Download Common Outpatient Infections

Common Outpatient Infections
Rodolfo E Bégué, MD
Chief, Pediatric Infectious Diseases
LSUHSC, New Orleans
Common Outpatient Infections
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Otitis Media
Sinusitis
Pharyngitis
Lymphadenitis
Pneumonia
Urinary tract infection
Diarrhea
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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
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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 ?