Download Infection

Symptoms, why children were examined at the
emergency unit at the University Children´s Hospital
Vienna (2012)
outpatient
60%
50%
40%
30%
20%
10%
vario
us
cryin
g
cons
t ipat
i on
ma
rash
/ecze
diarr
hea
coug
h
feve
r
0%
admission
The „banal“
Infection
Question to parents: Do you know
simple actions against….?
70
60
50
yes
no
40
30
20
10
0
fe
ve
r
pa
in
di
ar
rh
ea
/
vo
m
iti
ng
Assessement the severity of disease by parents and
nurses (accorting to the Manchester Triage Systeme)
parents
nurse
ning
reate
li fe t
h
very
seve
re
seve
re
mo d
erate
harm
l ess
80%
70%
60%
50%
40%
30%
20%
10%
0%
Drug therapy
symptomatic
vario
us
cry
cons
t ipat
i on
rash
diarr
hea
coug
h
feve
r
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
causal
nothing
2013: 80 cases; 6 deaths in
<3a and 1 in the age of 13a
Which „banal“ decisions must be made
•
•
•
•
•
Acute/chronic
Severe/harmless infection
no/further diagnostics
Immediate treatment in emergency unit
treatment at the ward
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
GCVIGILANCEGCVIGILANCE
Diarrhea and vomiting
Infectious diseases causing
causing diarrhea/vomiting
•
•
•
•
•
Gastrointestinal
Urogenital
ZNS
Respiratorisch
Cardial
Major criteria to identify the child at risk
suffering from diarrhea/vomiting
• Dehydration
general condition
vigilance
skin turgor
fontanelle
eyes: tears, dark eye circles
(Halo)
buccal mucosa: dry
Heart rate/blood pressure
urine production
<5%, 5-10%, >10%-dehydration
Juanita; Uni Münster
Useful laboratory examination in children with
dehydration for further acute management
•
•
•
•
Electrolytes
Blood gas analysis
BUN/Creatinin
Blood glucose
Pathogens
• Bacterial (ca. 5%)
Salmonella
Campylobacter jejunii
Shigella
Amebae; etc.
• Viral (ca. 95%)
Rotavirus
Adenovirus
Norovirus
Enterovirus
…..
Top 10 drugs frequently prescribed by family doctors in gastrointestinal infections
6.06.2014
Drug therapy in gastrointestinal infections
Evidence-based I
• carbon: obsolet
• Probiotics:
- Antibiotics-associated diarrhea (JAMA 2012):
13 patients must be treated to observe benefit in one
subject.(Metaanalysis)
- Infect-associated diarrhea (Cochrane Database of
Systematic Reviews 2010):
Shortening of duration of diarrhea from 3 days to 2.6
days, reduction of stool frequency on day 2 by factor
0.8 and so on
Drug therapy in gastrointestinal infections
Evidence-based II
• Electrolyte-solutions: no effect on duration or severity of
diesease, „gruesome“ flavour.
• Antibiotics: only in septicemia, salmonella infection of the
newborn, severe campylobacter infection,
immunodeficiency, amebae.
Treatment of diarrhea
• < 5%: dietary measures (treatment at home):
NO COCA COLA!!!!
• 5-10%: Compliance, assure that fluid intake is
guaranteed, vigilance/GC
• > 10%: acute life-threating, immediate parenteral
substitution (e.g. 0,9% NaCl 20ml/kg BW)
Symptomatic treatment of fever
• Thermical (cool wraps, vinegar wraps
(heat of evapuration)
• drugs:
Paracetamol
Mefenaminacid
Ibuprofen
Acetylsalicylic acid
Fever-associated symptoms leading to
diagnosis: PAIN
• Head – many causes
• Ear - Otitis media, Parotitis epidemica, Tonsillitis
• sore throat – Tonsillitis, Pharyngitis, Laryngitis
• thoracal - bronchitis, pneumonia, Pleuritis
• abdominal – infection of GIT, urinary tract
infection, pneumonia, infection of the upper
repiratory tract, appendicitis, meningitis
• Micturition – urinary tract infection
Possible other symptoms associated
with fever: likely diagnosis
• rhinitis- infection of the upper respiratory tract
• cough - acute bronchitis, pneumonia, pertussis,
infection of the upper respiratory tract
• dyspnea - pneumonia, bronchiolitis,
wheezy bronchitis
• vomiting – Meningitis/encephalitis,
infection of the GIT, urinary tract infection,
upper respiratory tract infection
• diarrhea – infection of the GIT, urinary tract
infection, upper respiratory tract infection
• cerebral seizures – Meningitis/encephalitis,
febrile convulsion (roseola infantum)
• journey abroad – Malaria, Dengue-Fever
Fever without focus: patients at risk
• Newborns: Infection, diabetes insipidus
• infants: bacterial infections only in 10-15% in the first
year of life, younger than 3 months of age only in 5%
CAVE: OCCULT SEPTICEMIA
• Increased risk for septicemia in the age up to 6 months
if temperature is >40°C, leucocytes are <5000 or
>15000/µl, CRP is increased.
