Common Outpatient Infections Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New...
-
Upload
gabriel-tredway -
Category
Documents
-
view
213 -
download
0
Transcript of Common Outpatient Infections Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New...
Common Outpatient Infections
Rodolfo E Bégué, MD
Chief, Pediatric Infectious Diseases
LSUHSC, New Orleans
Common Outpatient Infections
• Otitis Media• Sinusitis• Pharyngitis• Lymphadenitis• Pneumonia• Urinary tract infection• Diarrhea
• Impetigo/cellulitis• Wounds/bites• Infestations• Fungal• Parasites• Herpes • Exanthems
Otitis Media
Diagnosis
• Acute onset
• Inflammation
• Middle ear fluidNormal
AOM
Otitis Media
Etiology
• Streptococcus pneumoniae Penicillin-susceptible Penicillin-non susceptible
• Haemophilus influenzae (non-typeable)
• Moraxella catarrhalis
Otitis Media
Treatment
• ~ 80% resolve spontaneouslyantibiotics increase resolution to ~ 95%
• Priority to treat is children < 2 years and severe cases
• Drug of Choice:
AMOXICILLIN 80-90 mg/kg/d
Otitis Media
Failure:
• Amoxicillin / clavulanate
• Ceftriaxone (1-3 doses)
• Tympanocentesis
Otitis Media
Alternatives:
• Cefdinir (Omnicef)
• Cefuroxime (Ceftin)
• Cefpodoxime (Vantin)
• Ceftriaxone
• Azitromycin
• Clarithromycin
Recurrent Otitis Media
• 3 episodes in 6 months4 episodes in 12 months
• Check for environmental factors
• Chemoprophylaxis: amoxicillin (20 mg/kg/d) sulfisoxazole (35-70 mg/kg/d)
• Ventilating tubes
Otitis Media with Effusion
• Middle ear fluidNo inflammation
• Must de differentiated from AOM
Normal AOM OME
Management• Intervention only necessary if there is hearing
deficit (bilateral and >20db in “best” ear)• First 3 months:
watchful waiting (>95% will resolve)• After 3 months:
hearing testing (> 20 db?)• > 4 months:
discuss with ENTconsider ventilating tubes
Otitis Media with Effusion
AOMT
• Augmentin
• Ciprodex Ciprofloxacin 0.3% Dexamethasone 0.1%Cipro HC Ciprofloxacin HCl 0.2% Hydrocortisone 1%Floxin Ofloxacin 0.3%
Otitis Externa
• Swimmer’s ear• Staphylococcus aureus, Pseudomonas spp• Cleansing, drying• Neomycin otic solution with polymyxin B and
hydrocortisone (Cortisporin)Ciprofloxacin with hydrocortisone (Cipro HC Otic) Ofloxacin otic solution (Floxin Otic)
• 2% acetic acidGentamicin ophthalmic (Garamycin)Tobramycin opthalmic (Tobrex)
Sinusitis
• Diagnosis is clinical• URI symptoms that
persist > 10 days• URI symptoms that get
worse after 5 days• Sinus pain uncommon
• Do not do plain films• Do not abuse CT
Sinusitis
Etiology:• Similar to AOM
Treatment:• Similar to AOM,
except that duration is ~ 2 weeks (7 d after patient is free of symptoms)
Chronic Sinusitis
• UNCOMMON Suspect• Other etiologies (CF,
anatomical)• Other explanations
(asthma, allergies environmental factors
Pharyngitis
• Viral most common (EBV, rhinovirus, etc)
• Allergies
• Bacterial: Group A Streptococcus Other Streptococcus
Strept Pharyngitis
Diagnosis:
• Clinical > 2 years old, acute onset, fever,
unilateral lymphadenitis, no URI
• Rapid test
• Culture (GAS only vs others)
• Beware of carriers (need ASLO)
Pharyngitis
Treatment:• Penicillin V 250 mg PO bid x 10 days
amoxicillin 40 mg/kg/d div bid x 10 days • Alternatives:
benzathine penicillin G, erythromycin, clindamycin, cephalexin,
