TBL #1 Flashcards
what is the clinical presentation of bronchiolitis
rhinitis, cough, tachypnea, use of accessory respiratory muscles, hypoxia and variable wheezing/crackles on auscultation, nasal flaring, grunting, retractions
Diagnosis of bronchiolitis
AAP recommendations: should be clinical diagnosis without routine lab/radiographic findings, clinicians should assess for risk factors (LVLB)
- common CXR findings hyperinflation, areas of atelectasis, infiltrates that do not correlate with severity of disease and do not guide management
- viral studies not recommended
management of bronchiolitis
bronchodilators should not be used routinely (LVLB) monitored trial of alpha-adrenergic (epi) or beta adrenergic (albuterol) is an option with continuation only if response documented (LVL B) corticosteroids should not be used routinely (LVLB) Ribavarin should not be used routinely (LVLB) abx only if SBI (LVLB)
- chest physiotherapy should not be used (LVLB)
- Supplemental O2 if SPO2 <90
- antivirals not recommended for treatment
what is the role of laboratory testing in the diagnosis of bronchiolitis
viral isolation, blood serology, chest radiograph have little impact on diagnosis
what are the efficacies of current therapeutic interventions of treating bronchiolitis
most clinical interventions have no significant impact on length of hospital stay, or subsequent outcomes like recurrent wheezing
what is the prognosis of recurrent wheezing with bronchiolitis
maybe they have an underlying predisposition to the original RSV infection an dsubsequent recurrent episodes of wheezing
what is the risk of recurrent wheezing with bronchiolitis
40% of infants with bronchiolitis have subsequent wheezing though age 5, 10% after age 5
what is the most common lower respiratory tract infection in infants and children aged 2 and younger
bronchiolitis
what is bronchiolitis most commonly caused by
RSV
others: adenovirus, HMPV, influenza, parainfluenza
pathophys of bronchiolitis
acute infection of the epithelial cells lining the small airway of the lungs resulting in edema increased mucus production necrosis and regeneration of these cells
recommendation regarding palivizumab
recommended for infants with a hx of prematurity, chronic lung disease or congenital heart disease
-is antiviral against RSV
LVL A rec
-in 5 monthly doses beginning in Nov or Dec 15mg/kg IM
what is the most important step in preventing nosocomial spread of RSV?
hand decontamination-alcohol rubs preferred
what is recommended to decrease a childs risk of lower resp infection?
breastfeeding
what is the most common risk factor for hospitalization?
age-most under 1
RSV associated deaths more common in children with no pre-existing medical conditions true or false
true
what is the earliest and most sensitive vital sign change in bronchiolitis?
elevated RR
what are the most clinically significant parameters in assessing severity of illness?
RR, work of breathing and hypoxia
when do bronchiolitis symptoms peak?
illness days 3-4
what should be the basis for isolation procedures?
clinical signs
what is the most commonly diagnosed SBI with bronchiolitis?
urinary tract infection
what is the recommended management for bronchiolitis?
supportive care with oxygenation and hydration status monitoring
-give isotonic fluids NOT hypotonic-increases risk for hyponatremia bc bronchilitis causes release of ADH
when should oxygen be discontinued?
when pulse ox saturations rise between 90-92% for most of the time and the pt is demonstrating overall clinical improvement
strategies for minimizing unwanted consequences of prolonged monitoring in the hospital
1: scheduled spot checks with measurement of vitals and unscheduled checks when clinically indicated
2: scheduled spot checks after a fixed period of monitoring
should corticosteroids be used in the treatment of bronchiolitis?
no-no proven significant decreased length of stay or decreased severity of disease
when is ribavirin considered for treatment for bronchiolitis?
pts with pre-exisiting medical conditions like organ transplantation, malignancy or congenital immunodeficiencies or patients who remain critically ill despite maximal support
what treatment is recommended for influenza caused bronchiolitis?
oseltamivir for kids older than 1 year
and zanamivir for kids older than 5 years-neuraminidase inhibitors
what concurrent bacterial infection is diagnosed most commonly with bronchiolitis?
acute otitis media-treat for sure if less than 6 months with amoxicillin, if older only if certain about diagnosis
what can excessive suctioning lead to ?
nasal edema and additional obstruction
- most beneficial before feeding an din response to copious secretions
- no evidence for deep suctioning of the lower pharynx
are nasal decongestant drops supported? cough suppressants?
no
what is palivizumab?
a monoclonal antibody against RSV
when is palivizumab indicated?
in infants who have chronic lung disease, and infants born with hemodynamically significant congenital heart disease
-if born at 28 weeks or less should get it whenever theres a bronchiolitis outbreak in the community
-if born at 29 weeks through 32 weeks should get it during the first 6 postnatal months
should receive for the remainder of the bronchiolitis season
-pts born at 32-35 weeks should get it if younger than 6 months by the start of bronchiolitis season and either 2of these -at child care, school age sibs, exposure to envt air pollutants, congenital airway anomalies, severe neuromuscular disease
-pts 2 and younger with chronic lung disease, diuretic use, bronchodilator or corticosteroid therapy within 6 months before bronchiolitis season
what is the primary benefit of bronchiolitis prophylaxis?
decrease in RSV associated hospitalization
is pavilizumab effective at treating RSV?
no
besides hand hygeine what are other ways to prevent bronchiolitis?
avoidance of tobacco, encouraging breast feeding
unresolved bacteriuria
inadequate microbial therapy consider noncompliance, inadequate absorption, resistant uropathogens
bacterial persistence
occurs after sterilization of the urine has been documented
-same pathogen documented again
reinfection
different pathogens documented on urine cultures with each new UTI
uti occurence in kids
2.4-2.8% of children each year
uncircumsized boys in first year of life
have 10-12 fold increased risk for UTI, males have higher risk than females in first year of life for UTI
what is the most frequent UTI pathogen documented
E coli
what pathogen is more common in neonates than in older populations?
