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Infections Flashcards

1
Q

Where is the commonest site for infection in young children?

A

Respiratory tract

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2
Q

What can the symptoms of mild viral illness be similar to?

A

Symptoms of mild viral illness may be similar to serious bacterial infection
Viral illness can also be severe
Viral & bacterial illness may coexist / collaborate

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3
Q

Epidemiology of global burden influenza under 5s

A

2018 estimated influenza episode in under 5s 109.5 million ( 63.1-190.6)
Attributable ALRI hospital admission 870000
Attributable ALRI Hospital deaths 15,000 total death
Admission & mortality Improved from previous WHO 2008 statisitics due to role out of Pneumococcal conjugate vaccine

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4
Q

How does the influenza resp tract infection work?

A

Primary viral pneumonitis
Co infection with other virus/ bacteria
Pathway to secondary bacterial infection: chest .. Also ear & brain

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5
Q

Epidemiology of RSV in children under 5

A

33 million RSV LRTI
3.6 million RSV hopitalisation
457000 RSV attributable mortality 97% in low and middle income countries
Both RSV and influenza association with secondary bacterial infection
Impact of immunsition flu and pneumococoal on hospital admissions
Children source of infection to adults
Passive immunization RSV all infants: previously just risk group
Pregnancy immunization RSV: protects mum and young infants

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6
Q

What bacteria cause pharyngitis/ tonsilitis, epiglottitis and otitis media?

A

Pharygitis/tonsilits: Gp A Strep, adenovirus, EBV
Epiglotitis: Haemophilus influenza b
Otitis media: Pneumococcus, haemophilus, GpA Strep, moraxella

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7
Q

What bacteria cause croup, tracheitis, pneumonia?

A

Croup: Para flu..+
Tracheitis: S.aureus, GpA Strep,
Pneumonia: GpAStrep, Pneumococcus, S.Aureus ,Haemophilus influenza..(non b),TB.

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8
Q

What bacteria causes atypical pneumonia, broncholitis

A

Atypical pneumonia: mycoplasma, chlamydia
Bronchiolitis: RSV, rhino, flu, adeno paraflu, metapneumo

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9
Q

If there is a possible bacterial infection what should you do?

A

Use most appropriate antibiotic
… not so easy when you don’t know the cause
Narrow vs broad spectrum where possible
Obtain samples ( micro. & virology ) to help rationalize treatment
Document your plan and infection you think you are treating
Follow local guidelines
Infection control

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10
Q

How does the antimicrobial stewardship treatment algorithm work?

A

Start Smart - Dont start antibiotics in absence of clinical evidence of bacterial infection
1. Take drug allergy history
2. Initiate prompt effective antibiotic treatment
3. comply with prescribing guidance
4. Document clinical indication
5. Include review

Then focus
1. CLinical review and decision at 48-72 hours
2. If needed STOP antibiotic
3. IV to oral switch
4. change antibiotic
5. continue
6. OPAT

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11
Q

What are the difficulties with new antimicrobials in children?

A

Tolerability , formulation, toxicity & pharmacokinetics different in children
Studies in children more difficult to do
Paediatric access to new drugs may be 10 yrs behind adult availability
Need for parallel paediatric trials

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12
Q

Which diseases without treatment/ early ID may develop coronary artery aneurysms and risk of long term cardiac disease

A

VZV: self limiting but mortality if secondary infection staph or strep
Significant national increase in VZV & GpA strep 2022-23
Impetigo staph / strep vs HSV stomatitis, simple cold sore, severe if eczema occasionaly causes encephalitis, ( enterovirus may mimic hand foot and mouth )
Meningococcal sepsis
HSP
Kawasaki disease (KD): fever, rash, stomatitis, periphery change, adenopathy, conjunctivitis

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13
Q

Features of Kawasaki disease

A

Red bloodshot eyes
Red swollen hand and feet
Strawberry tongue
High fever
Rash on body
Common in infants

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14
Q

Treatment for Kawasaki disease

A

Typical
4/5 features
with 5 day of fever
ECHO
IVIG
Asprin
+/- steroids

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15
Q

What is sepsis?