• Hyperpyrexia: Meningitis, septicemia,pneumonia;
(T > 41°C) DD heatstroke
• fever with petechiae: septicemia
Primary care determines prognosis
The first 24 hours determine the outcome
Mortality in Austria 5-10%
DIAGNOSTICS in suspected
meningococcal infection
Obtain blood for blood culture
There is no need for lumbar puncture
– avoid waste of time
ANTIBIOTIC TREATMENT
• Penicilline G i.v. oder i.m.
oder
• Cephalosporine Ceftriaxone 100mg/kgKG i.v. oder i.m.
Treatment guidelines stable child
• Time to hospital ‹ 45 min
Antibiotics i.v. or i.m.
• Time to hospital › 45min
Volume + antibiotics i.v.
Treatment guidelines unstable
child
• VOLUME
20ml/kgKG in 10 min
• -300ml/kgKG/24h
• antibiotics
• intubation
• catecholamine
Conclusion
• Volume i.v.
• Immediate antibiotic treatment ofter
obtaining blood culture
COUGH
• IS A PROTECTIVE REFLEX
• Cough will be induced in the area of
nervus vagus.
COUGH
• Acute – chronic/recurrent
• Patient at risk: yes – no
• Accompanying symptoms (Fever, rhinitis,
pain, and so on)
COUGH
• Signs of hazard: Vigilance, GC, shortness
of breath, tachypnoea, dyspnoea,
cyanosis, accessory muscle use
COUGH – differential diagnosis
Infections
Bronchial hyperreactivity
Aspiration
Psychogenic
Toxic-Environmental
Anomalies
Autoimmune - disease
Tumor
COUGH- Infections
Upper respiratory tract
Lower respiratory tract
Upper and lower respiratory tract
Drug groups used for the
symptomatical treatment of cough
• Mucolytics (N-Acetylcystein, Ambroxol, ivy-extracts):
Cochrane Database Syst Rev 2010 and Cochrane
Database Syst Rev 2002: No benefit in acute respiratory
tract infections in children, side-effects (middle ear
effusion)
• Antitussiva (Codein, Pentoxyferin,Thyme-extract with
alcohol (4%):
Cochrane Database Syst Rev, 2008: should be avoided in
children due to side-effects and blocking of mucociliar
clearance
Symptomatic treatment of cough in
children
• Rhinitis + cough: decongesting nose drops
• Rhinitis + cough + wheeze: decongesting nose drops + inhaled
beta2-Agonists
• Pharyngitis/Tonsillitis + cough: nothing
• Pharyngitis/Tonsillitis + cough + wheeze: inhaled beta2Agonists
• Pneumonia + cough: inhaled beta2-Agonists
• Subglottic laryngitis: cold air, (topical or systemic steroids)
Does the X-ray help us in
identification of the pathogen?
• Radiologic findings are frequently not
associated with the pathogen in acute
pneumonia.
Age as possible evidence to the pathogen
age
bacteria
Virus
newborns
B-Streptoc., E.coli, Listerien,
Haem. infl.
CMV, Rubella, HSV
2.week – 12.week
Strept. pneum., Chlam. trach.,
Bordatella pert., Haem. infl. ->
only 10% of all pneumonia
RSV, Parainfluenza 1-3
Influenza, Adenovirus, CMV
Older
infants/toddlers
Streptoc. pneum., Haem. infl.,
Staph.aur., Mycobacterien,
Meningococcus
RS Virus, Parainfluenza,
Adenovirus., Influenza B,
Rhinovirus
School-aged
children/
adolscents
Mycoplasma pneumoniae
Haem. Infl., Chlamydia pneum.
Adenovirus, EBV,
Parainfluenza, Influenza,
Rhinovirus, RSV
Differenzierung zwischen bakterieller und
viraler/atypischer Pneumonie
Symptoms/results
Bacterial Pneumonia
Virale/atypical Pneumonia
onset
acute
creeping
fever
+++
++(+)
Rhinitis/Pharyngitis
rarely
commonly
dyspnoea
++(+)
+(+)
Myalgia
+
+++
wheeze
- (+)
+(+)
Pleural effusion
More frequent
rare
auscultation
+++
+
Leucozytosis
frequently
Rare (except Adenovirus)
CRP
increased
Normal to slightly increased
ESR
Normal to enhanced
enhanced
Age : Which empiric antibiotics?
age
Outpatient (p.o.)
hopsitalized(i.v.)
newborns
-
Ampicillin/Cefotaxime
Aminoglycoside
infants<6 Mo
-
Cephalosporine (e.g.
Cefotaxime),
Aminopenicilline/Clav.
infants >6 Mo
toddlers
Amox./Clav.
Cephalosporine (Cefuroxim,
Cefpodoxim, Cefixim)
Cephalosporine (e.g.
Cefotaxime),
Aminopenicilline/Clav.
School aged
children
Macrolide (Clarithromycine,
Josamycine)
Cephalosporine (Cefuroxime,
Cefpodoxime, Cefixime)
Amox./Clav.
Cephalosporine
(Cefuroxime, Cefotaxime),
Amox./Clav.
Macrolide