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Peds and Geriatrics > Week 2 > Flashcards

Week 2 Flashcards

1
Q

Etiology of bacterial Meningitis

Age <1 month

A

varies depending on age of pt

Age <1 month: commonly transmitted form mother to baby during delivery
*Group B streptococcus (GBS)
*Ecoli
*Klebsiella
*Listeria monocytogenes

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2
Q

Etiology of bacterial Meningitis

Age 1-23 months

A

Age1-23 months
*S. Pneumoniae
*Neisseria Meningitis
(these 2 are most common organisms causing meningitis in children, adolescents, and adults)
*H. Influenzas (Type B)
*E. Coli

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3
Q

Etiology of bacterial Meningitis

Age2-50 y.o

A

*S. Pneumoniae
*Neisseria Meningitis
(these 2 are most common organisms causing meningitis in children, adolescents, and adults)

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4
Q

Risk factors for bacterial meningitis in neonates

A

** usually due to pregnancy and/or delivery***

preterm birth

Low birth weight

chorioamnionitis

maternal endometriosis

maternal GBS colonization

prolonges duration of intrauterine monitoring

prolonges rupture of membranes

traumatic delivery

urinary tract abnormalities

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5
Q

risk factors for BM in children

A

*things that might impact the immune system

asplenia

primary immunodeficiency

HIV

sickle cell anemia

CSF leak

cochlear implant

recent URTI

daycare attendance

exposure to a case of meningococcal or H. Influenzas types meningitis

penetrating head trauma

lack of immunizations

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6
Q

Presentation of bacterial meningitis in infants

A

poor feeding

vominting

fever/temperature instabilities

seizures: present in up to 50% of infants with meningitis

irritbility

lethargy

bulging fontanelle (increased CSF pressure)

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7
Q

presentation of BM in children

A

fever

headache

lethargy

vomiting

myalgia

photophobia

stiffnecj

seizure

confusion

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8
Q

Dx of BM

A

hx of pt

analysis of CSF form lumbar puncture (LP)
*GOLD STANDARD
*elevated WBC (>1000 WBC)
*elevated protein (>45 mg/dL)
*low glucose
*positive bacterial cultures: MAIN DX feature to confirm BM
*CI to LP: INCREASED intracranial pressure, coagulopathy, hemodynamic/respirtory instability, skin infection over LP site

*blood cultures:
2 separate blood cultures and a complete blood count with differential should be obtained before starting abx

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9
Q

differentiating bacterial vs viral meningitis in meds

A

Glucose ratio:
*bacterial: lower glucose (<0.6 in neonates and <0.4 in al other ages)
*viral: normal glucose

protein:
bacterial:
viral: low-normal

wbc:
bacterial:
viral: can be elevated, but not as elevated as in BM

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10
Q

Emperic Therapy fr BM in peds

Age <1 month

A

Organisms
*GBS
*E. Coli
*Listeria monocytogenes
*klebsiella

Therapy:
Ampicillin + AG orrrr
Ampicillin +cefotaxime

ampicillin covers GBS and listeria:
AG or cefotaxime covers gram- like e.coli or klebsiella

*when would u choose an AG vs cefotaxime

*usually ag due to higher rates of resistance when using cefotaxime, however if pt has decreased kidney function, would not use AG

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11
Q

\

empiric therapy for BM in peds

1-23 months

A

organisms:
S. Pneumnaie
Neisseria meningitis
H. influenza type B

emperic theraoy:

Vancomicin (broadens strepcoverage to caover fo rany resistant strep spc.)
PLUS
CEfotaxime or ceftriaxone to cover gram neg. organisms

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12
Q

emperric theraoy for BM in

age group 2-50 y.o

A

organisms:
S. Pneumnaie
Neisseria meningitis
H. influenza type B

emperic theraoy:

Vancomicin (broadens strepcoverage to caover fo rany resistant strep spc.)
PLUS
CEfotaxime or ceftriaxone to cover gram neg. organisms

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13
Q

Considerations for use in peds for BM

AMPICILLIN

Neonate dosing:

Infant and children dosing:

Adverse effects:

Goal drug levels (if applicable)

