Immunity & Infectious Immunity & Infectious Disease Part IIDisease Part II

Dr. D BarryDr. D Barry

Previously covered…Previously covered…

► ImmunityImmunity

►VaccinationsVaccinations

►Vaccine Preventable diseaseVaccine Preventable disease

This lecture;This lecture;

1)1) Assessment of Febrile ChildAssessment of Febrile Child

2)2) Common Childhood InfectionsCommon Childhood Infections

3)3) Antibiotic choicesAntibiotic choices

4)4) Immunocompromised PatientImmunocompromised Patient

1; Clinical1; ClinicalAssessment of febrile childAssessment of febrile child

FeverFever

►Find a source!!!!!Find a source!!!!!► Is it benign viral?Is it benign viral?► Does it require anti-biotic cover?Does it require anti-biotic cover?► Who needs a septic work-up?Who needs a septic work-up?► Is it one of the critical illnesses? (sepsis, Is it one of the critical illnesses? (sepsis,

meningitis, pneumonia, septic arthritis, UTI)meningitis, pneumonia, septic arthritis, UTI)► Best tool; thorough history & examinationBest tool; thorough history & examination► Infections evolve & change… advise Infections evolve & change… advise

parents parents ► Other – PUO, complicated fevers, etc.Other – PUO, complicated fevers, etc.

History; symptomsHistory; symptoms

► Generalised;Generalised; irritability (?intermittent, on irritability (?intermittent, on handling, consolable), feeding, intake, handling, consolable), feeding, intake, drowsy, sleeping, sweating, etc. drowsy, sleeping, sweating, etc.

► Resp;Resp; cough, wheeze, rapid beathing etc. cough, wheeze, rapid beathing etc.► GIT/GU;GIT/GU; diarrhoea, vomiting, abdo pain, diarrhoea, vomiting, abdo pain,

pulling up legs, foul urine, etc.pulling up legs, foul urine, etc.► ENT;ENT; coryza, pulling at ears, sore throat coryza, pulling at ears, sore throat► CNS;CNS; headache, photophobia, seizure headache, photophobia, seizure ► Other;Other; rash, tender/swollen joints etc. rash, tender/swollen joints etc.

Other questionsOther questions

► ID contacts (creche, family, school)ID contacts (creche, family, school)►Special ID questions; Special ID questions;

travel, pets/animals, contacts, activitiestravel, pets/animals, contacts, activities

►Vaccination historyVaccination history►Antibiotic hx; allergies, how often on Antibiotic hx; allergies, how often on

a/b, previous admissions etc. a/b, previous admissions etc. ►Previous illnessesPrevious illnesses

On examinationOn examination

Tips;Tips; Observe firstly Observe firstly

► General inspection; C.H.A.N.D.L.E.R.General inspection; C.H.A.N.D.L.E.R.► Vitals (?sepsis) HR, BP, CRT +/- ABCVitals (?sepsis) HR, BP, CRT +/- ABC► Chest exam; CVS & respiratory Chest exam; CVS & respiratory (do early if settled)(do early if settled)► Fontanelle, Neck stiffness, Kernigs, Brudinski’sFontanelle, Neck stiffness, Kernigs, Brudinski’s► Skin – expose & examine all areasSkin – expose & examine all areas► Lymph nodesLymph nodes► JointsJoints► Ears & throat Ears & throat (at end; children don’t like this!)(at end; children don’t like this!)► Urine dipstick Urine dipstick ((nevernever omit this) omit this)

Septic work-upSeptic work-up►FBC, CRPFBC, CRP►Blood cultureBlood culture►Urine c + sUrine c + s►Swabs (wounds, throat, etc)Swabs (wounds, throat, etc)►CXRCXR►LPLP►Other (depends on clinical indication Other (depends on clinical indication

eg. eg. skin scrapings, s skin scrapings, sputum C+Sputum C+S

Important questions to Important questions to consider…consider…

►Have you found the source?Have you found the source?► Is it benign childhood illness?Is it benign childhood illness?►Does it require anti-biotic cover? +/- Does it require anti-biotic cover? +/-

f/u?f/u?►Does this child need a septic work-up?Does this child need a septic work-up?►Does this child need admission?Does this child need admission?► Is this child critical? (sepsis, meningitis, Is this child critical? (sepsis, meningitis,

pneumonia, septic arthritis, UTI)pneumonia, septic arthritis, UTI)►Notifiable dx? Trace contacts? Isolation?Notifiable dx? Trace contacts? Isolation?►Choice of antibiotic…Choice of antibiotic…

Take Home MessageTake Home Message

►Wide spectrum of infective diseaseWide spectrum of infective disease

►Your job to find out which (source of Your job to find out which (source of fever)fever)

►Thorough History & Exam!!!!Thorough History & Exam!!!!►+/- septic work-up+/- septic work-up

2; Common 2; Common Childhood Childhood InfectionsInfectionsThe Classic ExanthemasThe Classic Exanthemas

Describing a RashDescribing a Rash

1)1) What’s the What’s the primary lesion?primary lesion? Macule / papule / vesicle / bullae / haemorrhagicMacule / papule / vesicle / bullae / haemorrhagic

2)2) Surrounding skin? Surrounding skin? (eg erythematous / (eg erythematous / indurated etc.)indurated etc.)

