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Group 7 PR: Dia

2014-2015
Dra. Carlos | Date July 25 2014
Pediatrics II
2.1 Bacterial Infections
1st
2014 PEDIATRIC INFECTIOUS DISEASES HIGHLIGHTS
A. Plague
Caused by gram negative coccobacillus Yersinia pestis
Usually through bite of an infected rodent flea
Less common exposures include handling of infected animal
tissues, inhalation of infectious droplets from infected
animals and direct contact
Endemic in rural areas in central and southern Africa, central
Asia and the Indian subcontinent, the northeastern part of
South America, and parts of the southwestern United States.
Best known for the Black Death which killed millions in
Europe during the Middle Ages
July 2014 Yumen, China 30,000 people locked down and
151 placed in quarantine after the death of a 38 year old
victim
Incubation period: 1-6 days. S/Sx of 3 clinical presentations:
Bubonic (most common) rapid onset of fever; bubo (rapid
onset, extremely tender, swollen painful lymph gland)
usually inguinal
Pneumonic (most serious) high fever, pneumonia, bloody
sputum, chills
Septicemic fever, prostration, hemorrhage,
thrombocytopenia, acral gangrene
Y. pestis can be isolated from bubo aspirates, blood cultures,
or sputum culture if pneumonic. With Waysons stain:
bipolar safety pin appearance. Serologic test: F1 antigen.
1
st
line treatment: Parenteral Streptomycin
Alternate: IV Gentamicin; Oral Doxycycline
Typical Scenario
A 17 year old boy who has been camping in Africa complains of fever and swelling in
his groin area. PE shows an enlarged, tender inguinal lymph node and signs of flea
bites on his legs and feet. There are no penile lesions or discharge. Culture of
isolates reveals growing gram-negative rods with a safety pin appearance.

B. MERS-CoV (Middle East Respiratory Syndrome Corona Virus)
Caused by coronavirus called MERS-CoV
Spread by close person-to-person contact
Transmitted by respiratory droplet spread, fomites with
droplets and airborne spread
Incubation period: 2-14 days. S/Sx: viral prodrome - high
fever, chills, headache, feeling of discomfort and body aches
which progresses to severe acure respiratory illness - dry
nonproductive cough, shortness of breath, hypoxia
2
nd
most common cause of respiratory viral infections, next
to rhinovirus
First identified in the Arabian Peninsula from a 60 year old
man who died of severe pneumonia and renal failure
Have been found in camels
Proposed explanation: increased mixing between different
animal species and humans, climate change, intense
international travel, expansion of the immune suppressed
population, and changes in the virus itself to adapt to other
species.
PCR tests with respiratory samples and serology testing
using blood samples is used for identification of MERS-CoV
No specific antiviral treatment
No vaccine to prevent infection
Typical Scenario
A patient develops fever, cough and shortness of breath within 14 days of being in
Saudi Arabia.
C. Vaccine Preventable Diseases
Measles
Goal: eradication. At 9 mos, the cohort is set at 95%. At 15
mos, cohort for MMR is also set at 95%. The Philippines is
only at 88% leaving a 7% gap in our population.
Routine immunization of measles is at 9 mos. Vaccine
efficacy at 6 mos is 50%, at 9 mos is 85 % while at 1 year old
is 95 %. However, we cannot delay giving the vaccine at 1
year old because the attack rate of the measles virus is
higher when the child is less than a year old.
Pneumonia complication of measles which is the most
common cause of death in young children
Subacute Sclerosing Panencephalitis (SSPE) rare
postinfectious neurologic complication of measles
characterized by regressive changes in intellect and
personality. Within months, psychologic symptoms are
compounded by neurologic ones myoclonic jerks, mental
and motor deterioration culminating in extreme neurologic
dysfunction and death.
Pertussis
No pertussis-only vaccine is available. It is available as DTaP.
Waning immunity - getting sick with pertussis or getting
pertussis vaccines doesn't provide lifelong protection
Booster: DTaP
Poliomyelitis
Philippines is a Polio-free country but an evidence below
10% is needed to maintain our polio free status.
Regular submission of 2 stool samples with an interval of
2 weeks after the onset for all patients ages 0-15 years old
who present with weakness, regardless of the cause.

