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FAMILY MEDICINE
Volume 63, Issue 14
April 14, 2015
COMMON INFECTIONS AND THEIR PREVENTION
Beth Choby, MD, Associate Professor, Department of Medical Education, University of Tennessee College of Medicine, Memphis
Adenovirus: manifestations — acute respiratory illness; epidemic keratoconjunctivitis; pharyngeal conjunctival fever;
acute hemorrhagic cystitis; gastroenteritis; treatment — supportive care; studies have looked at cidofovir, ribavirin, and
ganciclovir in immunocompromised patients; steroid drops
may be helpful for adenovirus keratitis
Rhinovirus: symptoms — nasal congestion; sneezing; rhinorrhea; malaise; cough; sore throat; treatment — supportive care;
counsel about rehydration, hand washing, and that fever may
help inhibit infection
Croup: usually occurs in children between 6 and 36 mo of age
(peaks at age 2 yr; causes — human parainfluenza virus (hPIV)
types 1 and 3 most common; influenza viruses A and B; Mycoplasma and diphtheria infections; signs and symptoms — cough;
low-grade fever; coryza; inspiratory stridor; wheezing generally absent; diagnosis — based on patient history and physical
examination; rarely affects infants <3 mo of age; consider bacterial causes in patients with high-grade fever and toxic appearance; consider foreign body, angioedema, and retropharyngeal
abscess in patients with stridor; treatment — supportive care;
corticosteroids reduce laryngeal edema and decrease risk for
hospitalization and intubation; single dose of steroids recommended in all cases; dexamethasone (0.15-0.60 mg/kg) treatment of choice (lasts ≈72 hr); epinephrine can be considered
for moderate to severe croup
Bronchiolitis: causes — respiratory syncytial virus (RSV)
most common; human metapneumovirus; influenza virus;
adenovirus, hPIV; signs and symptoms — in children <2 yr
of age, symptoms of upper respiratory infection followed by
tachypnea and wheezing; runny nose; cough; nasal flare and
grunting; intercostal retractions; diagnosis — based on patient
history and physical examination; laboratory or radiologic
studies not routinely indicated; management — 2014 American
Academy of Pediatrics (AAP) guidelines recommend against
routine use of bronchodilators; bronchodilators can be continued if documented clinical response seen after first use; should
not be routinely treated with corticosteroids (evidence insufficient); 2014 AAP guidelines recommend against routine use of
ribavirin (consider for, eg, patients with severe RSV bronchiolitis and immunocompromise); use antibiotics only in children
with specific indication of coexisting bacterial infection; chest
physiotherapy no longer routinely recommended; give supplemental O2 therapy if O2 saturation rate <90%; children with
congenital heart or lung disease, and preterm infants should
also receive intramuscular (IM) palivizumab (Synagis; 15/mg/
kg per month for 5 mo)
Parvovirus: patients often asymptomatic or have mild nonspecific cold-like symptoms; fifth disease — most recognizable
Educational Objectives
The goal of this program is to improve prevention and management of common infections. After hearing and assimilating this
program, the clinician will be better able to:
1. Identify common viral and bacterial causes of croup and
bronchiolitis.
2. Recognize manifestations of parvovirus infection.
3. Select patients with otitis media for whom treatment is
appropriate.
4. Cite diagnostic criteria of group A β-hemolytic
streptococcal pharyngitis and infectious mononucleosis.