A

Considerations for use in peds for BM

Neonate dosing:
Post natal age(PNA)</7 days: 200-300 mg/kg/day IV q8-12hrs
PNA 8-28 days: 300 mg/kg/day IV q6-8 hrs

Infant and children dosing:
300-400 mg/kg/day q6h
MDD: 12g/day

Adverse effects: generally well tolerated. N/V/D, rash

Goal drug levels (if applicable):–

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14
Q

Considerations for use in peds for BM

cefotaxime

Neonate dosing:

Infant and children dosing:

Adverse effects:

Goal drug levels (if applicable)

A

Considerations for use in peds for BM

Neonate dosing:
PNA<7/ and >/2kg: 100-150 mg/kg/day IV q8-12h
PNA 8-28 days and >/2kg: 150-200 mg/kg/day IV q6-8 hrs
*note use smaller doses and longer intervals fo rneonates <2kg

Infant and children dosing:
225-300 mg/kg/day IV q6-8 h
max 12g/day

Adverse effects: N/V/D, rash, pruritis

Goal drug levels (if applicable)–

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15
Q

Considerations for use in peds for BM

CEftriaxone
Neonate dosing:

Infant and children dosing:

Adverse effects:

Goal drug levels (if applicable)

A

Considerations for use in peds for BM

Neonate dosing: *NOTE: DO NOT USE IN NEONATES due to risk of hyperbilirubinemia

Infant and children dosing:
100/mg/kg/day q12h

Adverse effects:
MDD: 4000MG/day

Goal drug levels (if applicable)–

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16
Q

Considerations for use in peds for BM

VANCO

Neonate dosing:

Infant and children dosing:

Adverse effects:

Goal drug levels (if applicable)

A

Considerations for use in peds for BM

Neonate dosing:
Post natal age(PNA)</7 days: 20-30 mg/kg IV q8-12hrs
PNA 8-28 days: 30-45 mg/kg/day IV q6-8 hrs
*neonates <2/ kg consider smaller doses and longer intervals

Infant and children dosing:
60-80 mg/kg/day q6h (infants >3mo-12 y.o)
60-70 mg/kg/day q6-8hr (children >12 y.o)
MDD: 12g/day

Adverse effects: nephrotoxicity, ototoxicity, infusion related reactions

Goal drug levels (if applicable):
AUC guided dosing: AUC/MIC 400-600
vanco trough concentrations: 7-10 mg/L (only to be used as a surrogate analysis along w. analysing pt response.

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17
Q

durations of treatment of BM depending on organism identified

A

Neisseria meningitis: 7 days
h. influenzae: 7days
s. pneumoniae: 10-14 days
GBS: 14-21 days
aerobic gram - bacilli:21
listeria meningitis: >/21

**note: duration in neonates: 2 weeks from first sterile CSF culture or >/3 weeks, whichever is longer

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18
Q

Special considerations associated w. use of dexamethasone in peds meningitis

A

use contreversial

used to decrease hearing loss in pts w. h. influenzae in pts >6 weeks old

however, rates of infection w. h. influenzae

administration: always be given before or given with first dose abx

dose: 0.15mg/kg/dose IV q6h for 2-4 days

idsa RECOMMENDATIONS:
H. influenzae: recommende dif initiated b4 admin of abx
S. pneumoniae: consider if high risk of mortality
N meningitis/other gram negative: not recommended

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19
Q

Prevention of BM

A

VACCINATION!

Hib vaccine (H. influenzae type B)

Pneumococcal conjugate vaccine(S. Pneumonia)

Meningococcal conjugate vaccine ( N. Meningitis)

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20
Q

Community Acquire Pnemoniae (CAP)

what is it

A

acute infection of pulomnary parenchyma (

presence of of FF of pneumoniae in previously healthy child caused by an infection acquires outside of the hospitsal

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21
Q

risk factors of CAP

A

*** recent hx of URTI: primary risk factor
aka viral respiratory prodrome
. virus ivades lungs, changes landscape of bronchi and introduces bacteria into lunghs

lower socioneconomic status

croded living environment

exposure to cigarette smoke

comorbidites
*asthma
bronchopulmonary dysplasia
cystic fibrosis
congenital heart disease