LEADING CAUSE OF MORTALITY WORLDWIDE UNDER 5
YEARS OLD

Figure 1. Distribution of causes of mortality in childern under 5yo.
Under 5 years old Mortality (infant and neonatal) is a good
indicator of the health system of the country.
Infant and neonatal mortalities are the most numerous and
major cause of mortalities. These are tied up with maternal
health.
Pneumonia is the major cause of deaths globally which is
vaccine preventable.
By 2015, the Millennium Developmental Goal 4 is to reduce
Under 5 Mortality to 18,000. According to the National
Statistical Board, the Philippines is on track from the
baseline of 57,000 (1990) to 25,000 (2008). However, MDG
has been extended to 2020.

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LEADING CAUSES OF VACCINE PREVENTABLE DISEASES
WORLDWIDE (2004)
1. Pneumococcal diseases
2. Diarrhea (rotavirus)
3. Measles
4. Haemophilus influenza type B
5. Pertussis
6. Tetanus (neonatal and non-neonatal)
13 Filipino children die every year due to diarrhea

TOP 10 CAUSES OF DEATHS IN THE PHILIPPINES FOR ALL
AGE GROUPS (2009)
1. Diseases of the heart
2. Cerebro-vascular diseases
3. Malignant neoplasm
4. Pneumonia
5. Tuberculosis
6. COPD
7. Diabetes
8. Nephritis/Nephrotic syndrome
9. Assault
10. Perinatal conditions
Pneumonia and tuberculosis are the top infections that can
cause death. The rest are secondary to lifestyle.

TOP 10 CAUSES OF ILLNESSES IN THE PHILIPPINES FOR
ALL AGE GROUPS (2010)
1. ACUTE RESPIRATORY INFECTION
2. ACUTE LOWER RESPIRATORY INFECTION AND PNEUMONIA
3. BRONCHITIS
4. Hypertension
5. ACUTE WATERY DIARRHEA
6. INFLUENZA
7. UTI
8. TB
9. Accidents
10. Injuries
7 out of 10 are caused by infectious diseases.
S. pnemoniae is your gram (+) diplococci with a very thick
capsule and this is the one that renders the organism
virulent. Its thick capsule resists phagocytosis.

IMCI GENERAL DANGER SIGNS
IMCI = Integrated Management of Childhood Illnesses
1. Is the child able to feed, drink or breastfeed?
2. Does the child vomit everything?
3. Does the child have convulsions during the present illness or has
convulsions now?
4. Is the child lethargic or unconscious?
A child with a general danger sign has a serious problem.
URGENT referral to a hospital!!!
Upon initial meeting of the baby, one can already check his
demeanor and ability to ambulate.

ASSESS MAIN SYMPTOM
Cough or difficulty of breathing - check Respiratory Rate for
a full 1 minute
Diarrhea - usually caused by enteric virus such as rotavirus
Ear problem/discharge
Undernutrition and anemia - check for pallor of conjuctiva
and palms
Convulsions - meningeal irritation, meningitis, encephalitis
Check immunization status

Assess other problems.
This is a good opportunity to remind the parents to update
immunizations and to assess for anemia and undernutrition.
When immunization targets fall short, at risk population
increases and accumulates. When someone or a few acquire
the disease, it can affect a whole lot of people causing an
outbreak.
When patients are seen in the ER, they are required to
follow up the next day at the OPD for completion of missed
out data, to chek if diagnosis was right or if the patient
needs to be admitted.

