Infectious Disease II Flashcards
Definition of Fever?
AKA as high fever or high temperature and defined as a rectal temp that exceeds 100.4(f)
Risk is greatest among febrile infants and children younger than ?
36 months
3 most common causes of FUO in order of frequency:
- Infectious disease
- Connective tissue diseases
- neoplasms
Several common bacteria cause serious bacterial infections:
5
- S. pneumoniae is leading cause of bacterial URI
- Meningitidis
- H influenzae type b
- E Coli
- Salmonella
Most common cause of UTIs?
E. Coli
75% of UTI’s have pyelonephritis can leading to scarring
History for FUO?
11
- Fever history
- Fever at presentation
- Current level of activity or lethargy
- Activity level prior to fever onset
- Current eating and drinking pattern
- Appearance: Fever can make kids appear ill
- Vomiting or diarrhea
- Ill contacts
- Medical history
- Immunization history (especially recent)
- Urinary output: Number of wet diapers
Workup for Non Toxic Appearing FUO
4
- CBC with diff
- UA by bladder catheterization and urine culture based on the following criteria:
- -All males younger than 6 months and all uncircumcised males younger than 12 mos.
- -All females younger than 24 months and older if symptoms suggest a UTI - Rapid testing for viruses (eg. Influenza, RSV)
- Consider obtaining stool for WBC counts and guaiac if diarrhea is present
Workup on Toxic Appearing
FUO?
8
- CBC with differential and CMP
- Obtain blood cultures
- Consider obtaining a chest radiograph
- –CXR on patients with elevated WBC count - UA by bladder catheterization and urine culture based on:
- -All males younger than 6 mos and all uncircumcised males younger than 12 mos
- -All females younger than 24 months and older female children if symptoms suggest a UTI - Obtain CSF for studies and culture
- Consider obtaining stool for WBC’s & guaiac if diarrhea is present
- Rapid testing for virus
- Admit these patients for further treatment
Imaging for FUO
2
- CXR for thorough eval of febrile child
2. Abdominal ultrasound
Who is the CXR indicated for with FUO?
4
CXR indicated if
- tachypnea,
- retractions,
- focal auscultatory findings or
- oxygen sat on RA less than 95%
Procedures for FUO
3
- Bladder Catheterization
- Suprapubic Aspiration
- LP
Patients aged 2-36 months may not require admission if they meet the following criteria:
5
- Pt was healthy prior to onset of fever
- Pt is fully immunized
- Pt has no significant risk factors
- Pt appears nontoxic and otherwise healthy
- Pt’s parents appear reliable and have access to transportation if symptoms should worsen
Treatment for FUO Non Toxic
2
- Schedule a serial f/u appt within 24-48 hrs and instruct parents to return with the child sooner if conditions worsen
- Hospital admission for children whose condition worsen or whose eval findings suggest a serious infection
Treatment for FUO Toxic?
2
- Admit child for further treatment, pending culture results,
- administer parenteral antibiotics
IV antibiotics for toxic FUO?
3
- Initially administer ceftriaxone,
- cefotaxime or
- ampicillin/sulbactam
Empiric antimicrobial therapy must be comprehensive and should cover likely pathogens:
- Ceftriaxone (Rocephin): 3rd Gen Cephalosporin with broad spectrum, gram-negative activity
- Cefotaxime (Claforan): For septicemia and tx.
- Ampicillin/sulbactam (Unasyn)
What antibiotic is useful in pediatric infections as an alternative to ceftriaxone in infants in the first month or two of life in whom bilirubin displacement from protein binding sites by the latter antibiotic may be harmful?
Cefotaxime (Claforan): For septicemia and tx.
What does Ampicillin/sulbactam (Unasyn) cover (3) and what is it a combo of?
Drug combo of beta lactamase inhibitor with ampicillin.
Covers
- skin,
- enteric flora
- anaerobes
- What is impetigo?
- Occurs most commonly in what demographic?
- What are the two types and what bugs are associated with them?