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22
Q

lung imaging presentation in CAP

A
  • can cause 2 diff types of clinical picture: lobar pneumoniae: heavy consolidated infiltration
    bronchpneumonia: diffuse pockets of bacteria throughout the lung. more ocmmon in staph infections
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23
Q

patho of CAP

A

can enter lungs thorugh:
1. inhaled aerosolized particles

through blood stream

aspiration

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24
Q

SS of CAP

A

two hallmark SS:
1. fever
2.cough

others include
pleuritic chestpain
purulent expectorant
tachypnea for age
respirtory distress (retractions, grunting, nasal laring, apnea
wheezing
crackled or rales
pulse ox <90% on room air
altered mental status

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25
Q

dx CAP

A

gold standard: chest xray
*looking for consolidation
*viral: diffuse hazyness
*bacterial: consolidation

also..
blood culture (rarely positive
sputum cultures
ciral testing (nasopharyngeal swabs; blood pcr)
lab tests (such as cbc, inflammatory markers)

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26
Q

to hospitalize or not to hospitalize for ACAP

A

hospitalize:
mod-severe CAP
significant respiratory distess (spo2<90%
all infants <3 mo of age

suspicioin of community acquires MRSA
concern for caretaker capabilities

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27
Q

most common pathogens for CAP

A

BACTERIA
** S. Penumoniae: most common pathogen

H. influenzae

S. Aureus

GAS

*atypical: (3-23%->more common in older children
*mycoplasma pneumonie
chlamydophila pnuemoniae
legionella (rare)

VIRSUES
most commin in children <2y.o
*influenzae
RSV
parainfluenza virus
adenovirus
rhinovirus

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28
Q

what is the best predictor of cause via identification of likely pathogen and exposure in CAP

A

AGE

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29
Q

CAP causative organisms base don AGE

birth-20 days:

3-weeks-3mo.

4months-4 years

5 years-15 years

A

birth-20 days: GBS, hram - enteric bacteria, listeria monocytogenes

3-weeks-3mo.
S. PMEUMONIAE
s. aureous
rsv
piv
bordetelle pertusis
chlamydia trachomatis

4months-4 years
S. PNEUMONIAE
atypicals (m. pnumoniae)
viruses

5 years-15 years
S. PNEUMONIAE
atypicals: m. pnuemoniae, , c. pneumoniae

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30
Q

symptom resolutoin time for abx trt for CAP

A

48-72 hrs

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31
Q

Out pt Trt of CAP

MEd: amoxicillin
Dose:
dosage forms
notes:

A

Out pt Trt of CAP

MEd: amoxicillin
Dose: 90 mg/kg/day BID or TID (mdd 3-4g/day)
dosage forms: various
notes: *must use high dose regimen vs standard dose(40-50 mg/kg/day to overcome s. pneumo mechanism of resistance which is production of penicillin binding proteins

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32
Q

Out pt Trt of CAP

MEd: augmentin (
Dose:
dosage forms:
notes:

A

Out pt Trt of CAP

MEd:
Dose:90 mg/kg/day BID or TID (MDD: 875-1000mg. must use high dose regimen vs standard dose 40 mg/kg/day

dosage forms: various. usefor ES (EXTENDED SPECTRUM)forms. helps to increase amox component of drug instead of clav component.

notes: food may enhance absorption and decrease gi upset . ADR=diarrhea

clavullanate covers b-lactmase producing organisms

33
Q

Out pt Trt of CAP

MEd: axithromycin
Dose:
dosage forms
notes:

A

Out pt Trt of CAP

MEd:

Dose: 10 mg/kg/day mdd 500 mg, then 5mg/kg/day days 2-5: mdd 250 mg
IV DOSE= PO DOSE

dosage forms: various

notes:
*food enhances absoprtion and decrease gi upset
teriblke aftertaste
*only 5 day treatment due to long t 1/2 and post antibiotic effect

34
Q

in pt Trt of CAP

MEd:Ampicillin
Dose:
dosage forms
notes:

