Pediatric Infectious Diseases

Dr.abdulmahi .A.hasan PhD, Pediatric & Mental health nursing

From Lice in the hair to blisters on their feet! Ear, nose, throat Respiratory infections GI Dermal Infections Common Viral Infections Their identification Their Treatment Lice Parasites that infest the head, body and pubic area A whole group of people now who are professional “ Nit pickers!” Not kidding Lice: Pediculus Humanus Spread by close person to person contact Life cycle is Nità Nymph à Adult Adult is the size of a pinhead, is rusty color and clings to hair Lice Treatment: Permethrin 1% cream rinse applied to clean dry hair and left on for 10 min. Repeat in 1 wk OR Ovide applied to dry hair for 8-14 hours then rinse OR a professional Nit picker in conjunction with the above. They use special fine tooth combs through every strand of hair. It’s costly though $330.00 for 3 sessions!!!!! The Eyes Have It! Conjunctivitis Etiology Acute conjunctivitis usually a bacterial or viral infection Characterized by a rapid onset Several days duration Common bacterial causes Nontypable H. influenza S. pnuemoniae M. catarrhalis N. gonorrhoeae P. aeruginosa Incubation 24-72 hours Conjunctivitis Common viral causes: Adenoviruses Coxsackieviruses Enteroviruses Herpes simplex Incubation 1-14 days Epidemiology Common in young children, especially if in contact with other children with conjunctivitis. Predisposing factors for bacterial infection include Nasolacrimal duct obstruction Sinus disease Ear infection Allergic children who rub their eyes frequently Allergic Seasonal, itchy, bilateral chemosis Conjunctivitis Clinical Manifestations Symptoms include Redness Discharge Matted eyelids Mild photophobia Foreign body sensation Physical examination findings include Chemosis Injection of the conjunctiva Edema of the eyelids Conjunctivitis Diagnosis Cultures are not routinely obtained because bacterial conjunctivitis is usually self-limited or responds quickly to antibiotic treatment. Treatment for bacteria Topical quinolone solution Trimethoprim-polymyxin B solution Sulfacetamide 10% solution Erythromycin ointment Conjunctivitis Treatment for viral Self limited Treatment for allergic Antihistamine, topical anti-inflammatory, cromalyn The Ears Have It ? Acute Otitis Media Etiology Arises as a complication preceding viral respiratory infection Secretions and inflammation cause occlusion Effusion fertile media for microbial growth

2 Rapid growth leads to infection Acute Otitis Media Etiology Suppurative infection of the middle ear cavity Common bacterial pathogens achieve access through blocked eustachian tube (infection, pharyngitis, or hypertrophied adenoids) Air trapping → negative pressure → bacterial reflux Bacterial reflux + obstructed flow → effusion Acute Otitis Media Common bacterial pathogens are S. pnuemoniae Nontypable H. influenza M. catarrhalis Group A streptococus Sterile effusions occur in approximately 20% of cases Acute Otitis Media Epidemiology One third of office visits to primary care. The peak incidence - second 6 months of life. By the first birthday, 62% of children experience at least one episode. Few first episodes after 18 months Acute Otitis Media More common in boys Lower socioeconomic status Seasonal disease (distinct peak in January and February) Corresponds to the rhinovirus, RSV, and influenza seasons Is less common from July to September Major risk factors for acute otitis media are Young age Bottle feeding Drinking a bottle in bed Parental history Sibling history Second hand smoke Daycare Acute Otitis Media Clinical Manifestations Symptoms often nonspecific, may include: Fever Irritability Poor feeding Otalgia Otorrhea Signs of a common cold Acute Otitis Media Diagnosis

3 Pneumatic otoscopy – standard for clinical diagnosis tympanic membrane is characterized by hyperemia Can be pink, white or yellow with bulging Poor mobility with negative or positive pressure Acute Otitis Media The light reflex is lost - middle ear structures are obscured A hole in the tympanic membrane or purulent drainage confirms perforation. Bullae maybe present on the lateral aspect Acute Otitis Media Acute Definition Recent Usually abrupt Signs of acute illness Fever Pain URI Middle ear inflammation Middle ear effusion Chronic Definition Presence of effusion without any other signs and symptoms of acute illness Acute Otitis Media Treatment Recommendations Infants younger than 6 months should receive antibiotics Children 6 months to 2 years should receive antibiotics if the diagnosis is certain Diagnosis uncertain observation period 48 to 72 hours with analgesics and follow up Children 2 years and older should receive antibiotics if diagnosis is certain or illness severe Observation period an option Acute Otitis Media Treatment Amoxicillin – First line therapy Second line therapy Amoxicillin-clavulanate Cefuroxime axetil Cefdinir ceftriaxone Say Aah! Pharyngitis Etiology Caused by many infectious agents Most common bacterial

