1 A 10-day-old, full-term male infant presents to the emergency department (ED) with a 1-day history of being fussy but consolable, slightly decreased oral intake, and a temperature of 38.5° C rectally. What is the risk for serious bacterial illness?

A published study demonstrated that the incidence in infants with fever who are < 28 days old is approximately 13%. Among 372 such infants, the etiology of fever was determined to be a nonspecific viral syndrome (65%), serious bacterial infection (12%), aseptic meningitis (8.1%), otitis media (5.1%), bronchiolitis (5.1%), nonbacterial gastroenteritis (2.7%), and viral stomatitis (1.0%).

Kadish H, Loveridge B, Tobey J, Bolte RG, Corneli HM: Applying outpatient protocols in febrile infants 1–28 days of age: Can the threshold be lowered?. Clin Pediatr 39:81–88, 2000.

Teague JA, Harper MG, Bachur R, et al: Epidemiology of febrile infants 14–28 days of age. Pediatr Res 53:214A, 2003.

2 Which bacterial agents are of most concern in an infant < 28 days old presenting to the ED with a fever?

Group B streptococci, gram-negative enteric organisms (Escherichia coli, Enterococcus spp.), Listeria monocytogenes, and, less commonly, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Neisseria meningitidis, and Salmonella spp.

3 A 26-day-old infant presents to the ED with a 1-day history of fever up to 39° C rectally. What should your initial management include?

For initial management of a newborn infant < 28 days old presenting to the ED with a temperature of 38.0° C:

4 How is an infant < 28 days of age classified as low-risk?

Several screening tools (Boston and Philadelphia protocols for the outpatient management of infants with fever) have been applied to infants < 28 days old presenting with fever to predict which of these newborns are less likely to have a positive bacterial culture on initial evaluation. Several of these criteria are as follows: gestational age > 37 weeks, uncomplicated prenatal course, no history of hyperbilirubinemia, no focal bacterial infection on physical examination except otitis media, no previous use of antibiotics, nontoxic appearance, and normal laboratory values (white blood count [WBC], 5000–15,000 cells/mm³, absolute band count < 1500 cells/mm³, < 10 WBCs/high-power field on urinalysis, and < 5 WBCs/high- power field on stool sample). Negative predictive values determined on infants assigned to the low-risk category were 95.4–99.1%.

5 A 6-week-old male infant presents to the ED with a temperature of 38.4° C. The infant appears nontoxic and is without an obvious source for the fever. How likely is this infant to have a bacterial infection?

A normal physical examination does not correlate well with the presence of a bacterial infection in this age group. In a study evaluating 747 febrile infants age 1–2 months, two thirds of infants with a documented bacterial infection appeared well to the attending pediatric emergency physician. The incidence of serious bacterial infection in febrile infants 1–2 months of age is 7.3%.

Bachur RG, Harber MB: Predictive model for serious bacterial infections among infants younger than three months of age. Pediatrics 108:311–316, 2001.

Baker MD, Bell LM, Avner JR: Outpatient management without antibiotics of fever in selected infants. N Engl J Med 329:1437–1441, 1993.

6 What is the cause of a temperature of 38.0° C in infants age 1–3 months who present to the ED?

A published study of 422 such infants determined the following sources:

Baker MD, Bell LM, Avner JR: The efficacy of routine outpatient management without antibiotics of fever in selected infants. Pediatrics 103:627–630, 1999.

7 A 2-month-old presents with a temperature of 40.5° C and otherwise appears nontoxic. Do infants with hyperpyrexia have a higher risk of having a serious bacterial infection?

A recently published retrospective study of infants younger than 3 months of age demonstrated that the prevalence of serious bacterial infection among febrile infants with temperatures > 40° C was 38% compared with 8.8% of those with temperature < 40° C.

Stanley R, Pagon Z, Bachur R: Hyperpyrexia among infants younger than 3 months. Pediatr Emerg Care 21:291–294, 2005.

8 What is the most common cause of sepsis in newborns?

Early-onset (birth to 7 days) group B streptococcal (GBS) infections, which may be secondary to maternal obstetric complications, prematurity, or lack of prophylactic antibiotics prior to delivery. Late-onset GBS infection (7 days to 3 months) is uncommonly associated with these factors (Table 38-1).

TABLE 38-1 EARLY-ONSET VERSUS LATE-ONSET GROUP B STREPTOCOCCAL INFECTIONS

GBS = group B streptococcus.

9 Does the immature neutrophil (band) count help in distinguishing bacterial infections from viral infections in infants age 3–36 months presenting to the ED with a temperature > 39.0° C?