A

in pt Trt of CAP

MEd:
Dose: emperic or S. pneumonaie: 150-200 mg/kg/day IV q6h
MDD: 2g/dose

GAS: 200 mg/kg/day iv q6h
p pneumoniae: MIC>/4; high resistance: 300-400 mg/kg/day IV q6h
dosage forms

notes: reach higher serum conc than amoxicillin, thats why recommended for inpt/ more sevre pts.
IV preffered

AE: diarrhea, rash, eosinophilia

35
Q

in pt Trt of CAP

MEd: ceftriaxone
Dose:
dosage forms
notes:

A

in pt Trt of CAP

MEd:
Dose: 50 mg/kg/dose IV q24h.

dosage forms IV or IM

notes: recommended in unimmunized children due to concern for h. flu-betalactamase producing

36
Q

antiviral Trt of CAP

MEd: oseltamavir
Dose:
dosage forms
notes:

A

in pt Trt of CAP

MEd:

Dose: 5 day course of therapy
<15 kg:30mg BID
15-23 kg: 45mg BID
23-40 kg: 60 mg BID
>40 kg: 74 mg BID

dosage forms: capsules, suspensions (6mg/mL)

notes: only to be effective if initiaed w.in 48 hrs of symptoms ( if severe, can still be peneficial)

37
Q

allergy alternatives for CAP trt

A

nonserious
*trial under med supervision
*use of cephalosporins: cefpedoxime, cefproxil, cefuroxime (only 60-70% effective against s. pneumo

hx of ANA
*can use resp. fluoroquinilones
linezolid
macrolide
clindamycin
sulfamethoxazole-trimethoprim

38
Q

duration of therapy for CAP

A

10 days(just as effective as 14 days)

azithromysin and olsetamivir only 5 days

CA-MRSA may need longer treatment

39
Q

vaccine prevention for CAP

A

pathogen: S. pneumoniae
vaccine: PCV13
schedule: 4 doses (2,4,6 mo). booster at 12-15 months

pathogen: h influenzae
vaccine: Hib
schedule: 3 or 4 doses (2,4,6 months . booster 12-18 months

pathogen: pertussis
vaccine:DTap
schedule: 5 doses: 2,4,6, 15-18 months, and then 4-6 years

pathogen: influenza
vaccine: influenza
schedule: annual for >6 months

pathogen: RSV immune prophylaxis
vaccine: Palivizumab (Synagis)
schedule: for high risk infants

40
Q

Risk factors for UTI in peds

A

younger age grousp (neonates and infants)

female sex

uncircumcised infants

cponstipation

anatomic abnormalities

functional abnormalities (neurogenic bladder)

female sexual acitivty

immunocompromised

DM

genetic predisposition

41
Q

infection pathways of UTI

A

retrograde asscent (most common (enter thorugh urethra and migrate to bladder

nosocomiakl (intro of foreign body like catheter. more resistant organisms

hematogenous route: outside originating infection cuases bacteriemia /sepsis

fistuala between ET and GI/vagina

42
Q

most common pathogen causing uti

A

e. coli (80%)

43
Q

recap: classificationf os uti

A

1.infection site
a. lower uti
bladder=cystitis)
urthra -urethiritis

upper UTI
a. kindey=pyelonephritis

urine: bacteria

  1. complicated vs uncompliated
    complicated: gu w. structural/functinoal abnormalities, catheters

uncomplicated: occurs in anatomically normal ut w. no prior instrumentation

44
Q

SS of uti in peda

A

neonates: jaundice, failure ot thrive, fever, difficulty feeding, irritability, and diarrhea

infants and children <2: nonspeciic SS similar to those in neonates w. exception of jaundice
cloudy or malordorous urine, hematuria, frequency, and dysuria

chiuldren>2 years:
fever, frequency, dysuria, enuresis (in a previously potty trained child) hematuria, abdominal pain

45
Q

dx of uti in peds considerations

A

rapid urine tests ar enot intended ot replace urine cultures, which are the gold standard

suprapubic aspiration is gold standard. but also canbe collected by catheterization, or clean catch.