4 Group A streptococci (Strep pyogenes) Group C beta hemolytic streptococcus Group G streptococci Neisseria gonorrhoeae Most common viral Rhinovirus Adenovirus Influenza A and B Parainfluenza Coxsackievirus Coronavirus Echovirus Herpes simplex virus EBV CMV Pharyngitis Diagnosis The challenge is to distinguish pharyngitis caused by group A streptococci from pharyngitis caused by nonstreptococcal organisms Throat culture is the diagnostic “gold standard” Rapid streptococcal antigen tests Pharyngitis Epidemiology Relatively uncommon before 2 to 3 years of age Increased incidence school-age children Decreased incidence in late adolescence and adulthood Occurs throughout the year in temperate climates Peaks during the winter and spring Easily spreads to siblings and classmates Pharyngitis Clinical Manifestations Inflammation of pharyngitis causes Cough Sore throat Dysphagia Onset often rapid and associated with Prominent sore throat Moderate to high fever Headache Nausea Vomiting Abdominal pain Pharyngitis Typical, florid case Pharynx is distinctly red Tonsils are enlarged, with a yellow, blood-tinged exudate

5 Petechiae or doughnut-shaped lesions on the soft palate and posterior pharynx may be present Uvula may be red, stippled, and swollen Anterior cervical lymph nodes are tender and enlarged Pharyngitis Treatment Untreated most episodes of streptococcal pharyngitis resolve Antimicrobial therapy accelerates clinical recovery by 12-24 hours Major benefit of antimicrobial therapy is the prevention of acute rheumatic fever Penicillin given orally three or four times daily for a full 10 days MRSA Keep this in mind with any dermal infection! Cutaneous abscesses that are stubborn, and require special treatment MRSA Should culture every abscess to R/O MRSA Important to differentiate due to different treatment protocol, and need for nasal and body eradication MRSA Must I & D if needed, Iodoform packing and dressing’s with bactroban topically Treatment is bactrim or clindamycin PO in children. Can use Doxy in children over 8 y/o Bad infections can require IV medication and hospitalization Contagious to others in household MRSA Eradication Culture Nares Consider culturing groin area in adolescents and adults Bactroban intranasal with q tip BID for 7 days for everyone in house hold to eradicate colonization “ Hibiclens” in shower BID for a period of 2-3 weeks to eradicate colonized areas on body Rotavirus Electron micrograph of rotavirus. I’m Thirsty! Baby being feed oral rehydration. Rotavirus Etiology Invades the epithelium and damages villi of the upper small intestine In severe cases involves the entire small bowel and colon Vomiting may last 3 to 4 days, and diarrhea may last 7 to 10 days Dehydration is common in younger children Primary infection with rotavirus in infancy may cause moderate to severe disease but is less severe later in life Rotavirus Epidemiology

6 Occurs in both developed and developing countries Peaks in the winter each year Highest rate of illness occurs in children 3-24 months of age Fecal oral route is the major mechanism of transmission Rotavirus Clinical Manifestation Fever (low grade) Lethargy Abdominal pain Dehydration Diarrhea is characterized by watery stools, with no blood or mucus Stools may be odorless or foul-smelling Vomiting may be present Dehydration may be prominent Rotavirus Diagnosis CBC BMP UA for specific gravity as an indicator of hydration status Stool specimens Stool cultures Rotavirus Treatment Most infectious causes of diarrhea in children are self-limited Correcting dehydration and electrolyte deficits Rotavirus Prevention Hand washing Diaper changing Water purification Vaccines RotaTeq – pentavalent RV5 (ages 2, 4, 6 mths) Rotarix – RV1 (2 mths and 4 mths) QUICK QUIZ? Rotavirus invades which portion of our intestinal tract? Large intestine Colon Upper small intestine Lower small intestine All of the above KFC Chickenpox (Varicella) Etiology Varicella-zoster (VZV) is a herpesvirus Humans are the only source of infection Chickenpox

