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ch.tyrrell
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What is the pathophysiology of osteomyelitis?
- 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
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What is the clinical presentation of osteomyelitis in neonates?
- may exhibit pseudoparalysis or pain with movement
- half of neonates do not have fever and may not appear ill
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What is the clinical presentation of osteomyelitis in older infants and children?
- more likely to have fever and localize pain
- localizing signs: edema, erythema and warmth
- limp or refusal to walk with involvement of lower extremities
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How is osteomyelitis diagnosed?
- clinical
- white blood cell count (WBC)
- erythrocyte sedimentation rate (ESR)
- c-reactive protein (CRP)
- plain radiographs
- computed tomography (CT)
- magneticc resonance imaging (MRI)
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What are the causes of osteomyelitis?
- bacteria = most common pathogens
- Staphylococcus aureus
- Group A streptococcus
- Group B streptococcus and enteric gram-negative bacilli
- Pseudomonas aeruginosa
- Salmonella
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What are the treatment options for osteomyelitis?
- empiric antibiotics
- surgery
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What is the duration of therapy for osteomyelitis treatment?
- minimum of 21 days
- --> patient shows prompt resolution (within 5-7 days)
- -->ESR and CRP normalized
- 4-6 weeks may be required
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What is the osteomyelitis empiric antibiotic treatment for neonates?
- antistaphylococcal penicillin + broad spectrum cephalosporin
- aminoglycoside may be used instead of a cephalosporin
- modify antibiotics based on culture results when possible
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What is the osteomyelitis empiric antibiotic treatment for infants and children?
- vancomycin 60 mg/kg/day divided q 6-8h
- goal trough:
- modify antibiotics based on culture results when possible
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What are the requirements for surgical treatment of osteomyelitis?
- frank pus from subperiosteal or metaphyseal aspiration
- penetrating injury
- retained foreign body is possible
- infection of hip and/or pelvis
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What monitoring is required with osteomyelitis?
- WBC, ESR, CRP
- children may need long term follow-up
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What is the pathophysiology of meningitis in newborns?
acquired during birth from contact with maternal genital and GI flora
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What is the pathophysiology of meningitis in older infants and children?
infxn of upper respiratory tract --> invasion of blood --> invasion of CNS --> immunologic cascade --> local tissue damage, edema, increased ICP
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What are the classic signs and symptoms (early) of meningitis?
- fever
- nuchal rigidity (neck stiffness)
- altered mental status
- severe headache
- photophobia
- kernig sign (+)
- brudzinski sign (+)
- petechial rash (N. meningitidis only)
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What are the late signs and symptoms of meningitis?
- irritability
- drowsiness
- seizures
- coma
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How can meningitis be diagnosed?
- history and physical examination
- lumbar puncture
- CSF gram stain and culture
- latex agglutination
- polymerase chain reaction (PCR)
- CT scan
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How does opening pressure present for normal, bacterial and viral meningitis?
- Normal: 75 - 175 mm H20
- Bacterial: elevated
- Viral: elevated
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How do WBCs present for normal, bacterial and viral meningitis?
- Normal: < 5 (cells/mm3)
- Bacterial: 1000-5000 (cells/mm3)
- Viral: 100-1000 (cells/mm3)
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How does the differential lab present for normal, bacterial and viral meningitis?
- Normal: > 90% monos
- Bacterial: > 80% PMNs
- Viral: 50% lymphs
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How does protein present for normal, bacterial and viral meningitis?
- Normal: < 50 mg/dL
- Bacterial: 100-500 mg/dL
- Viral: 30-100 mg/dL
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How does glucose present for normal, bacterial and viral meningitis?
- 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)
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What are the common pathogens for meningitis in < 1 month of age?
- Streptococcus agalactiae
- E. cole
- L. monocytogenes
- Klebsiella spp
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What is the antibiotic therapy for meningitis in < 1 month of age?
Ampicillin + Cefotaxime or Gentamicin
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What are the common pathogens of meningitis in 1-23 months?
- S. pneumoniae
- N. meningitidis
- S. agalactiae
- H. influenzae
- E. coli
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What is the antibiotic therapy for meningitis in 1-23 months of age?
Vancomycin + Ceftiaxone OR Cefotaxime
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What are the common pathogens of meningitis in children > 2 years?
- N. meningitidis
- S. pneumoniae
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What is the antibiotic therapy for meningitis in children > 2 years?
Vancomycin + Ceftriaxone OR Cefotaxime
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What are the doses of antibiotics for the treatment of meningitis in infants and children?
- 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
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What is the duration of treatment for meningitis?
- Based on pathogen:
- N. meningitides, H. influenza : 7 days
- S. pneumonia: 10-14 days
- S. agalactiae:
14-21 days - L. monocytogenes: > 21 days
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Discuss adjunctive dexamethasone therapy for meningitis.
- 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
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What prevention techniques are available for N. meningitidis?
- 1. chemoprophylaxis (close contacts or rifampin)
- 2. vaccination:
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Discuss chemoprophylaxis of N. meningitidis.
- 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
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What are the rifampin dosages for prevention of N. meningitidis?
- < 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
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What are the 2 types of vaccinations for meningitis and who are vaccines recommended for?
- 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
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What vaccines are available for meningitis due to S. pneumoniae?
- 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
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What are the s/sx of community acquired pneumonia?
- Infants: poor feeding, lethrgy, irritability, poor color, +/- fever, cough, grunting, nasal flaring, use of accessory muscles
- Older children: fever, cough, malaise, wheezing, chest pain
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What are the clinical s/sx of CAP?
- fever
- cyanosis
- respiratory distress: tachypnea, cough, nasal flaring, decreased breath sounds, rales
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What are the diagnostic tests used for CAP?
- CXR
- CBC w/ differential
- blood culture
- sputum culture
- rapid influenza
- ESR
- CRP
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What is the etiology of CAP?
- 1. Viral: RSV, influenza A or B, adenovirus, rhinovirus, parainfluenza viruses
- 2. Bacterial: S. pneumonia, H. influenza type b & Non-typeable H. influenza
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Which patients are eligible for hospitalization associated with CAP?
- 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
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Age 0 - 20 days: which pathogens, outpatient and inpatient treatment
- P: Group B streptococci, Listeria monocytogenes, gram neg enteric bacteria
- Out: none - admit pt
- In: ampicillin + gentamicin or cefotaxime
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Age 3 weeks to 3 months: which pathogens, outpatient and inpatient treatment?
- 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
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4 months to 4 years: which pathogens, outpatient and inpatient treatment
- P: RSV, S. pneumoniae, H. influenzae, Mycoplasma pneumoniae
- Out: amoxicillin PO 90 mg/kg/day divided BID
- In: ceftriaxone or cefuroxime IV
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5 years to 15 years: pathogens, outpatient and inpatient therapy
- 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
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What is the treatment for viral CAP?
- 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
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