• Others:clarithromycin, cefuroxime, cefixime, ceftibuten, cefdinir, cefpodoxime, azithromycin
Generalized
• Viral (EBV)
• Toxoplasmosis
• Syphilis
Single
• Acute:Staph / Strep
• Chronic:Bartonella henselaeMycobacteria
Lymphadenitis
Acute Lymphadenitis
• Clindamycin, cephalexin, macrolide
• US Aspiration
Gorup A Streptococcus Staphylococcus aureus
Chronic (sub-acute) lymphadenitis
• To consider: CBC, EBV, PPD, B. henselae titers, Toxo, others depending on risk factors
• Can treat as for “acute” first• Watch for 2-3 w and re-evaluate• If all negative and not any better, consider
wait vs re-test vs aspiration/incision/excision
B. henselae MAIC M. tuberculosis
CA Pneumonia
Etiologies• Viral
RSVInfluenza
• BacterialStrep pneumoniae
• AtypicalMycoplasmaChlamydiaTuberculosis
Treatment• Amoxicillin (2m- 5 yrs)• Macrolide
ErythromycinAzithromycin
• Antivirals(Oseltamivir)
Urinary Tract Infection
• Not difficult to treat, only difficult to diagnose but the implications of a missed diagnosis may be terrible
• 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
Urinary Tract Infection
Etiology• Escherichia coli• Enterococcus
Treatment• Amoxicillin• TMP / SMX• Cefixime• Quinolone
Follow-up• US, VCUG• DMSA scan• Consider prophylaxis
Acute Gastroenteritis
• “Always” infectious
• Viruses: rotavirus, calicivirus, others
• Bacteria: Campylobacter, Shigella, Salmonella, Yersinia, E. coli
• Antibiotics usually not required, unless diarrhea is dysenteric TMP/SMX, Azithromycin, Quinolones
• Clostridium difficile
Impetigo / cellulitis• Etiology:
Group A Streptococcus Staphylococcus aureus (MRSA)
• Treatment:Bacitracin, Mupirocin, RetapaluminCephalexin, clindamycin, TMP/SMX, erytho, linezolid Drain any abscess
Puncture wounds (foot)
Etiology• Staph aureus (~ 3 d)• Pseudom spp (~ 7 d)• Mycobacteria (~ 2-4 w)
Treatment• Wound care
Tetanus vaccineAnti-Staph antibiotics
• If no responseSurgical exploration cultureCeftazidime ciprofloxacin (for 2 w)
Bites
Etiology• Pasteurella multocida• Eikenella corrodens• Streptococcus spp /
Staphylococcus spp• Neisseria spp /
Corynebacterium spp• Anaerobes
• Polymicrobial
Prophylaxis and Treatment• Wound care
Tetanus shotRabies prophylaxis (?)
• Amoxicillin / clavulanate• clindamycin + TMP/SMX
Fungal Infections
• Oral candidiasisoral nystatin or clotrimazolefluconazole 3 mg/kg qd x 7d
• Tinea corporistopical clotrimazole or terbinafine bid 2-3 w+ fluconazole 3 mg/kg/w x 2-3 w
• Tinea capitisgriseofulvin 10 mg/kg qd x 4-8 wterbinafine 125 mg qd x 4 w (Lamisil)
ParasitesWorms• Enterobius vermicularis
(Ascaris)• Scotch tape test• Mebendazole 100 mg
Pyrantel pamoate 11 mg/kgAlbendazole 400 mg
• All repeat in 1 w
Protozoans• Giardia (Cryptosporidium)• Metronidazole 5 mg/kg q8h x 5-10d
Furazolidone 2 mg/kg q6h x 7-10dAlbendazole 400 mg/d x 5d(Nitazoxanide)
Uncertain significance
Entamoeba coli, Endolimax nana, Iodamoeba butschlii
Blastocystis hominis, Dientamoeba fragilis
Taeniasis• Praziquantel, different doses
Head Lice
Standard:• Permethrin: 1% Nix
(Tx of choice)• Pyrethrins: RID, A-200,
R&C, Pronto, Clear Lice System
• Lindane 1%: Kwell
Upgrade:• Permethrin 5%: Elimite• Malathion 0.5%: Ovide• Crotamiton 10%: Eurax• TMP/SMX PO• Ivermectin PO
200 g/kg
QUESTIONS ?