Common Outpatient Infections

Rodolfo E Bégué, MD

Chief, Pediatric Infectious Diseases

LSUHSC, New Orleans

Common Outpatient Infections

• Otitis Media• Sinusitis• Pharyngitis• Lymphadenitis• Pneumonia• Urinary tract infection• Diarrhea

• Impetigo/cellulitis• Wounds/bites• Infestations• Fungal• Parasites• Herpes • Exanthems

Otitis Media

Diagnosis

• Acute onset

• Inflammation

• Middle ear fluidNormal

AOM

Otitis Media

Etiology

• Streptococcus pneumoniae Penicillin-susceptible Penicillin-non susceptible

• Haemophilus influenzae (non-typeable)

• Moraxella catarrhalis

Otitis Media

Treatment

• ~ 80% resolve spontaneouslyantibiotics 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 (Omnicef)

• Cefuroxime (Ceftin)

• Cefpodoxime (Vantin)

• Ceftriaxone

• Azitromycin

• Clarithromycin

Recurrent Otitis Media

• 3 episodes in 6 months4 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 fluidNo inflammation

• Must de differentiated from AOM

Normal AOM OME

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 ENTconsider ventilating tubes

Otitis Media with Effusion

AOMT

• Augmentin

• Ciprodex Ciprofloxacin 0.3% Dexamethasone 0.1%Cipro HC Ciprofloxacin HCl 0.2% Hydrocortisone 1%Floxin Ofloxacin 0.3%

Otitis Externa

• 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 acidGentamicin ophthalmic (Garamycin)Tobramycin opthalmic (Tobrex)

Sinusitis

• Diagnosis is clinical• URI symptoms that

persist > 10 days• URI symptoms that get

worse after 5 days• Sinus pain uncommon

• Do not do plain films• Do not abuse CT

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

Generalized

• Viral (EBV)

• Toxoplasmosis

• Syphilis

Single

• Acute:Staph / Strep

• Chronic:Bartonella henselaeMycobacteria

Lymphadenitis

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

RSVInfluenza

• BacterialStrep pneumoniae

• AtypicalMycoplasmaChlamydiaTuberculosis

Treatment• Amoxicillin (2m- 5 yrs)• Macrolide

ErythromycinAzithromycin

• 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, RetapaluminCephalexin, 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 vaccineAnti-Staph antibiotics

• If no responseSurgical exploration cultureCeftazidime 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 shotRabies prophylaxis (?)

• Amoxicillin / clavulanate• clindamycin + TMP/SMX

Fungal Infections

• Oral candidiasisoral nystatin or clotrimazolefluconazole 3 mg/kg qd x 7d

• Tinea corporistopical clotrimazole or terbinafine bid 2-3 w+ fluconazole 3 mg/kg/w x 2-3 w

• Tinea capitisgriseofulvin 10 mg/kg qd x 4-8 wterbinafine 125 mg qd x 4 w (Lamisil)

ParasitesWorms• Enterobius vermicularis

(Ascaris)• Scotch tape test• Mebendazole 100 mg

Pyrantel pamoate 11 mg/kgAlbendazole 400 mg

• All repeat in 1 w

Protozoans• Giardia (Cryptosporidium)• Metronidazole 5 mg/kg q8h x 5-10d

Furazolidone 2 mg/kg q6h x 7-10dAlbendazole 400 mg/d x 5d(Nitazoxanide)

Uncertain significance

Entamoeba coli, Endolimax nana, Iodamoeba butschlii

Blastocystis hominis, Dientamoeba fragilis

Taeniasis• Praziquantel, different doses

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 ?