3) Pattern? 3) Pattern? (eg. confluent? discrete? isolated? etc)(eg. confluent? discrete? isolated? etc)

4) What’s the distribution? 4) What’s the distribution? (eg face/scalp? trunkal? Peripheral? Exposed areas etc.) (eg face/scalp? trunkal? Peripheral? Exposed areas etc.)

5) Other features? 5) Other features? (eg. Itchy? Oozing? Tender? etc)(eg. Itchy? Oozing? Tender? etc)

6) How did it evolve (time)? 6) How did it evolve (time)? [ask from history][ask from history]

1: Fever & rash1: Fever & rash

► High feverHigh fever► MiserableMiserable► CoughCough► Runny noseRunny nose► Day 6; rashDay 6; rash

face & face & spread spread down trunkdown trunk

► Description…Description…

macularmacular

papularpapular

confluentconfluent

‘‘morbilliform’morbilliform’

extensive spread extensive spread downwards.downwards.

Measles (rubeola)Measles (rubeola)

►Contact & spread; airborne/dropletContact & spread; airborne/droplet► Incubation; 10-14 days Incubation; 10-14 days ►Clinical; Prodrome; high fever, harsh Clinical; Prodrome; high fever, harsh

cough, coryza, conjunctivitis, cough, coryza, conjunctivitis, ►Rash; ‘morbilliform’, maculo-papularRash; ‘morbilliform’, maculo-papular

Begins d3-6 from hairline, down face to Begins d3-6 from hairline, down face to trunktrunk

Lasts up to 10/7Lasts up to 10/7

►Koplik’s spotsKoplik’s spots

The science bit… measles The science bit… measles (Rubeola)(Rubeola)

► RNA ParamyxovirusRNA Paramyxovirus► Clinical diagnosis Clinical diagnosis ► Salivary swab measles Salivary swab measles

IgMIgM► TreatmentTreatment

Supportive Supportive Ribavirin if patient Ribavirin if patient

ImmunocompromisedImmunocompromised ?Contacts?Contacts

► Prevention: HNIG within Prevention: HNIG within 6/7 if 6/7 if imunocompromised imunocompromised contactcontact

Complications;Complications;► Otitis, pneumonia, Otitis, pneumonia,

croupcroup► EncephalitisEncephalitis 1/5000 1/5000

within a week of rashwithin a week of rash 15% Mortality15% Mortality 20-40% Neuro 20-40% Neuro

sequelae sequelae ► Late complication;Late complication;SSPE (subacute SSPE (subacute

sclerosing sclerosing panencephalitis) panencephalitis) 1/100,000 1/100,000

MeaslesMeasles► Live vaccine (1960s)Live vaccine (1960s)► Mini-measles can occur 6 -10 days after Mini-measles can occur 6 -10 days after

immunisationimmunisation Mild pyrexia and erythematous rashMild pyrexia and erythematous rash

► Pre-vaccine; >500,000 cases/yr with 500 mortalitiesPre-vaccine; >500,000 cases/yr with 500 mortalities► Measles outbreak (when vaccine uptake ↓)Measles outbreak (when vaccine uptake ↓)

Immunise all susceptible individuals within 72 hrsImmunise all susceptible individuals within 72 hrs► Contraindications;Contraindications;

PregnancyPregnancy Untreated malignancy Untreated malignancy Immunodeficiency states (except HIV)Immunodeficiency states (except HIV) Immunosuppressive therapyImmunosuppressive therapy History of anaphylaxis to a previous doseHistory of anaphylaxis to a previous dose

2; Fever & rash 2; Fever & rash

► ErythematousErythematous► Coarse / sand-paperCoarse / sand-paper► Began on neck d2Began on neck d2► Extensive Spread Extensive Spread ► Esp. marked in folds Esp. marked in folds

(axilla, groin etc.) (axilla, groin etc.) but doesn’t blanch but doesn’t blanch here [Pastia lines]here [Pastia lines]

► Palms, soles often Palms, soles often involvedinvolved

► White strawberry White strawberry tonguetongue

► Red strawberry Red strawberry tonguetongue(prominent papillae)(prominent papillae)

► Circum-oral pallorCircum-oral pallor► Flushed faceFlushed face► Desquamates d5-7Desquamates d5-7

Scarlet FeverScarlet Fever

►Spread via droplets [school-age children]Spread via droplets [school-age children]►Strep pharyngitisStrep pharyngitis►2-5 day incubation; 2-5 day incubation; ►Sudden fever, sore throat, malaise, Sudden fever, sore throat, malaise,

+/- headache, vomiting etc. +/- headache, vomiting etc. lymphadenopathylymphadenopathy

►Rash from day 2; (as described)Rash from day 2; (as described)►Rash fades day 5-7 & desquamatesRash fades day 5-7 & desquamates

The science bit…The science bit…

►Group A (Group A (ββ-haemolytic) -haemolytic) strep strep “strep “strep Pyogenes”Pyogenes”

►Erythrogenic toxinErythrogenic toxin►Complications; Complications;