presentation of parvovirus B19 infection; prodrome includes
coryza, nausea, fever, and headache; “slapped-cheek” rash
with circumoral pallor; after 1 to 4 days, children develop
maculopapular rash on extremities and trunk (can last 1-6
wk); rash generally resolves without sequelae; arthropathy — in adults, proximal interphalangeal and metacarpophalangeal joints symmetrically involved; >80% of children
have knee or ankle involvement; generally does not cause
joint erosion and resolves in 3 wk; can last ≤6 mo in some
women; gloves and socks syndrome — papular-purpuric,
symmetric, painful, hand-and-foot erythema and edema;
physical findings include sharp demarcation at wrists and
ankles (skin above hands and feet generally unaffected);
resolves in 1 to 3 wk; hydrops fetalis — transplacental infection of fetus; fetus most vulnerable during second trimester (fetus can develop severe anemia and myocarditis); in
exposed pregnant women, check IgM antibodies or look for
seroconversion using IgG and perform weekly or biweekly
ultrasonography for next 10 to 20 wk; current guidelines do
not recommend screening pregnant women for parvovirus
Diagnosis and treatment: if patient has erythema infectiosum,
no further diagnostic testing needed; B19-specific antibody
testing and viral DNA testing available; presence of giant
pronormoblasts on peripheral blood smear suggests parvovirus; in patients with normal immune system, sensitivity of
serum IgM testing ≈90% and specificity ≈99%; for patients
with abnormal immune system or patients in transient aplastic crisis, gather viral DNA; most patients require nonsteroidal anti-inflammatory drugs (NSAIDs) for joint pain;
patients who develop aplastic crisis need blood transfusion
and higher acuity of care
Coxsackievirus: member of enterovirus group; causes acute
viral illness and oral vesicular eruptions in mouth, with
involvement of hands, feet, buttocks, and genitalia; coxsackievirus A16 strain most often involved
Enterovirus 71: more likely to cause neurologic sequelae (eg,
aseptic meningitis) and to be associated with vomiting; presentation — sore throat or mouth; malaise; macular lesions
of buccal mucosa develop into erosive vesicles with red or
erythematous halo; fever (38°-39°C) for 24 to 48 hr; diagnosis — laboratory testing generally unnecessary; virus can
be isolated by culture and immunoassay from cutaneous or
mucosal lesions or stool; in more severe cases (with, eg,
neurologic involvement), serotyping may be considered;
outcomes worst in young infants; complications due to dehydration, electrolyte imbalance, or metabolic acidosis; symptoms protracted in immunocompromised children
5. Prescribe appropriate outpatient or inpatient treatment of
pneumonia.
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support,
Audio Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within
the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that
this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported
nothing to disclose.
AUDIO DIGEST FAMILY MEDICINE 63:14
Otitis media (OM): 2014 AAP diagnostic guidelines require
moderate to severe bulging of tympanic membrane (TM), newonset ear pain not due to otitis externa (OE), and mild bulge of
TM associated with <48 hr of onset of ear pain or erythema;
OM with effusion — middle ear effusion with lack of acute
symptoms for acute OM (AOM)
Treatment of AOM: analgesics; important to treat children
before sleep; ibuprofen preferred unless toxicity from acetaminophen likely; topical analgesics; antibiotics for infants
<6 mo of age with severe symptoms (eg, moderate to severe
ear pain, temperature of 102.2°F, ear pain lasting >48 hr) and
children <2 yr of age with bilateral AOM; infants <2 wk of
age with suspected AOM should receive full septic workup
and antibiotic coverage for group B Streptococcus, Chlamydia, and gram-negative enterics; children 6 to 23 mo of age
with unilateral AOM and mild symptoms can be observed;
children >2 yr of age with mild symptoms and unilateral or
bilateral AOM can be treated; 2 in 3 children recover from
AOM without antibiotic use; American Academy of Family
Physicians (AAFP) recommends against treatment of children 2 to 12 yr of age with nonsevere symptoms (observe and
follow up); antibiotic recommendations for AOM — highdose amoxicillin (80-90 mg/kg in divided doses); high-dose
amoxicillin-clavulanate indicated for patients treated with
amoxicillin in past 30 days, children with concomitant conjunctivitis, and patients who need cover for β-lactamase
Children with penicillin allergy: second- and third-generation
cephalosporin (eg, cefuroxime) or single dose of IM or intravenous (IV) ceftriaxone can be used; 3-day injection course
superior to 1-day injection; consider single high dose of
