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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
dx CAP
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)
26
to hospitalize or not to hospitalize for ACAP
hospitalize: mod-severe CAP significant respiratory distess (spo2<90% all infants <3 mo of age suspicioin of community acquires MRSA concern for caretaker capabilities
27
most common pathogens for CAP
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
28
what is the best predictor of cause via identification of likely pathogen and exposure in CAP
AGE
29
CAP causative organisms base don AGE birth-20 days: 3-weeks-3mo. 4months-4 years 5 years-15 years
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
30
symptom resolutoin time for abx trt for CAP
48-72 hrs
31
Out pt Trt of CAP MEd: amoxicillin Dose: dosage forms notes:
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
32
Out pt Trt of CAP MEd: augmentin ( Dose: dosage forms: notes:
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
Out pt Trt of CAP MEd: axithromycin Dose: dosage forms notes:
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
in pt Trt of CAP MEd:Ampicillin Dose: dosage forms notes:
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
in pt Trt of CAP MEd: ceftriaxone Dose: dosage forms notes:
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
antiviral Trt of CAP MEd: oseltamavir Dose: dosage forms notes:
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
allergy alternatives for CAP trt
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
duration of therapy for CAP
10 days(just as effective as 14 days) azithromysin and olsetamivir only 5 days CA-MRSA may need longer treatment
39
vaccine prevention for CAP
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
Risk factors for UTI in peds
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
infection pathways of UTI
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
most common pathogen causing uti
e. coli (80%)
43
recap: classificationf os uti
1.infection site a. lower uti bladder=cystitis) urthra -urethiritis upper UTI a. kindey=pyelonephritis urine: bacteria 2. complicated vs uncompliated complicated: gu w. structural/functinoal abnormalities, catheters uncomplicated: occurs in anatomically normal ut w. no prior instrumentation
44
SS of uti in peda
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
dx of uti in peds considerations
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
definition of uti base don method of collection
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
general treatments of UTI
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
duraiton of trt for uti in peds
AAP: 7-14 days uncomplicated uti: 7 days pyelonephritis: 10-14 days
49
Vesicoureteral reflux (VUR)
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
VUR risk factors complications prognosis treatments
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
uti ppx w. abx goal: who should get it generally? trials
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
whoshould get abx ppx for UTI
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
ABX for UTI ppx
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
most common etiologies of acute otitis media (AOM)
Bacterial ~80%) s. pneumoniae h. influenzae Moraxella catarallis Virus ~20% RSV rhinovirus influenza adenovirus
55
antimicrobial resistance among bacterialpathogens in AOM
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
ss OF AOM
middle ear effusion ANDDD acute onset of symptoms (fever, rhinorrhea, irritability, otalgia, tugging/rubbing of ear)
57
classifications of AOM
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
recommendations fo rinitial mamagement for uncomplicated AOM in regards to age
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
AOM ABX therapy
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
alternative treatments for aom treatment
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
duratino of AOM treatment
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
failure of trtment for aom?
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
aom prevention
vaccines!! influenza and pneumococcal
64
appendicitis:
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
apendicitis patho
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
physical SS of apendicitis
N/V radiating pain in RLQ decreased appetite fever constipation
67
dx of appendicitis
physical examination: physical SS lab evbal: elevated wbc, ANC, CRP imaging: Ultrasound ct: modality of choice for definitive assessment of pts.
68
appendicitis treatment option sgeneral
fluid therapy abx surgicalapproach (appendectomy
69
fluis therapy and analgesia in appendicitis
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
causative organisms of appendicitis
bacteroides fragilis e. coli pseudamonas aeruginosa
71
iv ABX trt in appendicitis
iv abx 1st line therapy broad spectrum coverage non-perforated: cefotetan cefoxitin perferated ampicillin-sulbacatam pip-tazo
72
2nd gen cephs for iv coverage for appendicitis
"cephamycins" cefotetan-iv im cefoxitin-IV, IM COVERAGE: gram+ gram- expanded to HNPECK add anaerobic activity (b. fragilis)
73
extended spectrum pcn
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
duration of appendicitis trt
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
complicatinos of appendicitis
abcess perforation sepsis shock wound infection
76
surgical approaches for appendicitis
primary treatment for appendicitis is surgery *laparoscopic: open appendectomy is overall preferred
77
categories of vaccinestoxoids
diptheria tetanus
78
categories of vaccines inactivat

Peds and Geriatrics (5 decks)

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