A

Overwhelming life threatening response to an infection resulting in tissue damage, organ failure and death….”
“Body’s overactive toxic response to Infection”

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16
Q

Sepsis 6 in children

A

Fast breathing
fit or convulsion
Looks mottled, bluish or pale
Non blanching rash
Lethargic or difficult to wake
Feels cold to touch

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17
Q

Sepsis 3 in any child under 5

A

Is not feeding
Vomiting
Havent had a wee or wet nappy in 12 hours

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18
Q

Traffic light system for identifying risk of serious illness

A

Slide 21 of infection paeds

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19
Q

Treatment for sepsis in child under 3 months

A

Under 3 months: FBC, Blood culture, CRP, Urine cultur, other investigatiosn as indicated
Under 1 month: as above and Lumbar puncture (LP)
1-3 months LP if: Unwell or WBC <5 or >15
IV antibiotics:
All infants under 1 months and 1-3 months if unwell or WBC <5 or>15

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20
Q

Treatment for sepsis in child over 3 months

A

Child over 3 months
Red features: FBC, Blood culture, CRP, Urine culture
LP if clinical features or unwell
CXR consider if clinical features
Amber features: as for red unless experienced paediatrician reviews
CXR if WBC >20 and temp>39
Green features: urine test, no blood tests

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21
Q

2 week old
Fever 24 hours at home
Not feeding well
Crying constantly when awake and waking less often for feeds
Temp 38.5
Pale, cool peripheries
WBC 4 ( normal 5-10)
Neut 1.0,(low) lymphocytes 3.0 (normal)
CRP 50
U&E normal
LFT deranged
CSF WBC 200
Glucose reduced
Protein elevated
What does he most likely have?

A

Bacterial Meningitis

22
Q

Features of bacterial meningitis

A

Raised cell count (neutrophils)
Raised protein
Low glucose
Bacteria identified in blood or CSF culture or PCR

23
Q

Features of viral meningitis

A

Raised cell count (lymphocytes)
Normal protein
Normal glucose
Virus identified in CSF, stool, throat or blood
HSV encephalitis

24
Q

Causes of meningitis/ encephalitis under 3 months old

A

< 3 months: GpB strep,
Also: Ecoli, Listeria, pneumococcus, meningococcus
Cefotaxime ( ceftriaxone) & amoxicillin
Herpes simplex: aciclovir,
Enterovirus