azithromycin (30 mg/kg; consider resistance); trimethoprimsulfamethoxazole no longer considered effective
Otitis externa: “swimmer’s ear”; 98% of cases caused by bacteria (eg, Pseudomonas, Staphylococcus aureus); consider
malignant OE (invasion of surrounding soft tissue and bone) in
older patients with diabetes mellitus; clinical diagnosis based
on mild itching, edema, severe pain, external auditory canal
(EAC) occlusion, and erythema, redness, and tenderness of
pinna and tragus; pain correlates with disease severity; temperature >38.3°C indicates infection likely extending (consider
malignant OE); treatment — topical antibiotic; topical corticosteroids (result in rapid symptom improvement); use of acetic acid alone may require 2 additional days past usual course
of antibiotic treatment; NSAIDs and acetaminophen for pain;
consider opioids for extreme cases; evidence insufficient to
recommend benzocaine (may interact with antibiotic drops); if
TM intact with no hypersensitivity, then neomycin-polymyxinhydrocortisone combination generally considered first-line
therapy; if TM not intact (or uncertain whether TM ruptured),
or if patient may have reactions to aminoglycosides or allergies, ofloxacin or ciprofloxacin combined with dexamethasone
approved for middle ear use; patients improve in 1 to 2 days
with treatment; antibiotics given for 7 to 10 days (≤1 mo for
extensive infection)
Group A β-hemolytic streptococcal (GABHS) pharyngitis: signs and symptoms — sudden onset of sore throat and
temperature >38°C; prior exposure to Streptococcus in preceding 2 wk; anterior cervical nodes; pharyngeal tonsillar
inflammation and exudate; cough, coryza, conjunctivitis, and
diarrhea more likely with viral etiology; Centor criteria — 1
pt for each criterion: absence of cough, presence of swollen or tender anterior cervical nodes, temperature >38°C, and
tonsillar swelling or exudate; 1 pt for age 3 to 14 yr; subtract
1 pt if age >45 yr; if score 0 to 1, patient at low risk (no
further screening or treatment required); if score 2 to 3, perform rapid antigen detection testing (RADT) or obtain throat
culture (gold standard), and treat based on results; if score
>4, treat empirically; AAP and Infectious Diseases Society
of America recommend screening for Streptococcus or throat
culture in all patients at risk, and that children receive routine
backup throat culture when RADT negative (patients with
positive Streptococcus screen or RADT should be treated)
Treatment: antibiotic therapy decreases symptom duration by
≈16 hr, prevents suppurative and nonsuppurative complications (eg, retropharyngeal abscess), and reduces spread of
GABHS pharyngitis; oral penicillin B for 10 days; amoxicillin in children; penicillin G benzathine injection (single
dose of 1.2 million units) for adults; in patients with penicillin allergy, oral erythromycin for 10 days or first-generation
cephalosporin (if no immediate-type sensitivity to β-lactams)
can be used
Infectious mononucleosis: Epstein-Barr virus (EBV) most common cause; symptoms — sore throat; fever; swollen tonsils;
lymphadenopathy; fatigue; palatal petechiae; headaches; body
aches; splenomegaly; rash; symptoms generally last 2 to 4 wk,
but can last longer; Hoagland criteria — fever, pharyngitis,
lymphadenopathy, and >50% lymphocytes and ≥10% atypical lymphocytes on complete blood cell count; confirmation
with serologic testing; heterophile antibody by latex agglutination testing least sensitive in first 2 wk after infection, and less
sensitive in children <12 yr of age; elevated transaminase levels seen in ≈50% of patients; IgG and IgM testing more commonly used (useful in patients with clinical findings suggestive
of infectious mononucleosis and negative heterophile test
results); EBV nuclear antigen testing (not detectable until 6-8
wk after infection); management — hydration; NSAIDs; acetaminophen; lidocaine throat spray, gargle, or throat lozenges;
evidence on acyclovir or ranitidine limited; evidence insufficient to recommend steroids for symptom control; considerations — screen for Streptococcus; amoxicillin or ampicillin
causes rash; risk for splenic rupture 0.1% (athletes should not
participate in contact or collision sports for 3-4 wk after symptom onset; consider ultrasonography if symptoms last >8 wk)
Acute diarrhea: 75% to 90% of cases viral (eg, rotavirus);
≥3 watery or loose stools in 24 hr; cases lasting >14 days
more likely to be parasitic; consider toxins in patients with
neurologic changes; correcting dehydration critical; treatment — BRAT (bananas, rice, apple sauce, toast) diet no longer recommended; avoid water, soda, chicken broth, and apple
juice; rehydration solution with 1:1 ratio of sodium to glucose
