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Pediatric 10 CLIPP Case
Terms in this set (49)
Time frame of fever arising from vaccine
about 14-16 days from live-attenuated vaccine
Inactivated/toxoid vaccine = a few days
(generally not a cause of fever, should be a dx of exclusion)
Outline kernigs sign
Severe stiffness of the hamstrings causes an inability to extend leg when the hip is flexed to 90 degrees. (sign of meningitis, may not be positive in infants with meningitis) (Kernig starts with K --> knee)
Outline Brudzinski's sign
Brudzinski's sign is flexion of the hip and knee in response to flexion of the neck by the examiner. (sign of meningitis)
What is nuchal rigidity and what type of posturing can result in severe cases
Nuchal rigidity refers to involuntary resistance to neck flexion when the clinician flexes a patient's neck forward. In severe cases, increased extensor tone of neck and spine leads to hyperextension of the entire spine or "opisthotonos."
What is the DTaP vaccine? What type of vaccine is it?
Diphtheria, Tetanus, Pertussis. Inactivated vaccine
What is the PCV13 vaccine? What type of vaccine is it?
Pneumococcal conjugate vaccine (protects against 13 serotypes). Inactivated vaccine
Timing of fever for inactivated, subunit, or toxoid vaccines? Give examples
few days after administration (ex: PCV13 and DTap)
Timing of fever for live attenuated vaccine? Give example.
Virus in vaccine replicates, then induce immune response --> 6-14 days (ex: MMR and varicella)
Definition of "fever without a source" major and minor cause
term used to describe a fever after a complete history has been obtained and a detailed physical examination performed, and there is no identified source of the child's fever. Majority of causes is viral syndrome, minority have serious bacterial illness (SBI)
Etiologies of SBI (which is most common)
Urinary tract infection (UTI) - most common
Bacterial gastroenteritis Osteomyelitis
Which vaccine has significantly lowered the rates of SBI
What are the early guidelines for managing a fever without a source?
CBC, blood culture, empiric ABx if WBC > 15,000. Generally not necessary however given the vast majority of immunized, immunocompetent pts. will not have bacteremia.
Majority of infants with bacterial meningitis will not have a positive what two signs? What will they present with?
majority will not have a positive kernigs or brudzinski's sign.
Paroxysmal crying (crying when picked up) Poor feeding
What are indications for an LP
However, if a febrile infant demonstrates meningeal signs, you must assume that he or she may have meningitis and perform a lumbar puncture.
Outline how you would interpret an elevated WBC in a low risk vs a child who is high risk.
In a low-risk child (immunized and well appearing), given the low prevalence of bacteremia in that setting the positive predictive value of the WBC count would be very low. Almost all patients with a positive WBC would be false positives.
It is a piece of the puzzle, however, and in the setting of a child with an increased likelihood of SBI, the elevated WBC and bands increase the likelihood of a SBI.
Give the typical CSF values for bacterial meningitis vs viral meningitis
Glucose Low Normal
Protein Elevated Normal/slight elevated
WBC Elevated Elevated
Predom. WBC PMN Lymphocytes
Gram Stain Positive or neg Negative
When would parenteral admin of Abx for a UTI be indicated
inability to retain oral meds and/or poor compliance
Most common cause of UTI in pt. who has not recently been on Abx
E.Coli (85-90%), remainder = gram neg enteric bacteria (klebsiella or proteus) or enterococcus
Top 5 parenteral Abx for Pyelonephritis
Ampicillin/gentamicin, Ceftriaxone, Meropenem, Ciprofloxacin,
Overview of ampicillin/gentamicin for pyelonephritis treatment
Resistance rates of ampicillin to E. coli are rising, so ampicillin alone would not provide adequate coverage. (If sensitivity testing shows that the E. coli is sensitive to ampicillin, then ampicillin alone would be effective.)
When combined with gentamicin-which has excellent activity against coliforms-it is a good option for the treatment of pyelonephritis.
Ampicillin is also a good choice to treat enterococci.
Overview of ceftriaxone for pyelonephritis tx
Provides excellent coverage against most gram-negative bacilli (the major exception being Pseudomonas aeruginosa)
Not effective against enterococci
Excellent safety profile in children
Can be given once daily
Calcium-containing medications cannot be given through the same IV line as they may interact with ceftriaxone to form precipitates in the lungs and kidneys
Overview of Meropenem for pyelonephritis tx
Not first-line for Urinary Tract Infections, but may be indicated in regions where there is increasing resistance due to extended-spectrum beta-lactamases (ESBLs).