25
Causes of meningitis/ encephalitis over 3 months old
Meningococcus, pneumococcus ( haemophilus influenza non b ), Cefotaxime / ceftriaxone Herpes simplex: aciclovir, Enterovirus
26
8 year old Cold previous week New fever complaining of headache before going to bed Sleepy, confused when woken Neck stiff when examined Cool peripheries Poor Capillary return
Possible meningococcal septicaemia
27
Features of meningococcal septicaemia
Caused by meningococcus, usually GpB in UK now GpC previously common, GpA common in Africa/ middle east, , W&Y increasing in UK* Serogroup defined by polysaccharide capsule of organism with no cross protection between strains May or may not have associated meningitis Clinical presentation, rapid onset septic shock Management cefotaxime/ ceftriaxone, early PICU Septicaemia with other organisms may mimic: Pneumococcus, Toxin producing strains GpA Strep, Staph aureus
28
Symptoms of meningitis
Neck stiffness Sensitivity to light. ( not reliable in young children) Drowsy/ irritable Vomit Headache Full fontaelle
29
Symptoms of meningitis septicaemia
Red/purple non-blanching rash. Cold hands and feet. Tachypnoea. Flu like symptoms
30
4 month old No previous health problems Recurrent cough and noisy breathing past 3 days Sl indrawing RR 60, nasal flaring, alert, well perfused Temp 37.8 Bilateral crackles and wheese What is it?
Bronchiolitis
31
What are some causes of bronchiolitis?
RSV Paraflu Influenza A/B Rhinovirus Adenovirus H. Metapneumo Corona ( various
32
4 month old No previous health problems Recurrent cough and noisy breathing past 3 days Sl indrawing RR 60, nasal flaring, alert, well perfused Temp 37.8 Bilateral crackles and wheese weeks later Never really got better Not feeding well Clearly lost weight since last admission RR 60 Widespread crackles & respiratory distress Temp 38.2 PICU team alerted WBC 4 (neut 3.0, lymphocytes 1.0 ( 2.5-4)) CRP 23 Blood culture , urine culture no growth still RSV +ve and now para flu +ve IgG 1.5 ( 2.5-6) IgA < 0.04 IgM <0.08 ( 0.5 – 1.5 What is up with the child?
Bronchial secretions PCP ( pneumocystis pneumonia/jirovecii) “ opportunistic infection”
33
Immune deficiency in children
Infection common in children Immune deficiency rare : Sever Combined Immune deficiency (SCID) 1 in 50-60,00 Severe disease presenting in neonates/ infants, immunological emergency Not just infectious presentation: Failure to thrive, skin problems , chronic chest problems/organomegaly/adenopathy Normal infant lymphocyte count >2.5 Newborn screening for SCID on neonatal dry blood spot “TRECs” indication of thymic out put since September 2021 Genetic Immune defects may present in older child/Adults Immune defects associated with malignancy, autoimmunity and allergic disease
34
Pathophysiology of immune deficiency
-Inadequate number cell Number : X linked agammaglobulinaemia/ SCID/ Congenital neutropenia -Defect in cell function: chronic granulomatous disease neutrophil function defect Defect in cytokine production/ intracellular messaging
35
10 warning signs of primary immunodeficiency
1. 4 or more new ear infections within one year 2. 2 or more sinus infections in a year 3. 2 or more months on antibiotics with little effect 4. 2 or more pneumonia in a year 5. Failure to gain weight or grow normally 6. Recurrent deep skin or organ abcesses 7. Persistent thrush in mouth or fungal infection in skin 8. Need IV antibiotics to clear infections 10. 2 or more deep seated infections including septicaemia
36
Epidemiology of Severe combined immunodeficiency
US Experience 2010-2013 11 programmes, > 3 million births 52 SCID, 1:58000 births 411 non SCID lymphopenia: Di George, Trisomy 21 CHARGE, Trisomy 18, Ataxia telangiectasia False positive more likely in preterm infants UK estimates annually: 266 false positive, 31 Lymphopenic not SCID, 17 SCID Prevent 6.3 SCID deaths annually Neonatal BCG: plan to delay to 6 weeks
37
Who do we investigate for SCID?
Frequent or unusually severe infections Infection with unusual organism Family history Unusual inflammatory/ autoimmune or malignancy phenotype Low threshold in children with underlying syndromic/ chromosomal problems with infection
38
What tests to do for SCID?
FBC : low total WBC, neutrophil or lymphocytes Total Ig GAM +/-E Responses to routine immunisations Lymphocyte subsets: numbers of T and B cells Lymphocyte function Genetic panels
39
Treatment for SCID
Antibiotic / antiviral prophylaxis Prompt treatment of infections Replacement immunoglobulin ( usually subcutaneous infusion at home weekly) Bone marrow transplant Close Collaboration with other specialties : respiratory, rheumatology, gastroenterology, haematology, genetics
40
How do vaccines work
Generate immune response: T ( cell mediated) and B cells (antibody) for organism Antibody against toxin Induce immunological memory Protein antigens stronger stimulation eg tetanus toxoid vs Polysaccharide capsule meningo/ Pneumo Antibodies (B cell memory): easily measured Specific T cell memory ( more difficult to measure) Herd immunity Protective not harmful immune response