Rheumatic feverRheumatic fever Acute GlomerulonephritisAcute Glomerulonephritis

►Tests; throat swab +/- ASOT titreTests; throat swab +/- ASOT titre►Tx; Penicillin (phenoxymethylpenicillin) Tx; Penicillin (phenoxymethylpenicillin)

x10/7x10/7

Streptococcus PyogenesStreptococcus Pyogenes

► Skin infectionsSkin infections Impetigo, erysipelas, Impetigo, erysipelas,

cellulitis, cellulitis, ► URTIURTI

Sinusitis, otitis, Sinusitis, otitis, tonsillitistonsillitis

► InvasiveInvasive Sepsis, shock, Sepsis, shock,

nectrotizing fascitisnectrotizing fascitis

► Complications;Complications; Scarlet fever Scarlet fever Rheumatic feverRheumatic fever GlomerulonephritisGlomerulonephritis

ASOT;ASOT; Up to ~200 NormalUp to ~200 Normal Rises x 4/52Rises x 4/52 Plateau x 3-6/12Plateau x 3-6/12 Normal after 6-12/12Normal after 6-12/12

EBVEBV

► Incubation 1-2 monthsIncubation 1-2 months►Fever (prolonged)Fever (prolonged)►Lymphadenopathy (generalised)Lymphadenopathy (generalised)►Pharyngitis, tonsilitis with exudatesPharyngitis, tonsilitis with exudates►Palatal petechiae, Swollen uvulaPalatal petechiae, Swollen uvula►Splenomegaly (sometimes tender)Splenomegaly (sometimes tender)►Hepatomegaly +/- hepatitis Hepatomegaly +/- hepatitis ►ThrombocytopeniaThrombocytopenia►Rash (‘rubelliform’) 10% (↑with Rash (‘rubelliform’) 10% (↑with

amoxicillin)amoxicillin)

Tests;Tests;

►FBC – Lymphocytes (atypical)FBC – Lymphocytes (atypical)►Monospot (Paul Bunnel); (heterophile Monospot (Paul Bunnel); (heterophile

a/b)a/b) Wk l Wk l 38% +, 38% +, Wk 2 Wk 2 60% +, 60% +, Wk 3 Wk 3 80% + 80% +

(false + : Hepatitis/Rubella/Hodgkins)(false + : Hepatitis/Rubella/Hodgkins)►Serology antibody titresSerology antibody titres

ComplicationsComplications

►Haemolytic anaemiaHaemolytic anaemia►PneumonitisPneumonitis►Post-infectious malaisePost-infectious malaise►Lymphoma (Burkitts) / Lymphoma (Burkitts) /

lymphoproliferationlymphoproliferation

3; fever & rash3; fever & rash

► Mild fever & Mild fever & prodromeprodrome

► Rash (d1-3) Rash (d1-3) Begins on face Begins on face spreads spreads

downwardsdownwards generalisedgeneralised erythematous erythematous maculo papular maculo papular Last 3-5/7Last 3-5/7

RubellaRubella► Rubella – difficult to diagnoseRubella – difficult to diagnose

Fever <38.5, LN + (esp Post Triangle)Fever <38.5, LN + (esp Post Triangle) May have splenomegaly, palatal petechiaeMay have splenomegaly, palatal petechiae

► Mild self limited disease in children – 25 -50% Mild self limited disease in children – 25 -50% subclinicalsubclinical

► Incubation 2 – 3 weeksIncubation 2 – 3 weeks► Infectious (droplets) for <1wk from rash onsetInfectious (droplets) for <1wk from rash onset► Buccal swab, urine, rising antibody titreBuccal swab, urine, rising antibody titre► Rare complications:Rare complications:

Polyarthralgia / Polyarthritis Polyarthralgia / Polyarthritis Thrombocytopenia Thrombocytopenia Encephalitis (1 in 6000)Encephalitis (1 in 6000)

5; fever & rash5; fever & rash

► Fever Fever ► LethargicLethargic► Poor intake ? Poor intake ?

SoreSore► Rash;Rash;

Erythematous Erythematous cheekscheeks

Erythema Infectiosum / 5Erythema Infectiosum / 5thth disease / disease / Parvovirus B19Parvovirus B19

►20% asymptomatic20% asymptomatic►Outbreaks esp. Spring [4-15 yr olds]Outbreaks esp. Spring [4-15 yr olds]►Biphasic; Flu-like prodrome, Biphasic; Flu-like prodrome, ►1 week later; 1 week later; Rash!Rash!

Erythematous over cheeks; Erythematous over cheeks; ‘Slapped-‘Slapped-cheek’ cheek’ Macular over body (central Macular over body (central clearing) clearing) ‘lacy’ ‘lacy’

►May Recur May Recur

Complications;Complications;

►Arthritis (transient)Arthritis (transient)►Congenital infection; severe!Congenital infection; severe!

Intra-uterine deathIntra-uterine death HydropsHydrops Neonatal thrombocytopeniaNeonatal thrombocytopenia

►Pts with haemolytic anaemia;Pts with haemolytic anaemia; Aplastic crisis (attacks red cell Aplastic crisis (attacks red cell

precursors)precursors)

6: Fever then rash!6: Fever then rash!