recommended; premixed over-the-counter rehydration solution acceptable (10 mL/kg should be added for each loose stool
or vomiting episode); ondansetron reduces need for admission and significantly decreases vomiting; IV fluids (20 mL/
kg bolus with normal saline) and concomitant oral rehydration
for severely dehydrated children; monitor sodium levels and
watch for hypoglycemia; Cochrane Review showed that probiotics decreased diarrhea duration by 1 day when used with
rehydration supplements; antidiarrheals should be avoided;
rotavirus — gastrointestinal symptoms resolve in 3 to 7 days;
provide supportive care (no antiviral agents available); adequate hydration, control of fever and pain; children improve
after 3 to 5 days; bowel lesions improve in 7 to 10 days
Bronchitis: cough primary symptom; pneumonia more likely
with fever, tachypnea, tachycardia, and other lung findings;
90% of cases caused by viruses; routine serologic testing
not indicated unless influenza suspected; consider Bordetella pertussis in patients with cough for >3 wk with known
exposure or paroxysmal cough, or in unvaccinated patients;
treatment — American College of Chest Physicians (ACCP)
recommends against antibiotics for acute bronchitis; in patients
with pertussis, consider macrolide; supportive treatment with
antitussives, expectorants, β2 agonists; according to ACCP
guidelines, no consistent evidence supports use of codeine,
dextromethorphan, or hydrocodone (but can be helpful in
chronic bronchitis); avoid cough or cold preparations in children <6 yr of age; expectorants not highly beneficial (may
benefit wheezing patients); oral or inhaled steroids not thought
to be useful; Pelargonium (geranium) associated with modest
symptom relief
AUDIO DIGEST FAMILY MEDICINE 63:14
Pneumonia: causes include RSV, influenza A, and hPIV, S
pneumoniae, Mycoplasma, and Chlamydia; S aureus and
methicillin-resistant S aureus (MRSA) increasingly common;
diagnosis — tachypnea (negative predictive value ≈98%; positive predictive value ≈20%); fever, retractions, nasal flare,
crepitus, and grunting increases likelihood; chest x-rays can
be useful;, pleural effusion and lobar involvement more common with bacterial cause; outpatient treatment — for children
60 days to 5 yr of age, high-dose amoxicillin (80-90 mg/kg per
day in 2 divided doses) for 7 to 10 days; in patients allergic to
penicillin, options include azithromycin, clarithromycin, cefprozil, cefuroxime, or ceftriaxone (15 mg/kg in 1 IM dose);
for children 5 to 16 yr of age, azithromycin (10 mg/kg per day
on first day, then 5 mg/kg on days 2-5) recommended; admit
infants <4 mo of age unless viral infection or Chlamydia trachomatis pneumonia obvious; consider admission in children
with apnea, grunting, O2 saturation <92%, respiratory rate >70
breaths per min, and poor feeding; chest physiotherapy not useful in infants; inpatient treatment — for children 60 days to 5
yr of age, cefuroxime for 10 to 14 days; if child critically ill,
erythromycin often added to cefuroxime; in children 5 to 16
yr of age, cefuroxime and erythromycin for 10 to 14 days, or
cefuroxime and azithromycin for 5 days
Rotavirus vaccines: 2 available; Advisory Committee on Immunization Practices (ACIP) guidelines — maximum age for first
dose 14 wk and 6 days; minimal interval between doses 8 wk;
should not be started in infants >8 mo of age
Acknowledgments
Dr. Choby’s lecture is from the Audio Digest Family Medicine Board Review Course, a comprehensive review with approximately 60
hours of lectures presented by faculty from a variety of prominent teaching institutions across the country. For more information, please
visit audiodigest.org. The Audio Digest Foundation thanks Dr. Choby for her cooperation in the production of this program.
Suggested Reading
Brigden ML et al: Infectious mononucleosis in an outpatient
population: diagnostic utility of 2 automated hematology analyzers and the sensitivity and specificity of Hoagland’s criteria
in heterophile-positive patients. Arch Pathol Lab Med. 1999
Oct;123(10):875-81; Hauk L: AAO-HNSF Releases Clinical
Practice Guideline on Acute Otitis Externa. Am Fam Physician.
2014 Nov 15;90(10):731-6; Karabel M et al: The evaluation
of children with prolonged cough accompanied by American
College of Chest Physicians guidelines. Clin Respir J. 2014
Apr;8(2):152-9; King-Schultz LW et al: Stridor is not always
croup. Pediatr Emerg Care. 2015 Feb;31(2):140-3; Li F et al:
Correlation of an interleukin-4 gene polymorphism with susceptibility to severe enterovirus 71 infection in Chinese children. Arch
Virol. 2015 Feb 10 [Epub ahead of print]; Nascimento-Carvalho
CM et al: Is there any association of a specific chest X-ray pattern and bacteremia in children with penumonia? J Trop Pediatr.