46
Q

definition of uti base don method of collection

A

clean catch: >100,00 cfu/mL of one bacteria

catheterization : >50,000 cfu/mL of one bacteria

SPA (which is sterile): any growth of bacteria

47
Q

general treatments of UTI

A

first line: cephalosporins
TMP/SMX
b-lactam/b-lactamase inhibitors

parenteral: used in acutely ill (septic childen
0, <2 months, immunocompromised, unable to tolerate po.. continued until pt is afebrile, clinically stable

oral: complete treatment course in pt initiated on parenteral abx. initial trt in children who do not meet criteria for parenteral abx

48
Q

duraiton of trt for uti in peds

A

AAP:
7-14 days

uncomplicated uti: 7 days
pyelonephritis: 10-14 days

49
Q

Vesicoureteral reflux (VUR)

A

retrogade urinary flow form bladder and possible to renal collecting system, can cause recurrent UTI

incidence 1%

classified in grades I-V

prevalence in children w. febrile uti =25-40%

50
Q

VUR

risk factors
complications
prognosis
treatments

A

risk factors: febrile uti, parent/sibling w. vur, prenatal hydronephrosis

complications: recurrent uti, renal scarring, HTN

prognosis: spontaneous resolution of vur occurs in mosr young pts within 4-5 yrars follow up

treatments: observation, abx ppx, surgery

51
Q

uti ppx w. abx

goal:
who should get it generally?
trials

A

goal: prevent irrevrsible smage(scarring)

CHILDREN W. VUR!!!

immunocompromised, children w. dysfunctional voiding, reccurent utis depsite normal anatomy/function

ppx continued until resolution of underlying predisposing conditions

RIVUR tiral found that ppx abx treatment decreased rate of reccurent uti, but not scarring, and increased rate of resistance

52
Q

whoshould get abx ppx for UTI

A

target populations:
females, VUR grade IV or V
bladder/bowel dysfunction

need to ocnsider… short/long term morbidity of UTI
cost
SE
parental preference

duration?:
1-2 years
or until outgrown or surgically repaired

53
Q

ABX for UTI ppx

A

amoxicillin: 10-15 mg/kg once daily: n/v/d abdominal pain

nitrofurantoin 1-2 mg/kg once daily
ae: urine discoloration

tmp/smx: 2mg/kg once daily or 5 mg/kg biw.
ae: ematologic ae, interstitial nephritis, avoid in pts < 2 monnths

notes for ppx abx
neonates/infants up to 2 months” amoxicillin
infants>2 months: TMP/SMX or nitrofurantoin
generally avoid cephalosporins due to increased risk of multidrug resistamt pathogens

54
Q

most common etiologies of acute otitis media (AOM)

A

Bacterial ~80%)
s. pneumoniae
h. influenzae
Moraxella catarallis

Virus ~20%

RSV
rhinovirus
influenza
adenovirus

55
Q

antimicrobial resistance among bacterialpathogens in AOM

A

abx resistance has increased in s. pneumoniae
h. influenzae
Moraxella catarallis
to PCN…

we have increased doses and combos of beta lactams and betalactamase inhibitors to overcome resistance

56
Q

ss OF AOM

A

middle ear effusion

ANDDD

acute onset of symptoms (fever, rhinorrhea, irritability, otalgia, tugging/rubbing of ear)

57
Q

classifications of AOM

A

AOM: rapid onset of SS of inflammation of middle ear

severe AOM: mod-severe otalgia or fever >39 degrees (102.2)

non-severe AOM: AOM aom w. mild otalgia and temp <39 degrees (102.2)

recurrent AOM: >3 well documented seperate AOM episodes in the past 6 months, or >/4 in past 12 months with >1 episode in past 6 months

58
Q

recommendations fo rinitial mamagement for uncomplicated AOM in regards to age

A

otorhea with AOM

6mo-2y: abx
>/2 y.o”: abx

unilateral or bilateral AOM w. severe symptoms
6mo-2y: abx
>/2 y.o”: abx

bilateral aom w.o otorrhea
6mo-2y: abx
>/2 y.o”: abx OR OBSERVATION

unilateral aom w.o otorrhea
6mo-2y: abx OR observation
>/2 y.o”: abx OR observation

decision made by parents. engage pts family

59
Q

AOM ABX therapy

A

first lin trt: anixacillkin

amoxacillin 80-90 mg/kg/d in 2 divided doses
GIVE IF
*if havent recieved amox in past 30 days
does not have concurrent purulent conjunctivits
not allergic to pcn

amox/clav 90 mg/kg/day
GIVE IF recieved amox in past 30 days
has concurrent purulent conjunctivitis
hx of reccurent aom unresponsive to amoxicillin