In a prospective cohort study of 100 febrile children younger than 2 years old, the investigators concluded that there was no difference in percentage band count, absolute band count, or band–neutrophil ratio between bacterial and viral infections. Furthermore, children with bacterial infections had a higher mean absolute neutrophil count than children with respiratory viral infections.

Kuppermann N: Immature neutrophils in the blood smears of young febrile children. Arch Pediatr Adolesc Med 153:261–266, 1999.

10 Has the introduction of the heptavalent pneumococcal conjugate vaccine (PCV7) affected the incidence of occult bacteremia?

A retrospective cohort study of febrile infants age 2 months to 36 months conducted from 2001 to 2003 demonstrated that three of 329 blood cultures yielded a pathogenic bacterium (0.91% [95% confidence interval, 0–2.4%]); all were Streptococcus pneumoniae. One patient had a nonvaccine serotype, one was unimmunized, and the third was infected with an unknown serotype.

Stoll ML, Rubin LG: Incidence of occult bacteremia among highly febrile young children in the era of the pneumococcal conjugate vaccine. Arch Pediatr Adolesc Med 158:671–675, 2004.

11 How helpful is C-reactive protein in detecting serious bacterial infection in febrile children?

In a prospective cohort study of febrile children (> 39° C) age 1–36 months with clinically undetectable source of fever, only C-reactive protein (CRP) remained a predictor of serious bacterial infection after multivariate logistic regression analysis compared with WBC count and absolute neutrophil count. Receiver-operating characteristic analysis demonstrated CRP to be superior to WBC count and absolute neutrophil count. A CRP cutoff point of 7 mg/dL maximized both sensitivity and specificity.

Pulliam PN, Attia MW, Cronan KM: C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Pediatrics 108:1275–1279, 2001.

12 Do prophylactic antibiotics have a role in children with presumed bacteremia?

Studies comparing one dose of intramuscular ceftriaxone versus oral amoxicillin have had varied results. One study found that the use of ceftriaxone correlated with less persistent fever as compared to amoxicillin, although the incidence of subsequent bacterial infections was equivalent in both groups. Another study using meta-analysis to evaluate the efficacy of oral antibiotics in children with pneumococcal bacteremia concluded that there is a decrease in the risk of serious bacterial infections, but insufficient evidence to prove that oral antibiotics prevent meningitis.

13 Are febrile infants with influenza at lower risk for a serious bacterial infection?

A recently published retrospective cross-sectional study of infants age 0–36 months presenting to the ED with fever demonstrated that febrile infants with influenza A had lower prevalence of bacteremia (0.6% vs. 4.2%), urinary tract infections (1.8% vs. 9.9%), consolidated pneumonia (25.4% vs. 41.9%), meningitis (0% vs. 2.2%), or any serious bacterial infection (9.8% vs. 28.2%) compared with infants without influenza A.

Smitherman HF, Caviness AC, Macias CG: Retrospective review of serious bacterial infections in infants who are 0 to 36 months of age and have influenza A infection. Pediatrics 115:710–718, 2005.

14 Distinguish between the presentation of preseptal and orbital cellulitis in children.

See Table 38-2.

TABLE 38-2 PRESEPTAL VERSUS ORBITAL CELLULITIS IN CHILDREN

22 What organisms are associated with deep neck infections (peritonsillar abscess, retropharyngeal abscess, and lateral pharyngeal abscess) in children?

Aerobic (Streptococcus pyogenes, Staphylococcus aureus, and H. influenzae) and anaerobic (Prevotella, Fusobacterium, and Peptostreptococcus spp.) organisms are typically associated with deep neck infections in children. Almost 66% of deep neck abscesses contain β-lactamase–producing organisms.

23 Distinguish the features of deep neck infections in children.

See Table 38-4.

24 Which IV antibiotics are appropriate for retropharyngeal abscess?

As with other pediatric deep neck infections, the antibiotics expected to be efficacious include cefoxitin, clindamycin, imipenem or meropenem, and combination penicillin and β-lactamase inhibitors (ticarcillin-clavulanate).

25 Do all children with retropharyngeal abscess require surgical treatment?

Recent evidence suggests that the majority of patients with retropharyngeal abscess can be treated successfully with IV antibiotics. Surgical incision and drainage should be used in cases that do not respond to antibiotic therapy or in cases of persistent large abscesses.

Craig FW, Shunk JE: Retropharyngeal abscesses in children: Clinical presentation, utility of imaging, and current management. Pediatrics 111:1394–1398, 2003.