7 Epidemiology Person to person Occurs by direct contact with varicella or zoster and respiratory secretions Most common during late winter and early spring Most reported cases occur between the ages of 5 and 9 years Congenital varicella syndrome risk is about 2%, and is greatest in the first trimester Incubation 10 to 21 days after contact Cases most contagious 2 days before the rash appears, until 5 days after new lesions stop erupting Chickenpox Clinical Manifestation Rash has multiple stages Starts on the trunk, followed by head, face, then extremities The appearance of a typical rash that occurs in successive crops of macules, papules, and vesicles is distinctive Diagnosis Immunofluorescence of the vesicular fluid Culture of the vesicular fluid PCR of any tissue of vesicular fluid Chickenpox Treatment Acyclovir, vidarabine, famvir, foscarnet Acyclovir is the drug of choice for children Acetominophen may be used to control fever NO ASPIRIN Immunization Varicella MMRV ???? Impetigo Etiology Superficial skin infection involving almost any part of the body Two forms: bullous and nonbullous Bullous always S. aureus Nonbullous predominantly S. aureus but may also be A B-hemolytic streptococcus Impetigo Epidemiology Warm temperature High humidity Associated with socioeconomic disadvantage, especially crowding Most common bacterial skin infection in children Rare under 2 years of age; most common between 2 and 7 years of age Impetigo Clinical Manifestation

8 Bullous: transparent bullae that rupture easily, leaving a rim surrounding a shallow ulcer; normal surrounding skin; regional adenopathy rare Nonbullous: papule or vesicle progression to a honey-crusted plaque; erythema of surrounding skin; regional adenopathy common Impetigo Diagnosis Clinical diagnosis Treatment First line: cephalexin 50 mg/kg/d in two divided doses Topical Bactraban Altabax QUICK QUIZ? What age group is most susceptible to impetigo? 1 – 2 years 2- 7 years 6- 10 years 7-11 years Forgot the Sunscreen? Roseola Etiology A common illness in preschool aged children characterized by fever lasting 3 to 7 days followed by rapid defervescence and the appearance of a blanching maculopapular rash lasting only 1 to 2 days Major cause appears to be human herpesvirus 6 (HHV6) Human herpesvirus 7 (HHV7) may also play a role Roseola Epidemiology Occurs throughout the year Commonly affects children 3 months to 4 years The peak age 7 to 13 months 90% of cases occur in the first 2 years of life Affects males and females equally Incubation period is 5 to 15 days Roseola Clinical Manifestation Rash appears as fever disappears and last 1 to 2 days Cough Coryza Children remain alert and are not ill appearing Eyelid edema has been noted Lymphadenopathy Roseola Diagnosis Clinical History very important (telltale rash)

9 Can check blood test Treatment Supportive care Hand Foot Mouth Disease Enterovirus family Coxsackie virus A16 infection MCC Sores in mouth with associated blisters on hands and feet classically May only have sores in mouth on exam in a lot of cases Hand Foot Mouth Can’t catch it from animals! Mostly in children under 10 yo Spread to other children through hand contamination 3-7 day incubation period Hand Foot Mouth Exam shows ulcers or blisters in the pharynx, lips and or tongue Fevers, loss of appetite, headache Supportive treatment. Control fever, good hydration Has a benign course QUESTION? Predisposing factors for bacterial conjunctivitis include all except? Nasolacromal duct obstruction Sinusitis Asthmatic bronchitis Otitis media Allergic conjunctivitis QUESTION? A diagnosis of acute otitis media includes all of the following except? Fever Middle ear effusion without pain Middle ear inflammation Recent onset Otalgia QUESTION? Below what age is streptococcus pharyngitis rarely seen? 2-3 years 4-5 years 5-6 years 6-7 years 7-8 years QUESTION? Which virus appears to be the major cause of Roseola? Enterovirus Parainfluenza virus Human herpes virus Adenovirus Eptein barr virus

10 QUESTION? During which trimester of pregnancy is varicella of primary concern? Second First Third All the above Not a concern for pregnant women