60
Q

alternative treatments for aom treatment

A

pcn allergy?
non life threatening? use po cephalso[orin (cefdinir, cefuroxime, cefpodoxime)

lifethreatening: macrolides (azithromysin, clarithromycin), clindamycin

ceftriaxone 50 mg/kg IV or IM

61
Q

duratino of AOM treatment

A

10 days: severe < 2yo

7 days=2-5 years of age w. mild-mod

5-7 days=>/6 years of age w. mild-mod severe

reassess if SS worsen or fail to improve within 48-72 hours

62
Q

failure of trtment for aom?

A

1st line amoxacillin

if failed..
augmentin 90 mg/kg/d

if failed:
cephalosporin (ceftriaxone… 50 mg/kg IV or IM daily

if failied
clindamycin: 30-40 mg/kg/d in 3 divided doses +/- 3rd gen ceph.

63
Q

aom prevention

A

vaccines!!
influenza and pneumococcal

64
Q

appendicitis:

A

acute inflammatory process involving appendix caused by blockage due to hard mucosy stool ot swelling. causes appendix to swell and become inflateted, risking rupture (known as perforated appendix)

65
Q

apendicitis patho

A

luminal obstruction causs increase in pressure ww.in the lumen

appendix continues to secrete mucosal fluid, leading to distention

ischemia, bacterial overgrowth and eventual perfomation follpw suit

w.o dx and treatment, pts symptoms will worsen until perforation occurs.

66
Q

physical SS of apendicitis

A

N/V
radiating pain in RLQ

decreased appetite

fever

constipation

67
Q

dx of appendicitis

A

physical examination: physical SS

lab evbal: elevated wbc, ANC, CRP

imaging: Ultrasound

ct: modality of choice for definitive assessment of pts.

68
Q

appendicitis treatment option sgeneral

A

fluid therapy

abx

surgicalapproach (appendectomy

69
Q

fluis therapy and analgesia in appendicitis

A

fluid management critical

NS
LR

1x maintenance isn ormally used, but can use 1.5 x maintnance

analgesia:
mild pain: APAP, ibuprophen
mod/severe pain: OPIOIDS (morphine most common)

Avoid codeine and tramadol in peds due to cyp2d6 altered metabolism

70
Q

causative organisms of appendicitis

A

bacteroides fragilis

e. coli

pseudamonas aeruginosa

71
Q

iv ABX trt in appendicitis

A

iv abx 1st line therapy

broad spectrum coverage

non-perforated:
cefotetan
cefoxitin

perferated
ampicillin-sulbacatam
pip-tazo

72
Q

2nd gen cephs for iv coverage for appendicitis

A

“cephamycins”
cefotetan-iv im
cefoxitin-IV, IM

COVERAGE:
gram+
gram- expanded to HNPECK
add anaerobic activity (b. fragilis)

73
Q

extended spectrum pcn

A

apicillin/ sulbacton- iv
pip tazo: iv

coverage:
gram+: steptococci, enteroccci, mssa
gram-: hnpeck, anaerobes (b. fragilis)
pip tazo also covers pseudomonas and CAPES organisms

74
Q

duration of appendicitis trt

A

minimum of 5 days of abx treatment. some recommend 7-190 days

criteria for abx to be d/c

afebrile
adequate po/ intake tolerating regular diet
ambulating
bening abdominal examination

75
Q

complicatinos of appendicitis

A

abcess

perforation

sepsis

shock

wound infection

76
Q

surgical approaches for appendicitis

A

primary treatment for appendicitis is surgery

*laparoscopic: open appendectomy is overall preferred

77
Q

categories of vaccinestoxoids

A

diptheria

tetanus

78
Q

categories of vaccines
inactivat

A

Peds and Geriatrics (5 decks)

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