26 A 3-year-old boy with a history of mild to moderate eczema presents to the ED with ear pain and drainage. On physical examination, his tympanic membrane appears normal, although swelling of the ear canal makes it difficult to view the entire tympanic membrane. There is pain on movement of the tragus. There is no lateral displacement of the ear and no signs of mastoiditis. What is the likely diagnosis?

The clinical findings are consistent with otitis externa. Otitis externa is associated with Pseudomonas spp. in > 50% of patients; Escherichia, Proteus, Enterobacter, and Klebsiella spp. affect the other half. There is an increased incidence of otitis externa in children with eczema and other dermatologic disorders, as well as in children with a history of swimming, extensive cleaning of the ear, hearing aid use, immunocompromised state, and histiocytosis X.

27 How should otitis externa be managed?

Management of otitis externa includes the following: (1) gentle irrigation and suction of debris with hypertonic saline, 2% acetic acid, or alcohol with acetic acid; (2) topical antibiotics, such as neomycin-polymyxin B-hydrocortisone mixture or fluoroquinolone (using a wick in cases of severe canal edema); and (3) culturing the exudate in severe or unresponsive cases.

28 What is the best treatment for a young child with a runny nose, sore throat, cough, and fever?

The “common cold” or rhinosinusitis is caused by viruses, primarily rhinoviruses and coronaviruses. Rhinovirus has been associated with wheezing in the asthmatic child. Coronavirus causes most of the colds in young children. Antibiotics should not be used to treat the common cold because of their lack of efficacy and, more importantly, to prevent the further emergence of resistant bacteria. Over-the-counter cold remedies, such as antihistamines and decongestants, have not shown significant benefit, and in younger children may have significant side effects such as somnolence or hyperactivity. Nasal saline drops can be safely used for nasal congestion, although aggressive suctioning should be avoided.

29 List the three major causes of exudative pharyngitis in children.

Exudate refers to white or gray debris on the tonsils or pharynx. Causes include:

In developing countries, Corynebacterium diphtheriae should be included in this list. In sexually active adolescents or abused children, Neisseria gonorrhoeae should be considered. More recently, Arcanobacterium haemolyticum has been shown to cause an exudative pharyngitis, especially in adolescents.

30 A 7-year-old has fever, sore throat, tender anterior cervical lymph nodes, and lack of significant upper respiratory tract symptoms. Are these clinical features suggestive of GABHS pharyngitis?

Unfortunately, there are no clinical findings that are specific or sensitive for streptococcal pharyngitis. The absence of symptoms of upper respiratory tract infection and the presence of tender cervical nodes and a scarlatiniform rash are suggestive of the diagnosis. Some children may present with headache, abdominal pain, or nausea and vomiting. Exudative pharyngitis in children younger than 3 years of age does not tend to be streptococcal. Viral causes, such as adenovirus, predominate, especially in younger children. The diagnosis of GABHS infection is best made through culture or rapid streptococcal antigen tests.

Gerber MA: Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am 52:729–747, 2005.

31 What is the drug of choice for the treatment of streptococcal pharyngitis?

Amoxicillin or penicillin for a full 10 days to prevent rheumatic fever is the oral drug of choice. Erythromycin can be used in the penicillin-allergic patient. A single dose of intramuscular penicillin G benzathine may be indicated in specific cases in which nonadherence is a concern.

Gerber MA: Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am 52:729–747, 2005.

32 How is the diagnosis of otitis media made?

Otitis media is diagnosed as an acute otitis media or otitis media with effusion. See Table 38-5.

33 Which pathogens are implicated in acute otitis media?

Pelton SI: Otitis media: Re-evaluation of diagnosis and treatment in the era of antimicrobial resistance, pneumococcal conjugate vaccine, and evolving morbidity. Pediatr Clin North Am 52:711–728, 2005.

34 What is the drug of choice for treatment of acute otitis media?

Amoxicillin remains the drug of choice. High-dose amoxicillin (80–90 mg/kg) divided twice daily for 10 days is the best for the treatment of drug-resistant strep pneumococci, which causes 35% of cases and is less likely to resolve without treatment. Acute otitis media caused by H. influenzae and M. catarrhalis is more likely to resolve spontaneously. Recurrent acute otitis media may require the use of other antibiotics to address the problem of β-lactamase–producing bacteria or highly resistant Streptococcus pneumoniae. Shorter courses of treatment may be considered in nontoxic children older than 2 years.