Overview of Ciprofloxacin for pyelonephritis tx
Can be used, but is not the best choice due to cost and potential adverse reactions in children
Approved for children older than 1 year for complicated UTI with resistant organisms
Top 4 oral Abx for pyelonephritis tx
Cephalexin (keflex), Trimethoprim/Sulfamethoxazole, Nitrofurantoin, Amoxicillin/clavulanate (Augmentin)
Cephalexin (keflex) for pyelo tx overview
Provides good coverage for E.Coli and other enteric gram-negative rods Inexpensive and well tolerated
Trimethoprim/Sulfamethoxazole for pyelo tx overview
The combination of trimethoprim-sulfamethoxazole is effective at treating UTIs, with the exception of Pseudomonas and resistant E.Coli. A rare, but concerning side effect is Stevens-Johnson syndrome.
Nitrofurantoin for pyelo tx overview
An acceptable concentration level is reached only in the urine, not in the blood; therefore, approved only for the treatment of cystitis, not pyelonephritis
Amoxicillin/clavulanate (Augmentin) for pyelo tx overview
Would be effective, but-due to potential for skin and gastrointestinal adverse reactions-would not be the first choice.
What are some factors when prescribing an oral Abx to a pediatric patient
Timing of doses: twice daily dosing is more convenient than 3 or 4 doses per day
Ease of measurement: whole numbers (5 mL rather than 3.5 mL) may facilitate accurate dosing
Volume per dose: smaller volumes may be better tolerated by some children, particularly for medications with a strong or unpleasant taste
What is the work up for a fever without a source?
UA and urine culture (recall UTI is the most common cause of SBI)
CBC with differential: Abnormalities in the WBC count and the differential (such as a "left shift" toward more immature forms) can increase the likelihood that the child has serious bacterial illness.
A previously healthy child who looks well does not require a CBC.
Blood culture: A culture is warranted when a young child is ill appearing or unimmunized/underimmunized.
Lumbar Puncture: A lumbar puncture is indicated when a young child is ill-appearing, unimmunized/underimmunized, and when meningitis cannot be excluded by exam.
Why wouldn't you perform a strep test in the work up of SBI in a child?
Streptococcal pharyngitis is unusual in young children, and acute rheumatic fever rarely occurs in children younger than 3 years of age. Thus, there is no need to perform a throat culture or rapid strep test in children younger than 2 years old.
Three ways to Obtain a Urine Specimen in a Child
Suprapubic aspiration (procedure in which a needle is inserted through the lower abdomen into the bladder and urine is aspirated; this method is used only rarely, when catheterization is not possible)
When infection of the urine must be ruled out in an infant or child who is not toilet-trained, the sample should always be obtained by catheterization.
What are the benefits and drawbacks of "bag urine"
This method can be used in certain instances for the child who has not been toilet-trained and cannot void on demand.
A plastic collection bag with adhesive flaps adjacent to the bag opening is applied to the perineum.
While bagged specimens can be used for screening they have a high rate of contamination and therefore should never be used for culture.
The traditional definition of pyuria uses microscopic analysis, with > 5 WBCs per high-power field (hpf) in a centrifuged urine considered positive. If a counting chamber is used, then > 10 WBCs per microliter in uncentrifuged urine is considered positive.
what is the nitrite test and how do you interpret
A positive nitrite test occurs when gram-negative bacteria, which can reduce urinary nitrate into nitrite, are present in the urine (esp. E. coli, Klebsiella, and Proteus spp) for an adequate amount of time (3-4 hours).
A positive nitrite on urinalysis is extremely helpful: It is highly specific for the presence of bacteria in the urine (few false positives).
A negative nitrite, however, has a very poor sensitivity (lots of false negatives) for bacteruria, especially in young infants who urinate frequently.
What is the leukocyte esterase test and how to interpret
Leukocyte Esterase Test
A positive leukocyte esterase reaction detects esterases released from broken-down leukocytes.
A positive leukocyte esterase usually indicates the presence of white blood cells WBCs in the urine, but pyuria can be seen in a variety of conditions in addition to urinary tract infection. Thus, a positive leukocyte esterase test alone is insufficient to make the diagnosis of a urinary tract infection.
If both nitrites and leukocyte esterase are positive, it is strongly suggestive of a urinary tract infection.