► High fever (40High fever (40ooC)C)x 3/7, x 3/7,

► Otherwise wellOtherwise well► Fever settles Fever settles

abruptly; abruptly;

thenthen rash;rash;► Extensive, Extensive, ► Maculo-papularMaculo-papular► Lasts only 1-2 Lasts only 1-2

daysdays

Roseola / 6Roseola / 6thth disease / disease / exanthem Subitumexanthem Subitum

►HHV6HHV6►High fever +/- febrile convulsion (10%)High fever +/- febrile convulsion (10%)►Rash appears afterwardsRash appears afterwards►+/- red papules on palate / uvula +/- red papules on palate / uvula

(Nagayama)(Nagayama)

►Very common;Very common; 100% a/b + by 2 yrs age 100% a/b + by 2 yrs age►Herpes familyHerpes family►? reactivation in Immunocompromised ? reactivation in Immunocompromised

host?host?

Common Common childhood childhood infections;infections;The skinThe skin

Hand, Foot & Mouth diseaseHand, Foot & Mouth disease

►Coxsackie virus A & B, enterovirusCoxsackie virus A & B, enterovirus►Mild, self-limiting (1 wk) diseaseMild, self-limiting (1 wk) disease►Fever & m/p rash to vesiclesFever & m/p rash to vesicles

►Spread by direct contact, droplet, Spread by direct contact, droplet, faeco-oralfaeco-oral

Fever & Rash (vesicular)Fever & Rash (vesicular)

► VesiclesVesicles

► Varying stagesVarying stages

► ExtensiveExtensive

► ItchyItchy

Varicella ZosterVaricella Zoster Primary (chicken-pox). Reactivation (zoster) Primary (chicken-pox). Reactivation (zoster)

Both are infectious – spreading Varicella!Both are infectious – spreading Varicella!Chicken PoxChicken Pox► Incub 10-21 (14-16)Incub 10-21 (14-16)► Fever / malaise Fever / malaise ► rash (usually simultaneous with Symptoms)rash (usually simultaneous with Symptoms)► Maculae - papule - vesicle - pustule Maculae - papule - vesicle - pustule

[at different stages][at different stages]► Trunk/face - extremitiesTrunk/face - extremities► Typically 3 crops over 3-5 days Typically 3 crops over 3-5 days ► Infectious 24-48 hours pre-rash until last lesion is Infectious 24-48 hours pre-rash until last lesion is

crusted overcrusted over

Complications:Complications:► Cellulitis / lymphadenitisCellulitis / lymphadenitis► Encephalitis (1:1000), HepatitisEncephalitis (1:1000), Hepatitis► Post infectious cerebellar ataxiaPost infectious cerebellar ataxia► Pneumonia (adults & Pneumonia (adults &

immunocompromised)immunocompromised)► Haemorrhagic progressive VZV / Haemorrhagic progressive VZV /

thrompbocytopenia / purpura fulminans thrompbocytopenia / purpura fulminans (↓ protein C)(↓ protein C)

► Reyes syndrome (ASA ingestion)Reyes syndrome (ASA ingestion)► VZV - Reactivation - ZosterVZV - Reactivation - Zoster

TreatmentTreatment

►Symptomatic Symptomatic ►Vaccine AvailableVaccine Available► Immunocompromised Immunocompromised

Contact; VZIG within 72 Contact; VZIG within 72 oo of exposure of exposure Infected; Acyclovir within 24 Infected; Acyclovir within 24 oo of rash of rash

HSV-1HSV-1►Primary infection; herpetic gingivostomatitisPrimary infection; herpetic gingivostomatitis

Can cause acute vulvo-vaginitisCan cause acute vulvo-vaginitis Localised infection; herpetic whitlowLocalised infection; herpetic whitlow

►Fever 2-3/7Fever 2-3/7►UlcerationUlceration►Heal in < 1 weekHeal in < 1 week►Age 1-4 year oldsAge 1-4 year olds►Dormant in trigeminal ganglionDormant in trigeminal ganglion►RecurrenceRecurrence

ComplicationsComplications

►Herpetic KeratoconjunctivitisHerpetic Keratoconjunctivitis►Herpes encephalitisHerpes encephalitis►Neonatal herpes Neonatal herpes

►Treat complications (above) with HD Treat complications (above) with HD acycloviracyclovir

►Monitor U&EMonitor U&E

StaphlococcusStaphlococcus

► Skin Flora, Nasal ColoniesSkin Flora, Nasal Colonies

► Folliculitis / Furnacles / CarbunclesFolliculitis / Furnacles / Carbuncles► Impetigo (+ Bullous Impetigo)Impetigo (+ Bullous Impetigo)► Staph Scalded SkinStaph Scalded Skin► Surgical wounds (nb. ? MRSA)Surgical wounds (nb. ? MRSA)

► Other- cellulitis, LN, osteomyelitis, septic Other- cellulitis, LN, osteomyelitis, septic arthritisarthritis

Staphlococcus!Staphlococcus!