THE CHILD WITH FEVER
In children 4 weeks to 5 years, body temperature should be measured
using either:
rectal thermometer
electronic thermometer in the axilla
infrared tympanic thermometer (best > 3 months)
Fever Requiring Tests
Temp > 38C in infants < 3 months
Temp 39C in infants > 3 months
Fever is a very important symptom for a child.
usually admitted due to fever
common causes of absenteeism: fever, cough, diarrhea
If a patient < 3 months old comes with fever, it is considered severe.
< 3 months is near the neonatal period (some would even
say that 3 months is extended neonatal period)
neonates and patients until 3 months old have the same
pathogens.
age when etiologic agents change (remember that etiologic
agents can be based on age)
Neonates have an immature thermoregulatory center.
Even if a neonate doesnt present with fever, it doesnt
mean that he is well. There are times when the patient is
seriously ill but has no fever immune system if the patient
has not been fully developed yet.
Infants < 3 months with fever who appear generally well;
who have been previously healthy; who have no evidence of
skin, soft tissue, bone, joint, or ear infection; and who have a
total white blood cell (WBC) count of 5,000-15,000 cells/L,
an absolute band count of less than 1,500 cells/L, and
normal urinalysis results are unlikely to have a serious
bacterial infection.
Mothers tend to bring their child early but if you know the
family of the patient and you examine him from time to
time, you may opt not to require tests.
Body Temperature
regulated by thermosensitive neurons located in the
preoptic or anterior hypothalamus that respond to changes
in blood temperature as well as to direct neural connections
with cold and warm receptors located in skin and muscle.
Diurnal Circadian Temperature Rhythm lower body
temperatures in the early morning and temperatures
approximately 1C higher in the late afternoon or early
evening.
Fever
defined as rectal temperature of 38C
a controlled increase in body temperature over the normal
values
Hyperpyrexia temperature of 40 C
Fever patterns per se are NOT often helpful in determining a
specific diagnosis but observing the clinical characteristics of
fever can provide useful information.


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Single isolated fever spike is not associated with an
infectious disease. May be due to the following:
infusion of blood products
drugs procedures
manipulation of a catheter on a colonized or
infected body surface
Temperatures in excess of 41C are most often associated
with a non-infectious cause. Causes of very high
temperatures (>41C) include:
central fever (CNS dysfunction)
malignant hyperthermia
malignant neuroleptic syndrome o drug fever
heat stroke
Temperatures that are lower than normal (<36C) can be
associated with:
overwhelming sepsis
cold exposure
hypothyroidism
overuse of antipyretics

SERIOUS ILLNESS RISK CLASSIFICATION


Low Intermediate High
Color Normal Pallor Pale, mottled,
ashen, blue
Activity -Responds normally
to caretakers
-Is content and
smiles
-Stays awake or
awakens quickly
when aroused -
Strong, normal cry
Decreased activity -Unresponsive,
appears ill, and
barely rousable
-Weak high pitched
or continuous cry
Breathing -Regular
-Unlabored
Signs of
respiratory
distress
-Grunting
-Severe distress
Hydration Normal -Signs of
dehydration
-Poor feeding
-Decreased urine
output
-Capillary refill
time > 3 sec
Reduced skin
turgor
Others -Well- appearing -No
fever at time of
examination
-Fever > 5 days
-Swelling of limb
or joint
-Non-weight
bearing or not
using an extremity
-A new lump >
2cm
-Non- blanching
rash
-Fever at time of
examination
-Bulging fontanelle
-Neck stiffness
-Seizures or focal
neurologic
abnormality
-Bilious vomiting
Table 1. serious illness risk classification
A. LOW RISK OF SERIOUS ILLNESS
Color: Normal color of skin, lips and tongue
Activity:
o Responds normally to caretakers
o Is content and smiles
o Stays awake or awakens quickly weh aroused
o Strong, normal cry
Breathing: Regular, unlabored
Hydration: Normal
Others: well-appearing , no fever at time of examination
Management: Home management (give water and
Paracetamol)
B. INTERMEDIATE RISK OF SERIOUS ILLNESS
Color: Pallor (reported by parents/ caregivers)
Activity: Decreased activity
Breathing: signs of respiratory distress chest retractions
(subcostal, intercostal, suprasternal), nasal flaring
Hydration:
o Signs of dehydration (sunken eyes, decreased capillary refil
time, poor skin turgor, depressed fontanelles, dry mucosa,
decreased tear production.
o Poor feeding
o Decreased urine output (Ask for LAST URINE VOIDING)
o Capillary refill > 3 seconds
Others: Fever >/= 5 days, swelling of limb or joint, non- weight
bearing or not using an extremity, a new lump >/= 2cm
If intermediate to high risk, may warrant hospital admission

C. HIGH RISK OF SERIOUS ILLNESS
Color: Pale, mottled, ashen, blue
Activity: Unresponsive, appears ill, and barely rousable; weak
high pitched or continuous cry
Breathing: Grunting, severe distress
Hydration: Reduced skin turgor
Others: Non-blanching rash (= glass tumbler test), fever at time
of examination, bulging fontanelle, neck stiffness, seizures or
focal neurologic bnormality, bilious vomiting (green from bile,
there is an obstruction prior to ampula of Vater)
Management may have to be started at the ER

FEVER MANAGEMENT
Know the causative agent!
Bacteremia would present with non-specific manifestation
(ex. fever) versus sepsis which would present with clinical
manifestations.
Dont miss possible viral exantems.
Non-blanching rash - a rash that doesnt disappear when
pressing a glass. (+) glass tumbler test.