35 What is the mechanism of pneumococcal resistance?

Pneumococcal resistance is mediated by alterations in the penicillin-binding proteins. Resistance of H. influenzae and M. catarrhalis is mediated by a β-lactamase. This difference has important therapeutic implications, since β-lactamase–stable agents, such as amoxicillin-clavulanate, are more effective against H. influenzae and M. catarrhalis, but do not provide any advantage over amoxicillin in treating penicillin-resistant pneumococci.

36 Which antibiotics are considered second-line agents for the treatment of acute otitis media?

Amoxicillin-clavulanic acid, newer macrolides such as azithromycin, or cephalosporins such as cefdinir are suitable alternative agents if amoxicillin has failed. Intramuscular ceftriaxone, a broad-spectrum, third-generation cephalosporin, should be reserved for children who are vomiting and cannot tolerate oral medication, or for those with possible concomitant occult bacteremia.

37 List the risk factors for infection with drug-resistant pneumococci.

38 You decide to intubate the trachea of a young patient who presents with severe respiratory distress and stridor. On endotracheal intubation, purulent tracheal secretions are seen. What is the likely diagnosis?

Bacterial tracheitis, also called pseudomembranous tracheitis. This infection requires immediate attention and treatment. Copious amounts of secretions can obstruct the trachea or a major bronchus. This condition may resemble croup, which may be a predisposing risk factor. Because of inspiratory and expiratory wheezing, foreign-body aspiration may also be part of the differential diagnosis. The most common organisms recovered from infected patients are Staphylococcus aureus, H. influenzae, Streptococcus pyogenes, Streptococcus pneumoniae, and M. catarrhalis. Antimicrobial selection should be based on these pathogens, and cefuroxime or a combination of oxacillin plus a third-generation cephalosporin is a reasonable choice.

39 What are the common causes of stomatitis? How can they be distinguished?

Inflammation of the oral mucous membrane (stomatitis) is a common finding in children, usually presenting with ulcers or vesicles (“canker sores”). The differential diagnosis is based on the location of the lesions and clinical picture:

Recurrent lesions may be due to abnormalities in the immune system, such as in cyclic neutropenia or chemotherapy-induced neutropenia and chronic granulomatous disease. In association with recurrent fever, stomatitis may be due to PFAPA (periodic fever, adenitis, pharyngitis, and aphthous stomatitis).

Fisher RG, Boyce TG: Moffet’s Pediatric Infectious Diseases: A Problem-Oriented Approach. 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 62–67.

40 What are the clinical manifestations and management of a child with suspected acute mastoiditis?

Mastoiditis is an infection of the mastoid bones or air spaces that surround them. The mastoid air cells transmit to the middle ear, and their mucous membrane is in contact with the middle ear. It is a severe but rare complication of otitis media. It manifests as fever, ear pain, erythema, and retroauricular swelling resulting in a downward and outward deviation of the auricle. Computed tomography (CT) may be helpful when intracranial complications of mastoiditis are suspected. Children with mastoiditis should be admitted to the hospital and treated with IV antibiotics and myringotomy with tympanostomy tube placement.

41 What are the typical organisms causing sinusitis?

The typical organisms associated with acute sinusitis include:

42 What criteria define sinusitis?

American Academy of Pediatrics: Clinical practice guideline: Management of sinusitis. Pediatrics 108:798–808, 2001.

43 What is the differential diagnosis of acute bacterial sinusitis?

44 When is imaging necessary in the diagnosis of acute bacterial sinusitis?

The American Academy of Pediatrics recommends that for children < 6 years of age who have persistent respiratory symptoms that have not improved for > 10 but < 30 days, the diagnosis of acute bacterial sinusitis can be made on clinical criteria without radiographs. For children > 6 years of age with persistent symptoms and for all children with severe symptoms, radiography may be indicated. CT and plain radiographic findings in children with acute sinusitis include:

In children < 6 years old with persistent upper respiratory tract symptoms, 88% have abnormal sinus radiographs. Therefore, in uncomplicated cases of sinusitis in children < 6 years, radiographs are not necessary.

American Academy of Pediatrics: Clinical practice guideline: Management of sinusitis. Pediatrics 108:798, 2001.

Wald ER: Clinical features, diagnosis, and evaluation of acute bacterial sinusitis in children, 2006: www.uptodate.com

45 When is CT useful in the diagnosis of sinusitis?

CT (Fig. 38-1) is helpful in children with complications of acute bacterial sinus infection or those with very persistent or recurrent infections that do not respond to medical management.