► Impetigo; Impetigo; ►Skin flora; Staplococcal*/streptococcalSkin flora; Staplococcal*/streptococcal►Honey-crusted crustsHoney-crusted crusts►Very ContageousVery Contageous►Often superinfection of skin lesions; Often superinfection of skin lesions;

eczema / VZV / scabies etc…eczema / VZV / scabies etc…►Tx.; Fluclox +/- BzPenTx.; Fluclox +/- BzPen

Bullous ImpetigoBullous Impetigo

►Disrcete BullaeDisrcete Bullae►Toxin mediatedToxin mediated►Same treatment; Fluclox / BzPenSame treatment; Fluclox / BzPen►Skin careSkin care

Staphlococcal Scalded SkinStaphlococcal Scalded Skin

► SSSSSSSS► Toxin mediated Toxin mediated ► Systemically unwell; Systemically unwell;

? sepsis? sepsis malaise / fever / malaise / fever /

irritable / irritable / dehydration dehydration

pain +++pain +++

► Peeling off of sheets Peeling off of sheets of epidermisof epidermis

Nikolsky’s sign

Treatment of SSSSTreatment of SSSS

► IV antibiotics; Fluclox +/- BzPenIV antibiotics; Fluclox +/- BzPen

►Skin care; emollientsSkin care; emollients Prevention of 2ary infectionPrevention of 2ary infection

►Fluid & electrolyte balanceFluid & electrolyte balance

Common Childhood Common Childhood IllnessesIllnesses

Other Other

Describe Describe this….this….

What might What might this child this child

have?have?

Kawasaki SyndromeKawasaki Syndrome► Clinical featuresClinical features► Fever >5daysFever >5days

1.1. Maculo-papular rashMaculo-papular rash generalisedgeneralised

2.2. Conjunctival injectionConjunctival injection Bilat, non-purulentBilat, non-purulent

3.3. Extremity changeExtremity change Induration hands/feet, Induration hands/feet,

erythematous palms/soles, erythematous palms/soles, periungal desquatamionperiungal desquatamion

4.4. Oral mucosa change;Oral mucosa change; erythematous, red/cracked erythematous, red/cracked

lips, strawberry tonguelips, strawberry tongue

5.5. Cervical Cervical lymphadenopathvlymphadenopathv Unilateral, >1.5cmUnilateral, >1.5cm

► Differential Differential DiagnosisDiagnosis

► Viral exanthems Viral exanthems – – measles. measles.

adeno-/enterovirusadeno-/enterovirus► Gp A strept infectionGp A strept infection► Staph; toxin-mediated Staph; toxin-mediated

dxdx► Drug hypersensitivity Drug hypersensitivity ► Other; Other;

LeptospirosisLeptospirosis Rocky Mt. Spotted Fever Rocky Mt. Spotted Fever

(Ricketsial diseases)(Ricketsial diseases)

Other featuresOther features

► BCG scar inflammedBCG scar inflammed► Aseptic meningitisAseptic meningitis► Sterile pyuria (ureteritis)Sterile pyuria (ureteritis)► Hydropic gall bladder (abdo pain / vomiting)Hydropic gall bladder (abdo pain / vomiting)► Anterior UveitisAnterior Uveitis► Arthritis / ArthralgiaArthritis / Arthralgia► Pericardial effusion, myocarditis +/- ccfPericardial effusion, myocarditis +/- ccf

► coronarv arterv aneurvsms (late)coronarv arterv aneurvsms (late)

Kawasaki Syndrome; Kawasaki Syndrome; InvestigationsInvestigations

►Anaemia; Normochromic, normocytic Anaemia; Normochromic, normocytic ►Leukocytosis Leukocytosis ►Acute phase reactants Acute phase reactants ↑↑ ↑↑ (ESR, CRP)(ESR, CRP)►ThrombocytosisThrombocytosis after 7 days (~ 1% after 7 days (~ 1% ↓ ↓

plts.plts.))►↑ ↑ ALTALT, , hypoalbuminemiahypoalbuminemia►CSF pleocytosisCSF pleocytosis

►EchocardiogramEchocardiogram

Kawasaki SyndromeKawasaki Syndrome

► 80% < 4 years80% < 4 years► M > F M > F ► peaks late winter/spring peaks late winter/spring ► Asians > Africans > CaucasianAsians > Africans > Caucasian

► Aetiology unknownAetiology unknown► Diagnosis is clinical (? Work-up to exclude DD)Diagnosis is clinical (? Work-up to exclude DD)► Atypical Kawasaki’s if criteria not completedAtypical Kawasaki’s if criteria not completed

Kawasaki’s; ManagementKawasaki’s; Management

► IVIGIVIG 2g/kg over 10 hours (~ 5% require a second dose) 2g/kg over 10 hours (~ 5% require a second dose)► Give A.S.A.P. – (ideally within 10days of illness onset)Give A.S.A.P. – (ideally within 10days of illness onset)► AspirinAspirin 80 - 100 mg/kg d in 4 divided doses until d 14 80 - 100 mg/kg d in 4 divided doses until d 14

then reduce to 3 – 10 mg/kg/day as a single dosethen reduce to 3 – 10 mg/kg/day as a single dose

► Echocardiograph; A.S.A.P & 6/52 +/- follow-up if +Echocardiograph; A.S.A.P & 6/52 +/- follow-up if +► Aspirin can be discontinued if no coronary artery Aspirin can be discontinued if no coronary artery

aneurysms have been detected by 6 weeks afteraneurysms have been detected by 6 weeks afterillness onset.illness onset.