When there is no apparent source of infection, request for:
Blood: CBC, CRP, ESR, blood culture
Urine: Urinalysis, urine culture
CSF: Analysis, culture
Chest X-ray: if with pulmonary s/sx or high WBC

Check CBC for the predominant cellular action: is it
leukocytosis predominant lymphocytes? Or is it leukocytosis
predominant neutrophilic? Is there high stabs?
Leukocytopenia? Thrombocytopenia and thrombocytosis
can both be associated with infection.
CRP (C-Reactive Protein) and ESR (Erythrocyte
Sedimentation Rate) are on-specific, acute phare reactants.
They are indicative of infection, collagen disease or
inflammation.
In UTI, presence of gram negative organisms on blood
culture can be devastating as it can be associated with
shock.
A normal urinalysis does not rule out UTI, only culture will
do.
Meningitis is an emergency in pediatrics.
During the first 3 days of life, viral infections can present
with leukocytosis (WBC up to 50,000). But after the third day
or going to the fourth day, if it is viral, the true picture will
show that WBC becomes normal or leukopenic
predominantly lymphocytic.
If its bacterial, WBC will persistently go up.

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If its serious (especially gram negative infection), it can
present with leukopenia because the infection can be
inhibitory to your WBC.

Management
CBC with differential WBC count and urinalysis should be part of the
initial laboratory evaluation.
ANC < 5,000/L - evidence against indolent bacterial
infection other than typhoid fever.
PMN greater than 10,000/mL or nonsegmented PMN
leukocytes > 500/mL - high likelihood of having a severe
bacterial infection.
Direct examination of the blood smear with Giemsa or Wright stain
may reveal organisms of malaria, trypanosomiasis, babesiosis, or
relapsing fever.
Acute Phase Specific Reactants
ESR > 30mm/hr indicates inflammation and needs further
evaluation for infectious, autoimmune, or malignant
diseases.
ESR > 100 mm/hr suggests tuberculosis, Kawasaki disease,
malignancy, or autoimmune disease.
A low ESR does not eliminate the possibility of infection or
JRA.
CRP also becomes elevated and returns to normal more
rapidly than the ESR.
Aspirin has been associated with Reye syndrome in children and
adolescents, its use is not recommended for the treatment of fever.

ANTIBIOTICS FOR MANAGEMENT OF SERIOUSLY ILL
CHILDREN WITH FEVER OF UNKNOWN ORIGIN
A. Immediate Treatment
3
rd
Generation Cephalosporins (Cefotaxime or Ceftriaxone)
provides coverage for both gram (+) and gram (-) organisms
can traverse the blood brain barrier
Given to patients with:
Signs of shock or coma
Meningococcal disease
Age < 1 month
Age 1-3 months and unwell with WBC < 5 or >15 x
10 to the 9
th
/ L
On the 3
rd
to 4
th
day, one can differentiate between viral and
bacterial cause in WBC count.

B. Treatment for Suspected Bacterial Infection
3
rd
Generation Cephalosporins
Given if any of the following are suspected:
Neisseria meningitidis
Streptococcus pnemonia
E. coli
E. coli- most common cause of neonatal sepsis in the
Philippines
Pneumococcus sepsis/meningitis Case Fatality Rate is 33%
(2010)

Staphylococcus aureus infection
DOC: Methicillin
DOC for MRSA: Vancomycin
Community-acquired methicilin resistant Staphylococcus
aureus (CA-MRSA) is gaining prevalence, 58% national.




Haemophilus influenzae type B infection
DOC: Oxacillin / Vancomycin
Seldomly seen in children > 5 year old
Usually seen among 3 mos 5 years.
Neonates are at high risk for infections due to their
underdeveloped immune systems.

Bacteroides fragilis most common normal flora in the large intestine;
anaerobic
Small intestines gram (-) aerobic
Large intestines gram (-) anaerobic