Type 1- two bugs
Type 2- 1 bug
- Acute highly contagious gram positive bacterial infection of the superficial layers of the epidermis.
- Occurs most commonly in children especially in hot, humid climates.
Two types:
- Nonbullous impetigo: The most common skin infection in children
- -Staphylococcus aureus
- -Group A beta hemolytic streptococci (GABHS) - Bullous impetigo:
Almost exclusively by S. aureus
Intact skin is usually resistant to colonization or infection
Factors that can modify usual skin flora?
4
- High temp or humidity
- Preexisting cutaneous disease
- Young age
- Recent antibiotic treatment
Common mechanisms for disruption of skin that facilitates colonization or infection
7
- Scratching
- Dermatophytosis
- Herpes simplex
- Scabies
- Pediculosis
- Trauma
- Insect bites
Impetigo Differential Diagnosis
7
- Herpetic impetigo
- Pemphigus vulgaris (rare in children)
- Follicular mucinosis
- Folliculitis
- Erysipelas
- Insect bites
- Cutaneous candidiasis
Diagnosis of Impetigo
-Usually based soley on what? 2
Labs you could do? 1
- History
- Clinical Appearance
- -Erosions covered by “honey-colored” crust
Gram stain and culture to identify the bacteria
Treatment of Impetigo
2
- Local wound care
2. Antibiotic Therapy
Topical Abx for impetigo?
Oral Abx:
- What must you cover?
- 1st line? 2
- 2nd line? 2
Topical: Mupirocin (Bactroban)
- Oral: Must cover against Staph aureus & Strep pyogenes and watch out for MRSA.
- Cephalexin or Dicloxacillin (1st line)
- Erythromycin and Clarithromycin (2nd line)
Trimethroprim-sulfamethoxazole, clindamycin, or doxycycline (MRSA)
- What is Molluscum Contagiosum?
- Characteristic skin lesions look like?
- Common in what population?
- Benign viral infection (poxvirus)
- Single or multiple, rounded dome-shaped, pink, waxy papules, 2-5mm, umbilicated.
- Common in children and immunosuppressed
Molluscum Presentation
7
- Usually asymptomatic
- Pt may recall contact with family member or other person.
- Children sharing bath
- Athletes sharing gym equipment
- Parents may recall camp, school or public recreation
- Swimming Pools
- Sexual activity
Molluscum PE
Where will you find the lesions?
3
The distribution is influenced by what?
- Lesions may be located anywhere
- Predilection for the face, trunk and extremities in children
- Predilection for the groin and genitalia in adults
Distribution influenced by mode of infection
Molluscum Differential:
Cutaneous manifestations of other opportunistic infections
3
Other conditions to consider
2
- Cryptococcosis
- Histoplasmosis
- Aspergillosis
- Keratocanthoma
- Flat warts
Molluscum Diagnosis
3
- Easily established by distinctive, central umbilication of the done shaped lesion
- If uncertain can consider:
- Biopsy - If adolescent or adult
- Consider STD workup
Treatment Molluscum
5
What things to avoid?
3
1, Benign neglect: usually resolves within months
- Direct lesional trauma
- Antiviral therapy
- -Cimetidine - Topical therapy
- -Imiquimod
- -Cantharidin - Cryotherapy with curettage
Activity:
- Avoid sports
- Avoid physical contact between infected areas
- Sexual abstinence
What is Pediculosis (Lice)?
What are the two types?
Ectoparasites that live on the body and feed on human blood after piercing the skin.
Pediculosis capitus: head lice
Pediculosis corporis: body lice
Pediculosis Presentation
2
- Pruritis is most common symptom
2. Adults usually associated with sex and have groin and body involvement
How does the itching present wit lice?
2
What do you have to watch out for?
- -Kids have a hard time sleeping because of itching
- -Eyelashes or eyebrows
–Watch for secondary infection
Lice Physical Exam
- Observation of what? 3
- What else can we do to look at them? 2
- Eggs (nits)
- Nymphs
- Mature lice
- -Examining under the microscope
-Wood lamp of area
Yellow-green fluorescence of lice/nits
DDx for lice?