3) Take Home Message3) Take Home Message

► Many childhood illness have similar Many childhood illness have similar presentations & appearance – know the presentations & appearance – know the differentialsdifferentials

► Know how to describe a rash & ask pattern Know how to describe a rash & ask pattern etc.etc.

► Thorough exam for every child (elicit cause & Thorough exam for every child (elicit cause & out-rule critical illnesses)out-rule critical illnesses)

► ? Viral vs Bacterial? Viral vs Bacterial

Not discussed this lectureNot discussed this lecture

►UTIUTI►SepsisSepsis►MeningitisMeningitis►URTIURTI►LRTILRTI► Joint infectionsJoint infections

3) Antibiotic Choices3) Antibiotic Choices

Dr. D BarryDr. D Barry

General RulesGeneral Rules

►Most Hospital have formulary with Most Hospital have formulary with recommendationsrecommendations

► If recurrent infections – check previous If recurrent infections – check previous culture growth & sensitivitiesculture growth & sensitivities

► If long-term patient – check colonisation If long-term patient – check colonisation history ? MRSA / VRE / C. diff. etc.history ? MRSA / VRE / C. diff. etc.

►Otherwise, empiric therapy while Otherwise, empiric therapy while awaiting septic work-up results (C+S)awaiting septic work-up results (C+S)

ConditionCondition Likely BacteriaLikely Bacteria Antibiotic ChoiceAntibiotic Choice Admin.Admin.

Superficial Superficial Skin InfectionSkin Infection

Staph/Strep Staph/Strep ββ--haemhaem

Fluclox / BzPenFluclox / BzPen PO > IV 5-PO > IV 5-7/77/7

Cellulitis Cellulitis Staph/Strep Staph/Strep ββ--haemhaem

Fluclox / BzPenFluclox / BzPen IVIV

Necrotising Necrotising FasciitisFasciitis

Strep Strep ββ-haem-haem BzPen / Clinda / BzPen / Clinda / GentGent

IV IV DebridementDebridement

Bite WoundsBite Wounds Pasteurella Pasteurella species, oral species, oral anaerobes. anaerobes.

Co-amoxiclavCo-amoxiclav Po x 5/7Po x 5/7

Surgical Surgical WoundsWounds

Staph/Strep Staph/Strep ββ--haemhaem[? Clostridia etc][? Clostridia etc]

Fluclox / BzPenFluclox / BzPen[+/- clinda / [+/- clinda / ceftaz.]ceftaz.]

IV IV ??debridement debridement

OsteomyelitisOsteomyelitis Staph/Strep Staph/Strep ββ--haemhaem? Pseudomonas ? Pseudomonas (post- penetrating (post- penetrating injury)injury)

Fluclox IV, fusidic Fluclox IV, fusidic popo

Ceftazidime + GentCeftazidime + Gent

6 weeks IV 6 weeks IV txtx

Septic Septic ArthritisArthritis

Staph/Strep Staph/Strep ββ--haem pneumo-/ haem pneumo-/ meningo-meningo-

Fluclox+ fuscidic Fluclox+ fuscidic acid/acid/Cefotaxime/Cefotaxime/Ceftriax.Ceftriax.

IV x 14/7 IV x 14/7 minmin

ConditionCondition Likely BacteriaLikely Bacteria Antibiotic ChoiceAntibiotic Choice Admin.Admin.

SepsisSepsis Meningo / pneumo – Meningo / pneumo – others…others…

Ceftriaxone / Ceftriaxone / cefotaxcefotaxVancomycinVancomycin(*+ (*+ rifampicinrifampicin prophylaxis for prophylaxis for meningococcal contacts)meningococcal contacts)

IV x 7-14/7IV x 7-14/7

Central Central Line SepsisLine Sepsis

Staph / GNB / Staph / GNB / candida / candida / pseudomonaspseudomonas

Vanc + GentVanc + Gent+/- anti-fungal+/- anti-fungal

IV, +/- locks, IV, +/- locks, ? Remove line?? Remove line?

Abdominal Abdominal SepsisSepsis

E-Coli / enterococci / E-Coli / enterococci / Anaerobes Anaerobes

Amox. + Gent. + Amox. + Gent. + MetronidazoleMetronidazole

Infective Infective EndocarditiEndocarditiss

Staph / strep viridans / Staph / strep viridans / enterococcienterococci

Fluclox / BzPen Fluclox / BzPen (amox) + Gent(amox) + Gent

IV x 6/52IV x 6/52

MeningitisMeningitis?encephalitis

Meningo-/ Pneumo- / Meningo-/ Pneumo- / Nb? Herpes encephalitis?(* GBS, E-coli, listeria, in (* GBS, E-coli, listeria, in <3/12)<3/12)

Ceftriaxone / Ceftriaxone / cefotaxcefotax+/- Vanc./ +/- Vanc./ acyclovir(* + Amp/Gent for (* + Amp/Gent for <3/12)<3/12)

IV x 7-14/7IV x 7-14/7

VP shunt/ VP shunt/ ventriculitiventriculitiss

Staph aureus/ Staph aureus/ epidermidis, coliformsepidermidis, coliforms

Ceftazidime + Ceftazidime + VancVanc

Febrile Febrile NeutropeniNeutropenia a (*(*eg chemo.)eg chemo.)

