Peds

• 1. hematogenous spread most common in children
• 2. primarily develops in metaphysis of long bones
• 3. slowed blood flow predisposes area to bacterial invasion
• 4. acute infection and inflammation ensue
• 5. infection can spread and enter joint space

• may exhibit pseudoparalysis or pain with movement
• half of neonates do not have fever and may not appear ill

• more likely to have fever and localize pain
• localizing signs: edema, erythema and warmth
• limp or refusal to walk with involvement of lower extremities

• clinical
• white blood cell count (WBC)
• erythrocyte sedimentation rate (ESR)
• c-reactive protein (CRP)
• plain radiographs
• computed tomography (CT)
• magneticc resonance imaging (MRI)

• bacteria = most common pathogens
• Staphylococcus aureus
• Group A streptococcus
• Group B streptococcus and enteric gram-negative bacilli
• Pseudomonas aeruginosa
• Salmonella

• empiric antibiotics
• surgery

• minimum of 21 days
• --> patient shows prompt resolution (within 5-7 days)
• -->ESR and CRP normalized
• 4-6 weeks may be required

• antistaphylococcal penicillin + broad spectrum cephalosporin
• aminoglycoside may be used instead of a cephalosporin
• modify antibiotics based on culture results when possible

• vancomycin 60 mg/kg/day divided q 6-8h
• goal trough:
• modify antibiotics based on culture results when possible

• frank pus from subperiosteal or metaphyseal aspiration
• penetrating injury
• retained foreign body is possible
• infection of hip and/or pelvis

• WBC, ESR, CRP
• children may need long term follow-up

acquired during birth from contact with maternal genital and GI flora

infxn of upper respiratory tract --> invasion of blood --> invasion of CNS --> immunologic cascade --> local tissue damage, edema, increased ICP

• fever
• nuchal rigidity (neck stiffness)
• altered mental status
• severe headache
• photophobia
• kernig sign (+)
• brudzinski sign (+)
• petechial rash (N. meningitidis only)

• irritability
• drowsiness
• seizures
• coma

• history and physical examination
• lumbar puncture
• CSF gram stain and culture
• latex agglutination
• polymerase chain reaction (PCR)
• CT scan

• Normal: 75 - 175 mm H₂0
• Bacterial: elevated
• Viral: elevated

• Normal: < 5 (cells/mm³)
• Bacterial: 1000-5000 (cells/mm3)
• Viral: 100-1000 (cells/mm3)

• Normal: > 90% monos
• Bacterial: > 80% PMNs
• Viral: 50% lymphs

• Normal: < 50 mg/dL 
• Bacterial: 100-500 mg/dL
• Viral: 30-100 mg/dL

• Normal: 50-66% simultaneous serum value/ 0.6 CSF:serum glucose
• Bacterial: < 40 (<60% simultaneous serum value); < 0.4 CSF:serum glucose (> 2 months); < 0.6 CSF:serum glucose (neonates)

• Streptococcus agalactiae
• E. cole
• L. monocytogenes
• Klebsiella spp

Ampicillin + Cefotaxime or Gentamicin

• S. pneumoniae
• N. meningitidis
• S. agalactiae
• H. influenzae
• E. coli

Vancomycin + Ceftiaxone OR Cefotaxime

• N. meningitidis
• S. pneumoniae

Vancomycin + Ceftriaxone OR Cefotaxime

• Ampicillin: 100 mg/kg/dose IV q 6 h
• Cefotaxime: 225-300 mg/kg/day IV divided q 6-8 h
• Ceftriaxone: 100 mg/kg/day IV divided q 12 h
• Vancomycin: 15 mg/kg/dose IV q 6 h

• Based on pathogen:
• N. meningitides, H. influenza : 7 days
• S. pneumonia: 10-14 days
• S. agalactiae: 14-21 days
• Aerobic gram-negative bacilli: 21 days
• L. monocytogenes: > 21 days

• routine use controversial
• evidence of decreased hearing loss in infants & children w/ H. influenzae type b meningitis
• no significant difference in time to bacterial eradication
• administer before (up to 1 hr) or at the same time as 1st dose of abx
• dexamethasone 0.15 mg/kg/dose q 6 h for 2-4 days
• disadvantage: dec. amount of drug that penetrates CNS

• 1. chemoprophylaxis (close contacts or rifampin)
• 2. vaccination:

• 1. close contacts: persons w/ prolonged contact to infected person or their secretions w/in 1 wk before sx begin until 24h after abx are initiated
• 2. rifampin

• < 1 month: 10 mg/kg/day divided q 12 h x 4 doses
• infants & children: 20 mg/kg/day divided q 12 h x 4 doses
• adults: 600mg q 12 h x 4 doses

• 1. conjugated vaccine: Menactra > 9 months; Menveo > 2 years
• 2. polysaccharide: Menomune > 56 years

recommendation: all persons aged 11-18 yrs; persons 9-23 mos at inc risk, 2-10 yrs & 19-55 yrs at inc risk

• 1. pneumococcal polysaccharide vaccine (23-valent)
• - > 65 yo and 2-64 yo w/ increased risk factors
• 2. pneumococcal conjugate vaccine (13-valent)
• - all children < 23 mos and children 24-59 mos w/ chronic illnesses

• Infants: poor feeding, lethrgy, irritability, poor color, +/- fever, cough, grunting, nasal flaring, use of accessory muscles
• Older children: fever, cough, malaise, wheezing, chest pain

• fever
• cyanosis
• respiratory distress: tachypnea, cough, nasal flaring, decreased breath sounds, rales

• CXR
• CBC w/ differential
• blood culture
• sputum culture
• rapid influenza
• ESR
• CRP

• 1. Viral: RSV, influenza A or B, adenovirus, rhinovirus, parainfluenza viruses
• 2. Bacterial: S. pneumonia, H. influenza type b & Non-typeable H. influenza
• 3. Atypical: Mycoplasma pneumoniae & Chlamydia pneumoniae

• 1. Age: younger than 3-6 months
• 2. Social: family cannot provide adequate care
• 3. Hypoxia: oxygen saturation less than 90%
• 4. Moderate to severe respiratory distress: RR >70 breaths/min for infants < 12 mos of age and > 50 breaths/min for older children
• 5. Toxic appearance
• 6. Dehydration
• 7. Suspicious of MRSA or other particularly virulent pathogen
• Failed outpatient tx: 48-72 hrs w/o improvement

• P: Group B streptococci, Listeria monocytogenes, gram neg enteric bacteria
• Out: none - admit pt
• In: ampicillin + gentamicin or cefotaxime

• P: Chlamydia trachomatis, respiratorysyncytial virus (RSV), parainfluenza virus, Streptococcus pneumoniae
• Out: azithromycin 10mg/kg x 1, 5mg/kg x 4 doses; clarithromycin or erythromycin
• In: afebrile: azithromycin or erythromycin IV; febrile: IV macrolide + cefotaxime or ceftriaxone

• P: RSV, S. pneumoniae, H. influenzae, Mycoplasma pneumoniae
• Out: amoxicillin PO 90 mg/kg/day divided BID
• In: ceftriaxone or cefuroxime IV

• P: mycoplasma pneumoniae, chlamydia pneumoniae, streptococcus pneumoniae
• Out: azithromycin 10 mg/kg x 1, 5 mg/kg x 4 doses; clarithromycin or erythromycin
• In: macrolide IV + ceftriaxone or cefuroxime IV

• No abx initially: deterioration in clinical status should signal possibility of superimposed bacterial infx & abx therapy should be initiated
• Supportive measures: oxygen supplementation, fluids, antipyretics