5
- Dandruff
- Dried hairspray/gel
- Acne
- Impetigo
- Scabies
- Why may we need to retreat with medication?
- Which medications? 5
- What do we have to do to remove the nits?
- Environmental control?
2
- Not all medications are ovicidal so may need to retreat to kill the newly hatched eggs (7-10 days)
- Use as directed to ensure total eradication through their life cycle
- Permethrin (Nix) cream
- Malathion
- Benzyl alcohol
- Spinosad
- Ivermectin - Careful combing and removal of all nits
- Cleaning of other articles ie hair accessories, towels, bedding, clothing are essential
- Treat all persons who have contact with infested patients (especially sexual partners)
What is scabies:
- What bug?
- Found where? 6
- Diagnosis?
- Treatment? 2
- Sarcoptes scabiei
-Smaller than a louse - Linear burrows at the
-wrist,
-ankles,
-finger webs,
-axillary folds,
-genitalia or
-face
Can have excoriations - Diagnosis
Scrape unscratched papule with #15 blade and examine microscopically in immersion oil - Treatment
- Permethrin crème
- Ivermectin
Upper UTI’s (pyelonephritis) may lead to what?
3
- renal scarring,
- hypertension and
- end-stage renal disease.
Host Factors for UTI?
5
- Age: prevalence high in boys less than 1yo and girls less than 4yo
- Lack of circumcision
- -Uncircumcised with fever have 4-8 higher prevalence than circumcised - Race/ethnicity: Caucasian> African American by 2-4 times
- Urinary obstruction: anatomic
- Vesicoureteral reflux: (VUR) retrograde passage of urine from the bladder into the upper urinary tract
UTI
No one specific sign or symptom can be used
Watch for:
8
- Poor feeding
- Fever
- Failure to thrive (FTT)
- Vomiting
- Abdominal Pain
- Flank pain
- Frequency, urgency, dysuria
- Suprapubic tenderness
Diagnosis UTI
Four common ways to collect urine from a child?
4
“Please be toilet trained!” Four common ways to collect urine from a child: 1. Midstream clean catch 2. “Clean voided” bag for collection 3. Bladder catheterization 4. Suprapubic bladder aspiration
Midstream clean catch
1. Child needs to be?
Child needs to be toilet trained
Parents MUST be educated about appropriate technique
“Clean-voided” Bag Collection
- Should not be used for what?
- Who is this an acceptable method in?
- Should NOT be used for culture (high rate of false positives)
- Acceptable for urinalysis in infants and children between 2 mos and 2 yrs who have unexplained fever and do not appear ill enough to require immediate antimicrobial therapy
DO NOT administer antibiotics on the basis of a urinalysis from a what?
If urinalysis from this technique suggests UTI, your next step is to what?
clean voided bag urine specimen
Bladder Catheterization
Bladder Catheterization steps to the procedure?
4
- Child is restrained
- Anterior urethra cleansed thoroughly with Povidone-iodine solution
- Sterile lubricant jelly applied to the end of appropriately sized catheter
- Introduced via urethra until urine returns
Suprapubic Bladder Aspiration
- Reserved for who?
- Male example?
- Female example?
- Both example?
- Typically reserved for the male in whom catheterizing is difficult
- Uncircumcised boys with tight foreskin
- Girls with tight labial adhesions
- Children of either sex with clinically significant periurethral irritation
UTI Labs
5
- CBC &
- CMP
with presumptive pyelonephritis - Blood cultures (in patients with suspected bacteremia or Urosepsis)
- Renal function studies
- Electrolytes
UTI Imaging
4
- Not indicated for infants and children with a first episode
- UTI should be confirmed
- Voiding cystourethrography (VCUG)
- Renal US
Hospitalization of UTI
5
- Patients who are toxemic or septic
- Patients with signs of urinary obstruction or significant underlying disease
- Patients who are unable to tolerate adequate oral fluids or meds
- Infants younger than 2 mos with febrile UTI (presumed pyelonephritis)
- All infants younger than 1 month with suspected UTI even if not febrile
Treatment of UTI
1. FIRST LINE? 2
- Antibiotics for parenteral treatment
- Empiric Treatment? 2
- Amoxicillin and trimethoprim/sulfamethoxazole considered 1st line
- Antibiotics for parenteral treatment
- Ceftriaxone
- Cefotaxime
- Ampicillin - Empiric Treatment
- First or third generation cephalosporin
- Amoxicillin/clavulanate
What is a widespread inflammatory response that may or may not be associated with an infection?