GNB, staph (coag -), GNB, staph (coag -), strep, fungal strep, fungal (candida/aspergillus)(candida/aspergillus)

Piperacillin/Piperacillin/tazobact. & tazobact. & GentamicinGentamicin+/- vanc/teicoplanin+/- vanc/teicoplanin

+/- amphotericin B+/- amphotericin B

IVIV

ConditionCondition Likely BacteriaLikely Bacteria Antibiotic ChoiceAntibiotic Choice AdminAdmin

URTI;URTI; OM / OM / pharynx/ pharynx/ tonsils/sinusittonsils/sinusitisis

*? Viral**? Viral*Strep / staph / Strep / staph / moraxella / moraxella /

Amox / co-Amox / co-amoxiclavamoxiclav*Strep throat*Strep throat; ; PenicillinPenicillin

Be dubious!Be dubious!

LRTI;LRTI; tracheitistracheitis/epiglottitis /epiglottitis

H. Influenza / H. Influenza / Staph/ StrepStaph/ Strep((ββ--haem,pneumo)haem,pneumo)

Cefuroxime / Cefuroxime / CefotaxCefotax

IV 10-14 /7IV 10-14 /7

Community Community Acquired Acquired PneumoniaPneumonia

Strep pneumo, Strep pneumo, ****Atypical; Atypical; mycoplasma mycoplasma chlamydiachlamydia

CefuroximeCefuroxime+/- clarithromycin+/- clarithromycin

PO or IVPO or IV

CF with CF with PneumoniaPneumonia

Staph/ Staph/ Pseudomonas Pseudomonas /Serratia /Cepacia /Serratia /Cepacia etcetc

Ceftaz, Ceftaz, TobramycinTobramycin* Check previous C+S ** Check previous C+S *

LRTI with LRTI with effusioneffusion

Strep PneumoStrep Pneumo? Staph, ? Staph, mycoplasma, TBmycoplasma, TB

CefuroximeCefuroxime+/- clarithromycin+/- clarithromycin

Up to 4/52Up to 4/52

Cavitating Cavitating LRTILRTI

Staph, Staph, ? Klebsiella ? TB? Klebsiella ? TB

Fluclox + Fluclox + clindamycinclindamycin

>14/7>14/7

4) 4) ImmunodeficienciesImmunodeficiencies

►Suspect in recurrent, severe/invasive Suspect in recurrent, severe/invasive or unusual infectionsor unusual infections

►Persistent Diarrhoea +/- rashPersistent Diarrhoea +/- rash

►Which type/site of infection?Which type/site of infection?

►Which cells immunodeficient?Which cells immunodeficient?

Immune Work-upImmune Work-up

►FBC & differentialFBC & differential►Lymphocytes & subsetsLymphocytes & subsets► Immunoglobulins & subclassesImmunoglobulins & subclasses►Complement (classic & alternate)Complement (classic & alternate)►+/- OBT, vaccine a/b response+/- OBT, vaccine a/b response►HIV testHIV test

Inherited vs. AcquiredInherited vs. Acquired

► Consider if + FHx or Consider if + FHx or consanguinity consanguinity

► Many associated Many associated with hypersensitive with hypersensitive rashesrashes

Eg.Eg. IgA deficiencyIgA deficiency DiGeorge syndromeDiGeorge syndrome

► HIV infectionHIV infection► DrugsDrugs► Bone marrow Bone marrow

infiltration/failure & infiltration/failure & Lymphoproliferative Lymphoproliferative dxdx

HIVHIV

►HIV – lentivirusHIV – lentivirus► Infects CD4+ T lymphocytes & mInfects CD4+ T lymphocytes & mØØ►This results in reduction of cell-This results in reduction of cell-

mediated immunity and secondary B-mediated immunity and secondary B-cell dysfunctioncell dysfunction

►This immunocompromised state may This immunocompromised state may the lead to proliferation of opportunistic the lead to proliferation of opportunistic infections and malignancies (AIDS)infections and malignancies (AIDS)

HIV globalHIV global

► 33 mil prevalence (33 mil prevalence (2.1 mil children2.1 mil children))► 2.5mil incidence (2.5mil incidence (420,000 children / year420,000 children / year))► 2.1mil mortality (300,000 < 15 years)2.1mil mortality (300,000 < 15 years)► 11.4 mil AIDS orphans11.4 mil AIDS orphans

► >90% children perinatally infected>90% children perinatally infected► 15-25% rapid progressors (AIDS/death <1 15-25% rapid progressors (AIDS/death <1

yr)yr)► 25% intermediate (AIDS/death by 5 years)25% intermediate (AIDS/death by 5 years)► 50% slow progressors – survive to 10 years50% slow progressors – survive to 10 years

HIV in childrenHIV in children

►Children more susceptible to HIVChildren more susceptible to HIV► Immature immune systemImmature immune system►Developing brainDeveloping brain►Often poor social backgroundOften poor social background►Co-infections; esp TB., hepatitis etc.Co-infections; esp TB., hepatitis etc.