What are three follow up studies after a uti
Ultrasound study of the kidneys and bladder
- Provides information about renal structure and dilatations in the collecting system
- Has replaced the intravenous pyelogram (IVP) for providing this information
- Unless the illness is of unusual severity, or the child is not improving on antibiotics, the ultrasound may be obtained at completion of the antibiotic course.
Renal technetium scan
- Provides evidence of pyelonephritis
- Not required in a patient who has responded well to treatment
Voiding cystourethrogram (VCUG)
- Demonstrates presence of vesicoureteral reflux, an important risk factor for recurrences of urinary tract infections
- Should not be performed routinely in children after a first febrile UTI unless there are findings on the renal and bladder ultrasound that suggest high-grade vesicoureteral reflux, such as hydronephrosis.
-Recommended after a second febrile UTI.
What is on your differential for infant with fever
UTI, Pneumonia, Sepsis/Bacteremia, occult bacteremia, bacterial meningitis, viral meningitis, roseola, primary HSV gingivostomatitis, otitis media, viral URI,
Presentation of UTI
UTI commonly presents as fever and no focus on physical examination and a relatively unremarkable review of systems.
Fussiness and lack of appetite are common associated symptoms
Presentation pf pneumonia
Most children with pneumonia have cough, tachypnea, fever, rales, or low SaO2.
It is unusual (but not impossible) for a child with pneumonia to have no symptoms referable to the respiratory system.
Current guidelines recommend a chest X-ray if a child has respiratory findings and /or a WBC count > 20,000 cells x 103/μL.
Presentation of sepsis/bacteremia
Bacteremia refers to the presence of bacteria in the bloodstream.
Sepsis is a systemic response to an infectious agent, whether bacterial, viral, or fungal. Inflammation occurs in tissues throughout the body, resulting in vasodilation, leukocyte accumulation, and increased capillary permeability.
Fever is usually-but not universally-present; young infants may present with hypothermia. (due to blood shunting)
Children with sepsis generally do not look well.
Early in sepsis an elevated heart rate may be the only vital sign abnormality. Late signs include evidence of end-organ hypoperfusion: poor perfusion (delayed capillary refill), low blood pressure, altered mental status and other evidence of organ failure.
Presentation of occult bacteremia
In contrast to sepsis , the term "occult bacteremia" is applied when there is a positive blood culture in a well-appearing child.
The distinction is made because most children with occult bacteremia will NOT develop a serious bacterial illness (SBI), whereas a child with sepsis represents a medical emergency.
Presentation of bacterial meningitis
This is one of the most worrisome diagnoses to consider.
Both viral and bacterial meningitis occur in children, but typically the symptoms of bacterial meningitis are more severe.
Early in the illness, meningitis can present with fever and no other source of infection.
Most common causes in children are S. pneumoniae and N. meningitidis; remember, the conjugated pneumococcal vaccine protects against only 13 pneumococcal serotypes.
A fully immunized child 3-36 months of age who appears well, has a normal fontanel, and no nuchal rigidity or other signs of meningismus, is very unlikely to have meningitis. Therefore, no LP is needed in this group.
In very young children, the absence of meningismus cannot rule out this diagnosis
Presentation of viral meningitis
Symptoms typically less severe than with bacterial meningitis.
Commonly caused by enterovirus.
May be other symptoms such as loose stools, rashes, or upper respiratory symptoms.
Presentation of roseola
Common viral illness in children under 2 years of age. Caused by human herpes virus 6 (HHV-6).
A high fever is often the only symptom in the first few days of illness and typically lasts for 3 to 5 days.
Some patients develop a rash as the fever resolves; the rash can persist from 1 to 4 days.
Appropriate management for a child with roseola is to reassure the family that no other therapy is indicated.
Presentation of Primary herpes simplex virus (HSV) gingivostomatitis
Usually seen in young children between 10 months and three years. Estimated that only 10 to 30% of perioral HSV infections are symptomatic.
Fever and irritability may be the initial symptoms, but oral lesions that start as vesicles and evolve to ulcerations are seen shortly after the onset of symptoms.
Presentation of otitis media
With an OM poor mobility and at least mild bulging of the tympanic membrane should be demonstrated. Without either of these signs, an OM cannot be diagnosed.
A red tympanic membrane by itself has no positive predictive value.
Presentation of viral URI
Would expect congestion, cough, rhinorrhea.
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