Systemic inflammatory response syndrome (SIRS)
What is SIRS in the presence of suspected or proven infection?
sepsis
Risk factors for peds sepsis?
3
- Age younger than one month
- Serious injury
- Chronic debilitating medical condition
Peds Sepsis:
Pathogens
5
- Bacteria
- Viruses
- Fungi
- Parasites
- Toxic products of these organisms
Complete History: S&S
for sepsis?
11
- Fever (most common presenting symptom)
- Racing heart
- Rapid or labored breathing
- Cool extremities
- Color changes
Of course: - Activity level
- Mental status (relative to age)
- Urine output
- Immunizations
- Exposures to infectious disease
- Drug allergies
Physical Exam Sepsis
6
- Subtle changes in vital signs
- Hypotension
- Mental status changes
- Anuria
- Hypothermia (often more ominous than fever)
- Localizing signs of infection
Diagnosis Sepsis
7
- CBC
- Measures of clotting function and coagulation parameters
- Electrolyte levels
- Renal and liver function tests
- Urinalysis
- Tests for inflammatory markers
- Culture of blood, urine, cerebrospinal fluids
Imaging for Sepsis
4
- CXR
- Ultrasound
- CT
- Echocardiography
Management of Sepsis
5
- Aggressive fluid resuscitation and support of cardiac output
- Ventilatory support with supplemental oxygen therapy
- Maintenance of adequate hemoglobin concentration
- Correction of physiologic and metabolic derangements
- Monitoring of urine output and other end organ functions
Common Antimicrobial Agents for Sepsis:
- Newborns and infants in first 6-8 weeks of life? 3
- Older infants and children with unclear etiology? 3
- Ampicillin and Gentamicin
- Ampicillin and Cefotaxime
- Ampicillin and Ceftriaxone
- Third generation Cephalosporin
- plus Vancomycin
- Add clindamycin If S aureus or GABHS are possible etiologies
- What is meningitis?
- What are the types and what are the more severe?
4
Clinical syndrome characterized by inflammation of the meninges
2.
- Bacterial (life threatening that needs immediate medical attention)
- Viral (serious but rarely fatal)
- Fungal
- Parasitic
- Non infectious: cancers, systemic lupus, head injury
What kind of virus is usually the culprit for viral menigitis?
Enteroviruses
Signs and symptoms
1. Classic triad of bacterial meningitis?
- Other symptoms? 5
- Fever
- Headache
- Neck stiffness
- Other symptoms:
- Nausea
- Vomiting
- Sleepiness
- Irritability
- Delirium
Diagnosis of Meningitis
1. Identifying the causative organism
Blood studies? 4
2. In addition consider? 4
- CBC with diff
- Serum electrolytes
- Serum glucose (compare with CSF glucose)
- BUN or creatinine and liver profile
- Blood, nasopharynx, respiratory secretion, urine or skin lesion cultures
- Syphilis testing
- Lumbar puncture and CSF analysis
- Neuroimaging (CT of the head and MRI of the brain)
Meningitis Management Initial management? 1. Shock or hypotension? 2. Altered mental status? 3. Stable with normal vital signs?
- IV fluids
- seizure precautions and tx along with airway protection
- O2, IV access and rapid transport to the ED
Sexually Transmitted Diseases in children: What should we watch for? 3
Adolescents? 2
- Unusual injury pattern or behavior on visit
- Discloses to care giver
- Sexual assault
- Screen appropriately
- Fairly common
Syphilis
- First symptom?
