Common Pediatric Infections

Kathryn M. Edwards MD
Professor of Pediatrics
Vanderbilt University
 Case 1
Johnny, a two year old boy, had URI and cough
for two days.
He awakened suddenly in the middle of the night
with fever to 103oF, cough, and irritability.
He was given an antipyretic and taken to see
YOU, his physician the next morning.
His vital signs revealed a temperature of 103 oF,
pulse rate of 120 and a respiratory rate of 60
with nasal flaring.
 Diagnostic Evaluation
Chest X-rays (posteroanterior and lateral views
are standard, if there is consolidation or
evidence of effusion obtain decubitus view)
Sputum is rarely produced by children
Blood Culture
Complete Blood Count
Tuberculin Skin Test
If afebrile and < 20 weeks of age consider
Chlamydia culture or antigen testing
Chest Film
 Facts about Pneumonia
Pneumonia diagnosed in nearly 2% of infants <
1 year and in 4% of children aged 1 to 5 years.
Responsible agent determined in < 10%
Estimated that 90% of pediatric pneumonias are
caused by viral agents.
Approximately 50% of the documented viral
pneumonias in children are caused by
respiratory syncytial virus; 25% by parainfluenza
virus types 1 and 3
A smaller number from influenza and adenovirus
Bacterial and atypical agents also seen
 Considerations for Inpatient Management of Pneumonia
Toxic appearance
Respiratory distress
Pleural effusion
Age considerations:
<3 months
<3 years with lobar pneumonia
<5 years with lobar pneumonia (more than 1 lobe)
Existing chronic disease
Pulmonary (including asthma)
Metabolic disorders
Cardiac
Anemia (including sickle cell disease)
Renal
Malignancies
Diabetes Mellitus
Immunocompromised host
Progression during outpatient therapy
 Bacterial And Fungal Causes of
Pneumonia Related to Age of the
Pediatric Patient
Age Group Common Pathogens
0-48 hrs Group B. Streptococci
1-14 days Escherichia coli, Klebsiella pneumoniae, other
Enterobacteriaceae, Listeria monocytogenes,
Staphylococcus aureus, anaerobic bacteria, group B
streptococci
2 wks to 2 mos Enterobacteriaceae, Group B streptococci,
(premature Staphylococcus aureus, Staphylococcus
neonates) epidermidis, Candida Albicans, Haemophilus
influenzae, Streptococcus pneumoniae
2 mos to 5 yrs Haemophilus influenzae, Streptococcus
pneumoniae
5-10 yrs Streptococcus pneumoniae
10-21 years Mycoplasma pneumoniae, Chlamydia pneumoniae
(TWAR agent), Streptococcus pneumoniae
Bacterial Pneumonia Agent Dosage
Outpatient Pneumonia Oral amoxicillin 80-90 mg/kg/day
BID
Oral amoxicillin- 80-90 mg/kg/day of
clavulanate amoxicillin BID
Oral cefuroxime axetil 30 mg/kg/day BID
Oral cefdinir 14mg/kg BID

Inpatient Pneumonia Intravenous 100 mg/kg/day q12h

(Initial empiric ceftriaxone
therapy)
Pneumococcal Intravenous penicillin 250,000-400,000
susceptible Penicillin U/kg/day
MIC < 2 mcg/ml q4-6h
Pneumococcal
nonsusceptible to Intravenous 100 mg/kg/day q12h
penicillin, susceptible ceftriaxone or
to cephalosporin Intravenous cefotaxime 225-300 mg/kg/day
Pneumococcal Intravenous 40-60 mg/kg/day q6h
nonsusceptible to vancomycin
penicillin,
nonsusceptible to
cephalosporin
 Case 2
Bill, a six month old male, had the acute
onset of fever to 102o and irritability.
He was seen in your office and
examination of the tympanic membranes
revealed the physical findings noted.
 Symptoms of Otitis Media
Unusual Irritability
Difficulty Sleeping
Tugging Or Pulling At One Or Both Ears
Fever
Fluid Draining From The Ear
Loss Of Balance
Unresponsiveness To Quiet Sounds Or
Other Signs Of Hearing Difficulty
 Facts about Otitis Media
Seventy-five percent of children
experience at least one episode of otitis
media by their third birthday.
Almost half of these children will have
three or more ear infections during their
first 3 years.
It is estimated that medical costs and lost
wages due to otitis media account for $5
billion a year in the United States
 Risk Factors for Otitis Media
Children cared for in group settings
Children who live with adults who smoke
Infants who nurse from a bottle while lying down
Children who are not breast-fed
Cold and allergy medications such as
antihistamines and decongestants are not
helpful in preventing otitis
Vaccines against the bacteria that most often
cause otitis media are the best hope
Office Visits with Principal
Diagnosis
of Otitis Media in the US
Age-Specific Incidence of Otitis
Media

