infections Flashcards
leading cause of death in children?
Sepsis
what is Sepsis?
SIRS + suspected or proven infection
what is sever sepsis?
Sepsis + organ dysfunction
what is septic shock?
Sepsis + CVS dysfunction
criteria to have SIRS?
Temperature
>38°C or <36°C
WCC
>15 x 109/L or <5 x 109/L
Tachycardia
>2SD above normal for age
Tachypnoea
>2SD above normal for age
How might sepsis look in a kid?
Fever/hypothermia
Chills & rigors
Cold hands/feet + Slow cap refill
Muscle weakness & muscle/joint ache
Rash
Low UO, vomiting & diarrhoea -- 5 Sepsis 6 in kids is a bit different, what criteria do we use to spot it? - Hypotension - Fever/Hypothermia - Tachycardia - Tachypnoea - Alt Mental Status - Slow cap refill / poor perfusion / mottled peripheries
Sepsis 6 in kids is a bit different, what criteria do we use to spot it?
Hypotension
- Fever/Hypothermia
- Tachycardia
- Tachypnoea
- Alt Mental Status
- Slow cap refill / poor perfusion / mottled peripheries
Sepsis 6 is a bit different in kids, what are the 6 actions?
Take Blood cultures
- Give IV resus
- Give IV Abx
- Give Inotropes
- Give O2
Get Senior Help
What organisms cause sepsis?
Neonates: (BEL)
- Group B Strep,
- E. Coli
- Listeria Monocytogenes
Children: (PANS) - Pneumococcus, -Neisseria meningitidis (meningoccoccal) -Group A strep -Staph Aureus
what are infants under 3 months more at risk
Increased risk bacterial infection
Increased risk sepsis
Increased risk meningitis
May have minimal signs & symptoms
Presentation often non-specific
May not mount a febrile response (~50%)
Deteriorate quickly
RF for sepsis in infants <3months (I think this is the slide?)
Prematurity (< 37/40) PROM Maternal pyrexia/chorioamnionitis Maternal GBS (this pregnancy) Previous child with GBS Maternal STI (Chlamydia, Gonorrhoea, Syphilis, HSV)
how many mls per kg do u give for sepsis?
20ml/kg fluid bolus
how much glucose to give in sepsis?
don’t ever forget glucose’
2ml/kg 10% dextrose
what abs to give in sepsis?
3rd generation cephalosporin (eg Cefotaxime/Ceftriaxone)!!
add IV Amoxicillin if <1m old
investigations to do in sepsis?
Bloods FBC (leukocytosis, thrombocytopaenia) CRP Coagulation screen (DIC) Blood gas (metabolic acidosis, raised lactate) Glucose Blood culture
Cultures Blood Urine CSF (including send to virology) \+/- stool (micro + virology)
Imaging
CXR
Pathogenesis of Sepsis
Secretion of pro and anti-inflammatory cytokines
Activation of complement
Activation and mobilisation of leukocytes
Activation of coagulation and inhibition of fibrinolysis
Increased apoptosis
what is meningitis?
A disease caused by inflammation of the meninges
what is meningism?
The clinical signs and symptoms suggestive of meningeal irritation
Meningitis signs and symptoms in older children
classic symptoms
Fever Headache Photophobia Neck stiffness (nuchal rigidity) Nausea & vomiting Reduced GCS Seizures Focal neurological deficits
Meningitis signs and symptoms in young infants
lethargic, irritable
bulging fontanelle & “Nappy Pain”
Fever or hypothermia Poor feeding Vomiting Lethargy Irritability Respiratory distress Apnoea Bulging fontanelle
3 clinical signs of meningitis
-Nuchal Rigidity (Neck Stiffness)
Palpable resistance to neck flexion
-Brudzinski’s sign
Hips and knees flex on passive flexion of the neck
-Kernig’s sign
Pain on passive extension of the knee
Meningitis in kids often comes secondary to sepsis, what organisms cause it?
Neonates: (Same as sepsis)
- Group B Strep
- E. Coli
- Listeria Monocytogenes
Children - Pneumococcus - Neisseria meningitidis (meningoccoccal) - H. Influenzae
Haemophilus influenzae- what type of bacteria?
where is it found?
Small, non-motile, gram-negative coccobacillus
Nasopharyngeal carriage
what are the 2 types of Haemophilus influenzae
Encapsulated
Non-encapsulated
encapsulated H.influenza cause which disease?
