Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 fluid Normal AOM Otitis Media Etiology • Streptococcus pneumoniae Penicillin-susceptible Penicillin-non susceptible • Haemophilus influenzae (non-typeable) • Moraxella catarrhalis Otitis Media Treatment • ~ 80% resolve spontaneously antibiotics 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 • Cefuroxime • Cefpodoxime • Ceftriaxone • Azitromycin • Clarithromycin (Omnicef) (Ceftin) (Vantin) Recurrent Otitis Media • 3 episodes in 6 months 4 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 fluid No inflammation • Must de differentiated from AOM Normal AOM OME Otitis Media with Effusion 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 ENT consider ventilating tubes AOMT • Augmentin • Ciprodex Cipro HC Floxin Ciprofloxacin 0.3% Dexamethasone 0.1% Ciprofloxacin HCl 0.2% Hydrocortisone 1% 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 acid Gentamicin ophthalmic (Garamycin) Tobramycin opthalmic (Tobrex) Sinusitis • Diagnosis is clinical • Do not do plain films • URI symptoms that • Do not abuse CT persist > 10 days • URI symptoms that get worse after 5 days • Sinus pain uncommon 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 Lymphadenitis Generalized • Viral (EBV) • Toxoplasmosis • Syphilis Single • Acute: Staph / Strep • Chronic: Bartonella henselae Mycobacteria 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 RSV Influenza • Bacterial Strep pneumoniae • Atypical Mycoplasma Chlamydia Tuberculosis Treatment • Amoxicillin (2m- 5 yrs) • Macrolide Erythromycin Azithromycin • 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, Retapalumin Cephalexin, 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 vaccine Anti-Staph antibiotics • If no response Surgical exploration culture Ceftazidime 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 shot Rabies prophylaxis (?) • Amoxicillin / clavulanate • clindamycin + TMP/SMX Fungal Infections • Oral candidiasis oral nystatin or clotrimazole fluconazole 3 mg/kg qd x 7d • Tinea corporis topical clotrimazole or terbinafine bid 2-3 w + fluconazole 3 mg/kg/w x 2-3 w • Tinea capitis griseofulvin 10 mg/kg qd x 4-8 w terbinafine 125 mg qd x 4 w (Lamisil) Parasites Worms • Enterobius vermicularis (Ascaris) • Scotch tape test • Mebendazole 100 mg Pyrantel pamoate 11 mg/kg Albendazole 400 mg • All repeat in 1 w Protozoans • Giardia (Cryptosporidium) • Metronidazole 5 mg/kg q8h x 5-10d Furazolidone 2 mg/kg q6h x 7-10d Albendazole 400 mg/d x 5d (Nitazoxanide) Taeniasis • Praziquantel, different doses Uncertain significance Entamoeba coli, Endolimax nana, Iodamoeba butschlii Blastocystis hominis, Dientamoeba fragilis 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 ?