41
How do passive immunity and active immunity work?
Passive immunity: HBIG, ,VZIG, Rabies Ig, HNIG RSV Active: Live attenuated : MMR, BCG, nasal flu, rotavirus Inactivated: whole cell pertussis Inactivated toxin: Diptheria, Tetanus Recombinant components: acellular pertussis Conjugate vaccine: Bacterial Polysaccharide+protein carrier Cell wall/ envelope components: Flu, MenB
42
UK vaccine preventable diseases
Tetanus Diptheria Whooping cough Polio Measles Mumps Rubella Hib Men C Prevnar 13 Pneumovax* Meningococcus ACWY Varicella* TB* Hepatitis B Influenza* Rotavirus HPV Men B Rotavirus
43
Other meningitis vaccines
Gp B meningococcus (OMP veiscle) : Introduced Sept 2015 Impact on carriage unclear GpACWY meningococcus : Summer 2015 (teens) Haemophilus influenza B : Meningitis, epiglotitis Vaccine introduced 1992, disease virtually disappeared Pneumococcus: 100+ different serotypes Most invasive disease UK caused by ( was caused by?) 13 serotypes in Prevnar 13 ( conjugate, immunogentic in infants 2010) Meningitis, pneumonia, empyema, bacteraemia, otitis media still occur Problems with serotype replacement Pneumovax: 23 serotype, non immunogenic in infants , poor immune memory
44
Epidemiology of Pertussis (Whooping cough)
Vaccine introduced 1957 Scare in 1970s reduced vaccine uptake wP vaccine replaced with less reactogenic vaccine acellular pertussis 2000 2012 14 infants died in UK Unrecognsied burden of disease in adults / older children September 2012 pertussis immunization offered to pregnant women 2013 3 Uk infant death all to infants of unimmunsied mothers Now routine dTaP , Flu, and COIVD offered in pregnancy 250% increase in whooping cough 2023 ? Reduced pregnancy immunsiation & reduced population immunity
45
Immunisation challenges
Waning vaccine induced immunity Herd immunity Immunological memory Infectious disease Epidemiology and reporting Vaccine strategy Anti vaccine campaigns/ vaccine hesitancy Access to immunization Conflict/ famine/ widening health inequality COVID UNICEF Apr 2023 67 million children missed out on vaccines past 3 years
46
What is the R value
R value < 1 : less than one person infected by an index case Increasing R value increasing infectivity Infectivity affected by degree of contact, duration of index illness & host and index vaccination status Measles will infect 12-18 unimmunized exposed individuals
47
2 yrold Arrived in UK 2 weeks ago from Sierra Leone to live with mum Cranky, temp 39, RR 40, well perfused, no rash Hb 7.8 (low), Pl 180 (low normal), CRP 90 CXR bronchial wall thickening Malaria film & rapid test x3 negative Respiratory viral swabs sent IV ceftriaxone ? What is it
Typhoid
48
12 year old Arrived in UK from Zambia 6 months ago Chicken pox 4 weeks ago prolonged illness, 2 weeks antibiotics Readmitted 2 weeks later Cough, Temp 39, tachycardic, RR 50 Healing VZV scars WBC 20 CRP 75 What other investigations do you want? What other infections might a child born in sub-Saharan Africa be at risk of ?
Pneumococcus, GP A strep, Staphococcus aureus Tuberculosis
49
Features of TB
Latent disease: asymptomatic, uninfectious, treat to prevent disease in future Active disease ( symptomatic/ clinical evidence eg Xray, Lymphnodes): mortality high if untreated Children often not infectious ( older children may be) Diagnosis 1. symptoms: fever sweats wt loss cough 2. contact tracing 3. tests: sputum, tissue, X ray, Mantoux, IFN gamma blood tests BCG some protection, predominantly against neonatal TB meningitis
50
Epidemiology of TB
9.4 x 106 cases TB annually world wide 1 x 106 in children but may be underestimate Rates of TB overall are falling world wide BUT incidence of Drug resistant TB increasing Children still dying unnecessarily Ongoing infection in children provides a pool for ongoing infection in the community
51
Risk of congenital (perinatal) infection
HIV* maternal Rx Hepatitis B* Immunisation at birth CMV: treatment of infant modifies disease Rubella HSV: intervention pre & peri-delivery but not screened VZV: intervention if early neontal TB* maternal Rx Syphilis* maternal Rx GpB strep*? Maternal peri-delivery Rx
52
HIV Features
With treatment should live relatively normal life to late adulthood Transmission mother to infant 25% with no intervention Pregnant mother given medication with controlled infection Transmission in UK now << 1% due to screening and treatment in pregnancy Increased risk if late presentation/ poor compliance/ country or origin higher rates of infection C section necessary if detectable maternal virus Infant medication 2-4 weeks Breast feeding : not advised in UK but yes in resource poor setting Infection still a risk if: mum not screened in pregnancy ORBreast feeding with detectable virus OR discordant couples

3A Paediatrics (19 decks)

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