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This Enduring Material activity, Audio Digest Family Medicine Volume 63,
Issues 1-48, has been reviewed and is acceptable for up to 96.00 Prescribed
credit(s) by the American Academy of Family Physicians. AAFP certification begins January 1, 2015. Term of approval is for one year from this date.
Each issue is approved for 2.00 Prescribed credits. Credit may be claimed for
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Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s (ANCC’s)
2002 Aug;48(4):253-4; Nikolopoulos TP: To give or not to
give antibiotics in non-severe acute otitis media? The American
Academy of Pediatrics guidelines that do not guide. Int J Pediatr Otorhinolaryngol. 2014 Jul;78(7):983-4; No authors listed:
Rotavirus vaccines WHO position paper: January 2013 — Recommendations. Vaccine. 2013 Dec 16;31(52):6170-1; Roggen
I et al: Centor criteria in children in a paediatric emergency
department: for what it is worth. BMJ Open. 2013 Apr 22;3(4);
Sandkovsky U et al: Adenovirus: current epidemiology and
emerging approaches to prevention and treatment. Curr Infect
Dis Rep. 2014 Aug;16(8):416; Shatizadeh S et al: Epidemiological and clinical evaluation of children with respiratory virus
infections. Med J Islam Repub Iran. 2014 Sep 22;28:102; Walsh
P, Rothenberg SJ: American academy of pediatrics 2014 bronchiolitis guidelines: bonfire of the evidence. West J Emerg Med.
2015 Jan;16(1):85-8.
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AUDIO DIGEST FAMILY MEDICINE 63:14
COMMON INFECTIONS AND THEIR PREVENTION
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To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. Which of the following viruses is the most common cause of croup?
(A) Human parainfluenza virus **
(C) Adenovirus
(B) Enterovirus
(D) Bocavirus
2. Which of the following is routinely recommended for treatment of bronchiolitis?
(A) Bronchodilators
(C) Chest physiotherapy
(B) Corticosteroids
(D) None of the above **
3. Choose the correct statement about parvovirus.
(A) Fifth disease most recognizable presentation of parvovirus B19 infection **
(B) Associated arthropathy causes joint erosion
(C) Gloves and socks syndrome resolves in 1 to 3 mo
(D) Current guidelines recommend parvovirus screening for all pregnant women
4. Coxsackievirus infection most commonly causes an acute viral illness manifested by:
(A) Sneezing and rhinorrhea
(C) Oral vesicular eruptions in the mouth**
(B) Hydrops fetalis
(D) Keratoconjunctivitis
5. Which of the following is no longer considered effective for treatment of otitis media?
(A) Amoxicillin
(C) Ceftriaxone
(B) Trimethoprim-sulfamethoxazole **
(D) Azithromycin
6. Which of the following is first-line therapy for otitis externa in patients with an intact tympanic membrane and no
hypersensitivity?
(A) Acetaminophen
(B) Benzocaine
(C) Neomycin/polymyxin/hydrocortisone combination **
(D) Ciprofloxacin
7. When using Centor criteria for group A β-hemolytic streptococcal pharyngitis, 1 pt is subtracted for:
(A) Absence of cough
(B) Age >45 yr **
(C) Presence of swollen or tender anterior cervical nodes
(D) Temperature >38°C
8. Which of the following therapies for symptoms of infectious mononucleosis is not adequately supported by data?
(A) Hydration
(B) Nonsteroidal anti-inflammatory drugs (NSAIDs)
(C) Lidocaine throat lozenges
(D) Corticosteroids **
9. Which of the following should be avoided when treating acute diarrhea and dehydration?
(A) Antidiarrheal agents **
(B) Premixed over-the-counter rehydration solution
(C) Ondansetron
(D) Probiotics
10. Which of the following has a 98% negative predictive value for pneumonia?
(A) Intercostal retractions
(C) Tachypnea **
(B) Crepitus
(D) Apnea
Answers to Audio Digest Family Medicine Volume 63, Issue 12: 1-B, 2-A, 3-A, 4-B, 5-C, 6-C, 7-A, 8-C, 9-A, 10-B
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