AOM
Within days for young infants with severe episodes or children of any age with continuing pain
Within 2 wks for infants or young children with hx of frequent recurrences
1 month after initial examination for children with only a sporadic episode of AOM
No follow up necessary for older kids
What are some preventions for AOM
pneumococcal and influenza vaccinations
Reduction of preventable risk factors
What are tympanostomy tubes? When are they indicaged?
Small ventilation tube inserted through tympanic membrane to provide drainage for eustachian tubes
Indivated in recurrent AOM
- 3 or more episodes in <6 mo
- 4 or more episodes in < 12 mo
advantages/disadvantages of tympanostomy tubes
Advantages- decrease AOM by 50%
- help restore hearing
Disadvantage- have to be placed under anesthesia
Can lead to scarring of tympanic membrane
If a patient has AOM, when should we consider ear drops
With tympanostomy tubes
tx of uncomplicated otorrhea with tympanostomy tubes
Topical quinolone drops are better than oral therapy
Oflafloxacin, ciprofloxacin
4-5 drops in affected ear BID x 5-7 days
What happens if we use tubes in pts without tubes
Topical quinolones can increase risk of perforation in pts without tubes
What is CSOM? What is it characterized by?
Chronic suppurative otitis media
Most severe form
Characterized by perforated TM w persistent drainage lasting >6wks
Most common isolate with CSOM
MRSA
Where does CSOM come from usually? What may it cause? Treatment?
Can be a complication of tympanostomy tube
May result in abscess or hearing loss
Initial tx ofloxacin or cipro ear drops x 2 weeks
What to do if tx failure of CSOM
Cukture is indicated and potentially requiring IV therapy or surgery
acute otitis externa other name? What can cause it?
Swimmers ear
Can be caused by trauma or trapped moisture
What are organisms seen in acute otitis extera
Different from AOM
Pseudomonas, S. aureus, consider fungal if no improvement)
How to treat acute otitis externa
Polymyxin B, Neomycin and hydrocortisone
Ofloxacin
Ciprofloxacin with hydrocortisone
Risk factors in febrile infants for UTI for girls and boys
Girls
- white
Age < 12 months
Temp > or =39
Fever > or = 2 days
Absence of another source of infection
Boys
- non black race
Temp > or = 39
Fever > or = 24 hours
Uncircumsized
Absence if another source of infection
Pathogenesis of UTI
Retrograde ascent
Nosocomial infection
Hemoatogenous spread
Fistula formation
common pathogens with UTI
E coli
signs/symptoms/diagnosis of UTI in newborns? Infants/young children? School aged children?
Newborns- Jaundice, sepsis, failure to thrive, vomiting, fever
Infants/ young children- Fever, strong smelling urine, hematuria, Abdominal/flank pain, new onset urinary incontinence
School aged children- Sx similar to adults including Dysuria, frequency urgency
Name methods of urine collection? Describe them?
-Clean catch- older patients
-Catheterization- Preferred for <24 months
-Sura pybic aspiration (SPA)- gold standard but invasive (reserved for young children who failed catheterization)
-Bag specimen- High rates of false postives.
What do we look for in a urinalysis? Chances of false positive/negative?
Leukocyte esterase suggest inflammation
Nitrite
When nitrite and leukocyte esterase are both negative -> 100% predictive
When both pisitive-> 80-90% sensitive and 60-98% specific
Cut offs for positive urine culture
SPA>10,000
Catheter specimen> 10,000
Clean catch >100,000
Treatment of UTI oral or IV? WHen would we use each
Oral and IV equally efficacious
Most patients can have oral
Choose IV for patients who are “toxic”, unable to retain oral intake
When can we switch from IV to oral in UTI pts
24-48 hrs
Duration of therapy for UTI
7 days for uncomplicated
Pyelonephritis- 10-14 days
7-14 days for ages 2-24 months
Treatment options for UTI
cephalexin Q6 or Q8H
Amoxicillin traditionally 1st line (e coli makes beta lactamase, amox clav might be better choice; klebsiella makes beta lactamase as well)
Higher cure rates with TMN-SMX or amox clav
When should we use each tx option for UTI
Amox/clav can target E coli that make B lactamase
SMX/TMP- E coli susceptibility varies
Nitrofurantoin- Must confirm ONLY cystitis. We can not use it in pyelo.
Why do we not use nitrofurantoin in UTI
It is very hard to see if a child has pyelo
Fluoroquinolones in chuldren UTI? Makor concern? When can they be used?
Traditionally not used in children.
Major concern is resistance
May be useful in MDR pathogens. Or if IV is not feasible or possile
Follow up for UTI
COnsider renal/bladder ultrasounds in all boys, all girls <3 years old, girls 3-7 years with fever >38.5
When can prophylaxis be used in UTI?
Some benefits seen with severe VUR (Vesicoureteral reflux)
What is bronchiolitis? What is it characterized?
Caused by viral lower respiratory tract infection in infants and young children
Acute inflammation, edema, increased mucus
clinical presentations of bronchiolitis? Duration to resolve?
Fever, Rhinorrhea, cough, sneezing
More severe sx can be increased work of breathing
- nasal flaring, accessory muscle breathing can progress to resp failure,
May take up to 2 wks to resolve?
most common virus that causes bronchiolitis? 2nd most common?
1st- Respiratory syncytial virus (RSV)
Rhinovirus is 2nd
How common is RSV?
90% of children infected before 24 mo.
Risk factors for RSV?
Age<6 months
Pre-term birth
Cyanotic or complicated CHD
Chronic lung disease
Weakened immune system
Treatment of RSV
SUPPORTIVE THERAPY (O2, hydration, mechanical ventilation, ECMO (life support))
Prevention of RSV
Non pcol- Hand washing, isolation, sick pods
Pcol- Influenza vaccine, RSV specific (nirsevimab, maternal RSV vaccination)
What are 2 ways to protect babies from severe RSV disease
- vaccination of pregnant people
- monoclonal antibody for infants (palivizumab, Nirsevumab)
When should pregnant people get RSV immunization?
Abrysvo if delivered during RSV season (32-36 weeks pregnancy)
provides protection if given at least 14 days before delivery.
Administer before and during start of RSV szn (sept through jan)
What to do if birth parent did not get RSV vaccination 14 days before deivery?
Give Nirsevimab.
Typically for < 8 mo of age
Only should be given during RSV season.
Dosing of nirsevimab
<5kg=50 mg
5kg or more =100 mg
How long does nirsevimab last
71 days (lasts longer than RSV vaccine)
Timing of Nirsevimab
If born during RSV szn, get it in the hospital
If born outside of RSV szn(summer) get it at the PCP when the season starts
Who needs second nirsevimab dose?
Chronic lung disease
Immunosuppressed
American indian or alaska native