GBS
what pathogen can be documented in pts with UTI and catheter?
Candida
what are common types of nosocomiual UTIs
E coli, candidia, enterococcus, enterobacter, pseudomonas
what is the main defense mechanism against UTI?
constant anterograde flow or urine from the kidneys to the bladder with emptying via the urethra
what properties of the urine are protective against UTI?
low pH, polymorphonuclear cells, tammHorsfallglycoprotein (inhibits bacterial adherence to the bladder mucosal wall)
when does UTI occur
when introduction of pathogens adhere to the mucosa of the urinary tract
how does E coli cause UTI
adhesins bind specific receptors of the uroepithelium-fimbriae and mucosal receptors trigger internalization of the bacteria in the cell–> apoptosis, hyperinfection and invasion
what toxins have been identified in uropathogenic E coli?
cytolethal distending toxin, alpha hemolysin, cytotoxic necrotizing factor, secreted autotransporter toxin
what are the risk factors for pediatric UTI?
-prematurity: incomplete immune system (breastfeeding helps iwth IgA)
foreskin: harbor higher concentrations of pathogenic microbes
gender
fecal and perianal colonization: most UTI fecal to perianal flow
urinary tract anomalies: generally seen in children younger than 5, may serve as reservoir for bacterial persistence or may decrease washout , higher incidence of multidrug resistant organisms like pseudomonas and enterococcus
functional anomalies: ie neurogenic bladder-clean cath occasionally
immunocompormised states
sexual activity: risk factor in women not men esp with diaphragm and spermicide use
clinical presentation of UTI
vague and non specific, CVA and suprapubic tenderness not helpful
may see
(in kids 60-90 days)
FTT< diarrhea, irritability, letharfy, malodorous odor, fever, asymptomatic jaundice, oliguria, polyuria,
in kids younger than 2 most common fever, vomiting, anorexia, and FTT
after 5 classic UTI symptoms dysuria, urgency, urinary frequency and CVA tenderness more common
signs associated with neurogenic bladder:
dimples, pits or sacral fat pad
all boys with suspected UTI should be evaluated for
epididymitis or epididymo-orchitis
definitive diagnosis of UTI
requires isolation of at least one uropathogen from a urine culture-should be obtained before the initiation of antimicrobial therapy
how is urine most commonly collected in kids for uti dx
urtehral catheterization -reliable but unfortunately is invasice
-suprapubic aspiration is the gold standar for accurately identifying bacteria within the baldder
what does the AAP recommend in collecting urine from kids?
suprapubic aspiration (most reliable) or urethral catheterization (easier to accomplish)
diagnosis of UTI
quantitative culture of urine obtained (from suprapubic asp or cath) and demonstrated 105 CFU colony forming units of a single uropathogen
evidence of UTI (chemical markers)
leukocyte esterase (produced by WBCs) and nitrites (reduced from nitrates by gram - bacteria)
when should a renal us be considered
if symptoms persist after 2 days of antimicrobial therapy can use reanl US or CT to rule out disease that would require invasive testing like renal abscesss, pyonephrosis, urinary calculi or surgically correctable anatomic abnormalities
should infants and young children be evaluated after proper response to antimicrobial therapy?
yes to rule out urinary tract anomalies
what increases a childs risk for renal scarring
high grade vesicouretral reflux
uncomplicated nontoxic child with UTI treatment
amoxicillin, trimethoprimsulfamethoxazole, nitrofurantoin and cephalosporins
-children younger than 2=short course
-
treatment for immunocompromised pt, younger than 2, or a complicated UTI
hospital admission, rehydration, parenteral brough specturm antmicrobial therapy
- amp and gent or ceph
- usually 48-72 hrs and then changed to PO to complete 7-14 day course
what is the criterion for therapy for fungal UTI
10^4 colonies on suprapubic aspiration or catheterization
when should prophylaxis for UTI be considered
-in neonates or infants once they complete their therapy course until they have proper imaging done and urinary tract evaluation
-history of VUR
-immunosuppression
-partial urinary obstruction
-recurrent UTI with normal anatomy
-
what is recommended for asymptomatic bacteriuria?
follow up with pts periodically without concurrent antimicrobial therapy bc asymptomatic bacteriuria is not associated with renal damage and the incidence of actual symptoms is low
how often is renal scarring seen?
20-30% after UTI
what are the three likely mechanisms for PCV7 asociated decrease in disease
individual risk decline, decline in antibiotic resistant bacteria, and herd immunity
can a response to antipyretics give you a clue as to whether the illness is bacterial or viral?
no
neonate
0-28 days
young infant
1-3 months
older infant/toddler
3-36 months