Prognostic IndicatorsPrognostic Indicators

►CD4 count, CD4 % (more sensitive < CD4 count, CD4 % (more sensitive < 5yrs)5yrs)

►Viral LoadViral Load►Nutrition StatusNutrition Status►HbHb►SymptomsSymptoms►Viral Suppression with ARTViral Suppression with ART

Clinical PresentationsClinical Presentations

1)1) Screening asymptomaticScreening asymptomatic (at risk) children (at risk) children

2)2) Symptoms of HIVSymptoms of HIV (non-AIDS defining illness) (non-AIDS defining illness)► persistent fever, diarrhoea, persistent fever, diarrhoea, ► intractable thrush, intractable thrush, recurrent infectionsrecurrent infections (LRTI) (LRTI)► chronic parotitis, Mucocutaneous eruptions chronic parotitis, Mucocutaneous eruptions ► generalised lymphadenopathy, generalised lymphadenopathy, ► delay in development with failure to thrivedelay in development with failure to thrive

3)3) AIDS; opportunistic infections etc.AIDS; opportunistic infections etc.

Mother to Child TransmissionMother to Child Transmission

Reducing Risk MTCTReducing Risk MTCT

►Pre-natal; HAART for MumPre-natal; HAART for Mum►Peri-natal; elective C/section (esp. if Peri-natal; elective C/section (esp. if

↑↑VL)VL) ART (zidovudine) during labourART (zidovudine) during labour

►Post-partum; triple ART x 4-6/52Post-partum; triple ART x 4-6/52 Monitor LFTs & FBCMonitor LFTs & FBC

►Breast-feeding not recommendedBreast-feeding not recommended

Infants born to HIV+ mothersInfants born to HIV+ mothers

► Antenatal booking bloods for MumAntenatal booking bloods for Mum HIV a/b, CD4, VLHIV a/b, CD4, VL

► HIV A/bHIV A/b day 1, at 6/12 & day 1, at 6/12 & 18/1218/12 (maternal a/b crosses placenta)(maternal a/b crosses placenta)

► HIV PCRHIV PCR day 1, 6/52, 3/12, day 1, 6/52, 3/12, 6/126/12

► Vaccinations;Vaccinations; Hep A, Hep BHep A, Hep B Defer BCG until HIV testing complete & Defer BCG until HIV testing complete &

negativenegative Normal Immunisation schedule otherwiseNormal Immunisation schedule otherwise

Considerations for children with Considerations for children with HIVHIV

► Screening & diagnosing HIV in children & Screening & diagnosing HIV in children & implications for familyimplications for family

► Effect of HIV on developmentEffect of HIV on development► Effect of treatment on child (toxicity)Effect of treatment on child (toxicity)► Compliance & risk of resistance with long-Compliance & risk of resistance with long-

term therapyterm therapy► Disclosure of child’s HIV status to childDisclosure of child’s HIV status to child► Disclosure of family member’s status to Disclosure of family member’s status to

childchild

4) Summary4) Summary

►Suspecting immunocompromised Suspecting immunocompromised patientpatient

► Immune work-upImmune work-up

►HIV; risks of transmission & preventionHIV; risks of transmission & prevention

► CellulitisCellulitis

Local swellingLocal swelling

s/c tissues/c tissue

? systemic disease, ? systemic disease, LNLN

Entry point & source; Entry point & source; bites / grazes etc.bites / grazes etc.

IV fluclox / BzPenIV fluclox / BzPen

No improvement 24-No improvement 24-484800 ? NF ? ? NF ? unusual / resistant unusual / resistant bacteriabacteria

► Necrotising Necrotising FasciitisFasciitis

Pain > findingsPain > findings

Woody indurationWoody induration

↓ ↓ sensationsensation

ToxicToxic

X-ray; ? Gas in soft X-ray; ? Gas in soft tissuetissue

Surgical explorationSurgical exploration

HD IV a/bHD IV a/b

SinusesSinuses

Maxillary & Ethmoid @ Maxillary & Ethmoid @ birthbirth

Sphenoid Sphenoid (pneumatises @ 2-3 (pneumatises @ 2-3 yrs)yrs)

Frontal Frontal (pneumoatises @ 3-7 yrs)(pneumoatises @ 3-7 yrs)

Complete by 12 years!Complete by 12 years!

SinusitisSinusitis

► Acute; fever > 3/7, purulent dischargeAcute; fever > 3/7, purulent discharge +/- headache, tenderness (still viral > bacterial)+/- headache, tenderness (still viral > bacterial) Strep pneumo, haemophilus, moraxellaStrep pneumo, haemophilus, moraxella

► Chronic; prolonged discharge & cough > 10/7Chronic; prolonged discharge & cough > 10/7 S aureus, anaerobesS aureus, anaerobes

► X-ray (if chronic & ? DD) X-ray (if chronic & ? DD) < 6 years; AP & lat [max / ethmoid]< 6 years; AP & lat [max / ethmoid] > 6 years; lat view [frontal / sphenoid]> 6 years; lat view [frontal / sphenoid] ? Sinus opacification / mucosal thickening / air-? Sinus opacification / mucosal thickening / air-

fluid levelfluid level► Treat until resolution of symptoms + 7/7 afterTreat until resolution of symptoms + 7/7 after► PO Amox / Co-amoxiclavPO Amox / Co-amoxiclav