Figure 38-1 Computed tomographic scan of sinusitis.

46 Describe the treatment of acute bacterial sinusitis.

1 For uncomplicated acute bacterial sinusitis of mild to moderate severity:

Amoxicillin (45–90 mg/kg/d twice daily)

Or amoxicillin-clavulanate (45–90 mg/kg/d in two divided doses)

2 For children with acute bacterial sinusitis of at least moderate severity or who have received an antibiotic in the past 90 days or who attend day care:

Amoxicillin-clavulanate (80–90 mg/kg/d in two divided doses)

Or cefdinir (14 mg/kg/d in one or two doses)

Or cefuroxime (30 mg/kg/d)

Or cefpodoxime (10 mg/kg/d once daily)

3 Children with vomiting can be treated with one dose of IV ceftriaxone followed by oral antibiotics after vomiting has subsided.

Wald ER: Microbiology and treatment of acute bacterial sinusitis, 2006: www.uptodate.com

47 What is Pott’s puffy tumor?

Pott’s puffy tumor (Fig. 38-2) was first described by Sir Percivall Pott in 1760, and appears as a soft, fluctuant, painful forehead or scalp swelling usually associated with frontal sinusitis. Patients tend to be febrile and appear toxic. It is usually seen in children after 8 years of age when the frontal sinuses begin to develop. It represents osteomyelitis of the frontal bone with subsequent subperiosteal elevation. CT is essential for diagnosis and to evaluate other possible areas of spread. Successful treatment usually involves both antibiotics and surgical drainage.

Figure 38-2 Pott’s puffy tumor.

48 Which infectious organisms are associated with the three primary cardiac infections?

See Table 38-6.

49 What are some of the signs and symptoms of myocarditis in infants and children?

Children presenting to the ED with myocarditis may initially report a nonspecific, flulike illness or gastroenteritis. Within 1–4 weeks, fever, malaise, dyspnea, tachypnea, chest pain, pallor, or cool, poorly perfused distal extremities may develop. Infants may present with feeding difficulties, listlessness, cardiac signs, or respiratory distress. The cardiac examination may reveal sinus tachycardia at rest, muffled and distant heart sounds, lateral displacement of the point of maximal impulse, and a gallop rhythm suggestive of congestive heart failure. Other findings on physical examination associated with heart failure include jugular venous distention, weak pulses, cyanosis, poor perfusion, or hepatosplenomegaly.

50 What diagnostic test results in the ED support the suspicion of myocarditis?

51 What is the acute management of myocarditis in infants and children?

52 What are the common symptoms, signs, and laboratory findings in infants and children with infective endocarditis?

See Table 38-7.

TABLE 38-7 SYMPTOMS, SIGNS, AND LABORATORY FINDINGS IN INFECTIVE ENDOCARDITIS

53 Differentiate among Osler nodes, Janeway lesions, and Roth spots.

Although commonly seen in adults, these findings are rare in infants and children with infective endocarditis. Other embolic phenomena associated with endocarditis include splinter hemorrhages and conjunctival hemorrhages.

54 How do you make the diagnosis of infective endocarditis?

For a definitive diagnosis of infective endocarditis, you must have evidence, either based on surgery or autopsy histology or positive bacteriology, of valvular vegetations or peripheral embolus. Probable diagnosis is based on (1) persistently positive blood culture plus either a new or changing cardiac murmur or predisposing heart disease plus vascular phenomenon (petechiae, splinter hemorrhages, conjunctival hemorrhages, Roth spots, Osler nodes, Janeway lesions, aseptic meningitis, glomerulonephritis, pulmonary emboli, or coronary or peripheral emboli), or (2) negative or intermittently positive blood cultures plus all three of the following: fever, new or changing cardiac murmur, and vascular phenomenon as defined above.

55 What antibiotics are recommended for the presumptive diagnosis of infective endocarditis?

Vancomycin plus gentamicin is recommended for nosocomial infections associated with a vascular cannula or “early” prosthetic valve endocarditis (< 60 days after surgery), and a penicillinase-resistant penicillin plus gentamicin for a natural valve or “late” prosthetic valve endocarditis (> 60 days after surgery).

56 What are the clinical manifestations and diagnostic findings associated with pericarditis?

Clinical Manifestations:

Diagnostic Findings:

57 What is the antimicrobial agent of choice for the presumptive diagnosis of bacterial pericarditis?

Until pericardial cultures return, initial antibiotics should include oxacillin or nafcillin or vancomycin plus cefotaxime or ceftriaxone.