- What usually follows?
- Stages? 4
- First symptom may be a sore that forms on the genitals or mouth
- A fever,
- sore throat,
- headache or
- joint pain usually follows
Stages of:
- Primary: one or more painless sores
- Secondary: copper penny rash on hands & feet
- Latent: inactive (lies dormant)
- Tertiary: severe problems with heart, brain, nerves if not treated.
- Syphilis bug?
2. Congenital Newborn presents with what? 6
- Caused by spirochete Treponema pallidum
- -Usually asymptomatic
Can present with
-Jaundice
-Hepatosplenomegaly
-Edema
-Signs of meningitis
-Bulging fontanelle
Presentation of congenital syphilis in young infants?
4
Children? 2
- Mucocutaneous lesions
- Pseudoparalysis of arms or legs
- Hepatomegaly
- Rash on palms and soles
- Bilateral interstitial keratitis
- Periosteum thickening of tibias
Syphilis Diagnosis?
3
- Darkfield microscope
- -Serologic testing - VDRL and RPR (nontreponemal)
- FTA-ABS (treponemal)
Syphilis treatment?
Penicillin G 50,000 units/kg/dose q8-12hr for 10 days
Chlamydia symptoms can include what? 5
If not treated in women what can it cause?
- dysuria,
- vaginal discharge,
- cervicitis,
- PID, and
- epididymitis in males
If not treated in women, it can cause infertility
Chlamydia labs? 2
Treatment?3
Labs
- Urine specimen
- Culture
Treatment
- Patient and partner (need to abstain for seven days)
- Doxycycline 100mg x 7days
- Azithromycin 1000mg po once.
Neisseria Gonorrhea
- Sites of infection? 4
- Symptoms? 3
Sites of infection
- Cervix
- Urethra
- Rectum
- Pharynx
Symptoms
- Dysuria
- White, yellow or green discharge
- Painful or swollen testicles
N. Gonorrhea:
Diagnosis? 3
Treatment? 2
Diagnosis
- First-catch urine for NAAT
- Culture (Thayer-Martin agar)
- Gram stain
Treatment
- Ceftriaxone 250mg IM plus
- Azithromycin 1gram single dose
Chancroid: what is it caused by?
Describe the Ulcer:
- Progression of ulcer?
- Pain?
- Borders?
- Blood?
Caused by Haemophilus ducreyi
- 1 day to 2 weeks develop small papule in genitals which then becomes an ulcer within a day of it appearance
- Ulcer is painful
- Sharply defined borders
- Base bleeds easy
Diagnosis and treament 2 of chancroid?
Diagnosis
1. Gram stain
Treatment
- Azithromycin 1 g single dose
- Ceftriaxone 250mg single dose
- What is HPV aka?
- What types are usually found in genital warts? 2
- Cervical dyplasia? 2
- How does it present?
2
- Human Papilloma Virus (Condylomata acuminata)
- Types 6 & 11 usually found in genital warts
- Types 16 & 18 cause cervical dysplasia
- Asymptomatic
- Develop lesions on genitals
HPV
- Diagnosis? 2
- Treatment? 4
- Vaccines to prevent? 3
- Diagnosis
- Biopsy
- Pap smear - Treatment
- Podofilox
- Trichloroacetic acid
- Cryotherapy
- Laser surgery - Vaccines
- Gardasil
- Gardasil 9
- Cervarix
- What are the two types of herpes?
- Recurrences can be caused by what? 2
- Signs and symptoms? 3
- Diagnosis? 3
- Herpes type 1 (HSV-1) oral herpes
- Herpes type 2 (HSV-2) genital herpes
- Recurrences can be
- spontaneous or
- due to stress and immunosuppression - Signs & Symptoms
- Grouped vesicles on an erythematous base
- Fever and malaise
- Tender regional adenopathy - Diagnosis
- Cultured vesicles from epithelial sites
- Immunofluorescent stains
- ELISA
Herpes treatment?
3
- Acyclovir
- Famciclovir
- valacyclovir