Resist phagocytosis & complement mediated lysis
6 serotypes (a-f)
Hib main cause of invasive H. influenzae infection
Bacteraemia, Meningitis, Epiglottitis, Pneumonia
RF – asplenia, sickle cell disease, antibody deficiency
Non-encapsulate H.influenza cuase which disease?
otitis media & sinusitis
invasive infection rare
neisseria meningitides (meningococcal) type of bacteria? transmission?
Gram negative diplococcus
Humans only natural hosts
Nasopharyngeal carriage
Transmission via respiratory secretions
Infection often follows viral URTI
what is the capsule in meningococcus?
Polysaccharide capsule
capsule composition determines serogroup (eg. A, B, C, W, Y)
Endotoxin (LPS)
Invasive Meningococcal DiseaseRisk Factors
Age <1 year or 15-24 years
Unimmunised
Crowded living conditions
Household or kissing contact
Cigarette smoking (active or passive)
Recent viral/Mycoplasma infection
Complement deficiency
meningitis and septicaemia- same symptoms?
Petechial/Purpuric Rash
septicaemia symtoms?
Fever Headache Myalgia Vomiting Abdominal pain Limb pain Reduced GCS Signs of shock
Other than the brain where might you find H influenzae infection?
Septicaemia
Pneumonia
Epiglottitis
characteristic of invasive meningococcal disease?
the rash
Invasive Meningococcal Disease complications?
Significant long term sequelae
Amputation (14%)
Scarring (48%)
Hearing Loss
Cognitive impairment/epilepsy
Are pneumococcus & H influenzae Gram -ve or +ve?
Pneumoccous is gram +ve
Haemophilus is Gram -ve
pneumococcus
- gram pos or neg
- type of polysaccharide?
- transmission
Pneumo: Positive, Polysach, nasoPharynx, resP
Gram positive, lancet-shaped, diplococcus
Facultative anaerobe
Polysaccharide capsule:
- inhibits neutrophil phagocytosis
- inhibits complement mediated cell lysis
> 90 known serotypes
All serotypes can cause invasive disease
Colonises nasopharynx (11-93%!)
Preceeding URTI RF for invasive infection
Respiratory droplet transmission
Where can pneumococcal infections occur in the body and what is likely to precede them?
Viral inf tends to predispose to invasive pneumococcal disease.
Can be found:
- Pneumonia
- Meningitis
- Septicaemia
- Otitis Media
- Sinusitis
- Arthritis
- OM
- Peritonitis
Invasive Pneumococcal DiseaseRisk Factors
Age <2 years Cigarette smoking (active or passive) Recent viral URTI Attendance at childcare Cochlear implant Sickle cell disease Asplenia HIV infection Nephrotic syndrome Immunodeficiency/Immunosuppression
Pneumococcal Meningitis
complications?
Neurological sequelae common Hydrocephalus Neurodisability Seizures Hearing loss Blindness
Case fatality in children 8%
Management of Meningitis The basics (the same as sepsis)
Airway
Breathing
Circulation – 20ml/kg fluid bolus, inotropes
DEFG – ‘don’t ever forget glucose’
2ml/kg 10% dextrose
Antibiotics
- 3rd generation cephalosporin
(e. g. Cefotaxime/Ceftriaxone) - add IV Amoxicillin if <1m old
Meningitis investigations?
Bloods FBC (leukocytosis, thrombocytopaenia) U&Es, LFTs CRP Coagulation screen (DIC) Blood gas (metabolic acidosis, raised lactate) Glucose !!!!Blood culture!!!! Meningococcal/Pneumococcal PCR
signs of meningitis?
Signs of raised ICP GCS <9 Abnormal tone or posture HTN & Bradycardia Pupillary defects Papilloedema Focal neurological signs Recent seizure Cardiovascularly unstable Coagulopathy Thrombocytopenia Extensive or extending purpura
what to request on LP in meningitis
Microscopy Gram Stain Culture Protein Glucose Viral PCR
what findings in LP show bacterial meningitis
Turbid or purulent High opening pressure HIGH WCC (polymorphs) HIGH Protein LOWGlucose (<50% serum)
What’s special about meningococcal infection?
Its very very fast. Once it hits the blood stream you get:
- septic shock within 12hrs
- Meningitis within 18-36hrs
Also can cause meningococcal rash
1st line sepsis treatment? in kids
3rd gen cephalosporin!!!
invasive menigoccal disease is caused by…
Neisseria meningitidis
