infectious diseases emergencies
TRANSCRIPT
Antibiotic Choices for Infections which Require Hospitalization
Rodolfo E. Bégué, MD
Chief, Infectious Diseases
Pediatrics, LSUHSC
Infections which require hospitalization
Examples:r/o sepsismeningitis / encephalitisbrain abscess / orbital cellulitispneumonia / endocarditisacute abdomenurinary tract infection bone & jointskin & skin structures
r/o sepsis
• Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis.
• Hyperthermia or hypothermia• Tachycardia• Tachypnea• Leukocytosis or leukopenia
Sepsis work-up
• Cell Blood Count (CBC).
• Urine analysis.
• Chest roentgenogram.
• Lumbar puncture.
• Cultures: blood, urine, stool, CSF
• Other: NPA
• (CRP, Procalcitonin)
Etiologies of Sepsis
< 1 month of age
• Group B Streptococcus
• Escherichia coli
• (Listeria monocytogenes)
1-3 months of age
• Streptococcus pneumoniae (↓)
• Group B Streptococcus
• Neisseria meningitidis
• Salmonella spp
• (Haemophilus influenzae b)
• (Listeria monocytogenes)3-36 months of age
• Streptococcus pneumoniae (↓)
• Neisseria meningitidis
• (Haemophilus influenzae b)
Antibiotics for a child with r/o Sepsis
Empiric Antibiotic Treatment:< 1 month:Ampicillin + Gentamicin
Ampicillin + Cefotaxime1-3 months: Ampicillin + Cefotaxime> 3 months: Cefotaxime
(Vancomycin?)
x 7-14 days
Is it a contaminant?
• 1 vs >2 positive culture
• Pathogen vs no pathogen
• Symptoms vs no symptoms
• Plate vs broth (“thio”)
• Timing
Central Line Infection
• Central & Peripheral Blood Culture
• Gram-positive, Gram-negative, Fungi
• If possible, change line(Staph, Enteroc, GN, Fungi, Mycobact)
• vs treat through line
• If line out: ~ 1 weekIf line in: ~ 2 weeks
• Antibiotic lock
Bacterial Meningitis
• Diagnosis: LP, LP, LP
• Should I do an LP?
• Increased intracranial pressure
• Prior antibiotics
• “Bloody tap”
Bacterial Meningitis: Treatment
• Empiric treatment with:cefotaxime plus vancomycin
• Modify according to susceptibilities:penicillincefotaximevancomycin plus cefotaxime
• Corticosteroids (?)
• Rifampin (?)
Aseptic Meningitis
• Viral (enterovirus vs others)
• “Partially treated”
• Other causes only on special populations
Encephalitis
• Not bacterial
• Viral HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc
• ADEM
HSV Encephalitis
Acyclovir:
60 mg/kg/d div q 8 hr
750 mg/m2/d div q 8 hr
x 21 days IV
Brain abscess
Source:
• Proximity: middle ear, sinuses
• Meningitis
• Hematogenous
• Penetrating: wound, surgery
Brain abscess
Triad:
• Headache
• Focal neurologic findings
• Fever
Treatment:
• Surgery
• Antibiotics: Cefotax + Vanco + (Metro)
• for 4-8 weeks (IV)
Orbital Cellulitis
Triad:
• Proptosis
• Decreased eye movement
• Pain on eye movement
Orbital Cellulitis
Treatment:
• Antibiotics:Cefotax + Vanco + (Metro) Cefotax + Clindax 10-14 d IV and 7-14 d PO
• Surgery (ORL, Ophthalmology)
HSV Keratitis
Management:
• With an ophthalmologist
• antivirals:1-2% trifluridine1% iododeoxyuridine3% vidarabinex 14-21 days
• topical corticosteroids contraindicated
• No need for systemic acyclovir
Pneumonia
• Viral:Influenza, RSV
• BacterialStreptococcus pneumoStaph aureusGroup A Streptococcus
• TB
• ChlamydiaMycoplasma
• Fungal
Empiric Treatment for Pneumonia
• If sick enough to require admission (assuming viral panel negative), the regular r/o sepsis regimen is usually OK:• Ampi + genta / Ampi + cefotax / Cefotax• Usually add a macrolide (erythro or azithro)• Add Vancomycin if VERY sick or necrotizing• Others (TB, Gram-negative, PCP, fungal) only if a
good reason to suspect
Endocarditis• Acute Staph (MRSA)
• Subacute viridans Strept
• Antibiotics: Vanco + gentamicin
• X 2 w, 4-6 w
• Surgery (?)
Pericarditis• “Purulent pericarditis”
• Strept PneumoStaph aureus (MRSA)
• Antibiotics: Ceftriaxone + Vancomycin
• X 4 weeks
• Surgery (?)
Acute Abdomen
Treatment
• Surgery
• Antibiotics
Mild-moderate Severe
Ampi/sulb, Ticar/clav Piperac/Tazobactam
Imipenem, Meropenem, Ertapenem
Cefazolin or cefuroxime+ metronidazole
Cefotax, ceftriax, ceftaz, cefepime+ metronidazole
Gentamicin (Tobra) plus Clinda (Metronidazole) + ampicillin
Cipro, levoflox, gatiflox+ Metronidazole
Aztreonam + Metronidazole
For 5-7 days IDSA. CID 2010;50:133-64
Urinary Tract Infection
• Always suspect in febrile children < 2 yrs of age
• Dx of UTI requires a UCx (bag-specimen not good)
• UA (WBC), dipstick OK as a guide, especially in combination
• Gram stain (“unspun” urine)
Etiology
• Escherichia coli
• Enterococcus
Urinary Tract Infection
Follow-up
• US, VCUG
• DMSA scan
• Consider prophylaxis
Inpatient
• Cefotaxime or Ceftriaxone
• Ampicillin + gentamicin
Septic arthritis
• Fever, joint pain/swelling, decreased ROM
• Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)
Septic arthritis
Treatment:
• Aspirate vs Surgery: hips, shoulders
• Antibiotics:Oxacillin + cefotaximeCefuroxime
• x 3 weeks (IV/PO)
Etiologies:
• Staph aureus
• Streptococcus (GAS, Strept pneumo)
• Kingella kingae
• Neisseria (GC, N. meningitidis)
• (H. influenzae)
Osteomyelitis
• Staph aureus
• (Others in especial populations)
• ClindamycinVancomycinLinezolid
• X 4 weeks (IV/PO)
• Surgery
Puncture wounds (foot)
Etiology
• Staph aureus (~ 3 d)
• Pseudom spp (~ 7 d)
• Mycobacteria (~ 2-4 w)
Treatment
• Wound careTetanus vaccineAnti-Staph antibiotics
• If no responseSurgical exploration → cultureCeftazidime → ciprofloxacin (for 2 w)
Skin and Soft Tissue
• Etiology:Group A Streptococcus Staphylococcus aureus (MRSA)Strep pneumo / Hib
• Treatment:Vancomycin or Clindamycinadd genta or rifampin?linezolid??
• Drain any abscess
D test
• MRSA
• Erythro RClinda S
• D test negative: OK to use Clinda
• D test positive: do not use Clinda
Siberry et al. CID 2003;37:1257-1260