Any AOM
1st AOM

Teele, et al J Infect Dis 1989

 Bacteriology of Acute Otitis Media
2,087 ears: Childrens Hospital of Pittsburgh, 1980-89

No growth
16%
Strep. pyogenes 3%
Strep.
Staph. aureus 1% pneumoniae
Other
Others 8% 12% 35%

M. catarrhalis
14%
H.
influenzae
23%
AOM Rates During Respiratory Virus
Infection

Henderson, et al. NEJM, 1982

 Guidelines for Treatment
Schedule an appointment within 24 hours
A clinical examination is necessary
Educate parents on measures to prevent otitis
Prescribe amoxicillin when the diagnosis of
otitis media is made.
Prescribe second-line antibiotics when patient
fails first-line drugs
Recheck in 3 to 4 weeks or at next well visit
 Treatment
First-Line Medications
Amoxicillin (40 mg/kg/day) if low risk (> 2 years, no
day care, and no antibiotics for the past three
months).
80 mg/kg/day if not low risk or for resistant AOM if the
lower dose was used initially.
Therapeutic (10 day) course of antibiotics.
Consideration may be given to a shortened
course of antibiotics (5 days) for children who
are at low risk ( i.e., age > 2 years, no history of
chronic or recurrent otitis media and intact
tympanic membranes).
 Second Line Agents
Recommended second-line medications include
Amoxicillin/Clavulanate Potassium (Augmentin)
Cefuroxime Axetil (Ceftin)
Ceftriaxone Sodium (Rocephin): Prescribe One
Dose For New Onset Otitis Media And A Three-day
Course For Resistant Otitis Media Or If Oral
Treatment Cannot Be Given.
Cefprozil (Cefzil)
Loracarbef (Lorabid)
Cefdinir (Omnicef)
Cefpodoxime proxetil (Vantin)
 Case 3
Susie, a two year old child, had the acute
onset of dysuria and frequency. She was
seen in your office.
 Epidemiology
Gold standard: growth of bacteria in urine
UTI present in 5% of febrile infants and
2% of febrile children < 5 years of age
Recurs in 50% of school-aged girls within
6-12 months
UTI more common in white children
Males have more UTI in first 3 months, but
after that females have more than males
 Facts about UTI
Cystitis classically presents with urgency,
frequency, dysuria, secondary enuresis, and foul-
smelling urine.
Pyelonephritis presents with spiking fever, flank
or abdominal pain, and irritability.
Chronic pyelonephritis presents with recurrent
abdominal pain, recurrent fever, and failure to
thrive.
A higher index of suspicion is necessary to
diagnose UTI in the infant in whom sepsis,
lethargy, and jaundice may be the initial
symptoms.
 Other Causes Of Urinary Tract
Symptoms
Urethritis
Meatal irritation
Vulvovaginitis
Medications
Vaginal foreign body
Pinworms
Candida
Trichomonas
Trauma (including masturbation and sexual abuse)
 Diagnostic Studies
Routine Urinalysis
White blood cell count 10/high-power field
Leukocyte esterase (Correlates with pyuria)
Nitrites (bacteria slowly reduce nitrate to nitrite)
Bacteria (Presence in unspun urine correlates with
105 bacteria/ml)
White blood cell casts (Indicative of pyelonephritis)
Serum C-Reactive Protein
Elevated with pyelonephritis
 Criteria for Culture Diagnosis
Specimen Positive Result

Suprapubic aspiration >100

Catheterized urine >50,000

Clean-voided (male) >100,000

Clean-voided (female) >100,000

Bagged urine *** Not Acceptable

*** Only acceptable if culture is negative

 Treatment of UTI
Choice based on most likely organism
Clinical trial by Hoberman compared IV
cefotaxime (200 kg/kg/day X 3 days, followed by
oral cefoxime) with oral cefoxime (16 mg/kg
once, followed by 8 mg/kg/day for 14 days) in
children with febrile UTI
Comparable outcomes seen
AAP recommends parenteral antibiotics in toxic
children or those who cannot tolerate oral intake

Hoberman et al. NEJM 2003;348:195-202

 Recommendations for
Radiographic Evaluation
AAP subcommittee recommends VCUG
and ultrasound for all children < 2 years
However, Hoberman et al reported that
ultrasound at the time of acute UTI is of
little value and that VCUG only useful if
prophylactic antibiotics will be given
Area of continued controversy

Hoberman et al. NEJM 2003;348:195-202