Peds ID

AOM most common bacteria

• streptococcus pneumoniae

• haemophilus influenzae (most common)

• morexella catarrhalis

AOM risk factors

o   Age < 2 years

o   Bottle feeding

o   Recent viral URI

o   Daycare attendance

o   Male

o   Cleft palate

o   Immunodeficiency

o   Allergies

o   Pacifier use

CAP is it mostly viral or bacterial

·       Mostly viral (<5 years) (~65%) ; 8% bacteria

o   Up to 80% of CAP cases in children <2 years of age are viral

CAP pathophysiology

• occurs by impairment of host defense, invasive pathogen, or overwhelm by inoculum

• lower respiratory tract infection causing inflammation of the alveoli, allowing them to fill with fluid and pus

CAP risk factors

o   Age < 5 years

o   Heart disease

o   Pulmonary disease

o   Diabetes

o   Immunocompromised

o   Sick cell disease

bacterial causes for neonates (<30 days)

• E.coli, Group B steptococcus, listeria monocytogens, mycobacterium

bacterial causes for infant (1 month - 24 months)

• streptococcus pneumoniae, Haemophilus influenzae, chlamidia trachomatis

bacterial causes for children >2 yo

• streptococcus pneumoniae, atypical pathogens

CAP immunocompromised considerations

normal skin flora, fungus

CAP cystic fibrosis considerations

P, aeruginosa, stenotrophomonas

CAP sickle cell considerations

atypicals, encapsulated organisms

GAS organism

• Streptococcus pyogenes (𝛽-hemolytic)

  • Produces beta-hemolysis when grown on blood agar

• 𝛽-hemolytic Strep maintain susceptibility to all 𝛽-lactams despite being from the Streptococcus genus

common ages of bacterial pharyngitis

5-15 yo

when is testing for GAS not recommended

< 3yo

GAS risk factors

contact with an individual who has GAS pharyngitis

GAS incubation period

2-5 days

GAS complications

o   Post-Streptococcal sequalae​

o   Acute rheumatic fever (ARF)​

o   Post-Streptococcal glomerulonephritis (PSGN)​

o   Streptococcal toxic shock syndrome​

early onset sepsis

·       Presents within first 72 hours of life

·       Vertical transmission (mother-to-infant)

common bugs in early onset sepsis

• Group B strep (streptococcus agalactiae)

• E. coli

late onset sepsis

·       Presents at 3-7 days of life

·       Horizontal transmission; nosocomial or community-acquired

common bugs in late onset sepsis

o   Coagulase-negative staph

o   MRSA

o   Gram-negatives

risk factor for neonatal sepsis

o   Prematurity (<37 weeks GA)

o   Preterm labor

o   Prelabor rupture of membranes (PROM)

o   Intra-amniotic infection

o   GBS colonization without treatment

o   Environment/central line (late onset)

AOM medical management

• Supportive care

  • Antibiotics do not provide symptomatic relief in the first 24 hours

• Pain can persist up to 3-7 days after

  • Acetaminophen 10-15 mg/kg/dose PO q4-6h (max 75 mg/kg/day)

  • Ibuprofen 5-10 mg/kg/dose PO q6-8 h (max 40 mg/kg/day)

    • Avoided in ages ≤6 months

AOM: < 6 mo, otorrhea with AOM or severe AOM

antibiotic

AOM: 6-24 mo, otorrhea with AOM or severe AOM

antibiotic

AOM: ≥24 mo otorrhea with AOM or severe AOM

antibiotic

AOM: < 6 mo, bilateral AOM without otorrhea

antibiotic

AOM: 6-24 mo, bilateral AOM without otorrhea

antibiotic

AOM: ≥24 mo, bilateral AOM without otorrhea

antibiotic or observation

AOM: <6 mo, unilateral AOM without otorrhea

antibiotic

AOM: 6-24 mo, unilateral AOM without otorrhea

antibiotic or observation

AOM: ≥24 mo, unilateral AOM without otorrhea

antibiotic or observation

AOM first line antibiotic

Amoxicillin (high dose) 90 mg/kg/day PO divided q12h

(max 4000 mg/day)

AOM first line if antibiotic within 30 days

Amoxicillin-clavulanate (high dose) 90 mg/kg/day PO divided q12h (max 4000 mg/day)

AOM alternative for PCN allergy

Cefuroxime 30 mg/kg/day PO divided q12h (max 500 mg/dose)

Cefpodoxime 10 mg/kg/day PO divided q12h (max 200 mg/dose)

Ceftriaxone 50 mg/kg IM/IV 1-3 days (max 1000 mg/dose)

AOM duration of therapy (age)

o   <2 years or severe AOM: 10 days

o   2-5 years: 7 days

o   ≥6 years: 5-7 days

AOM treatment failure

• 48-72 hours

• recurrent AOM within 30 days

• escalate therapy

AOM treatment failure drugs

First line	Alternative
Amoxicillin-clavulanate (high dose) 90 mg/kg/day PO divided q12h (max 4000 mg/day)	Clindamycin 30-40 mg/kg/day PO divided q8h (max 600 mg/dose) +/- 3rd generation cephalosporin
Ceftriaxone 50 mg/kg/day IM/IV x 3 days (max 1000 mg/dose)

recurrent AOM

• 3+ episodes in 6-month period OR 4+ episodes in 12-month period   (including 1 episode in preceding 6 months)

• Guidelines broadly recommend against antibiotic prophylaxis in most patients

AOM prevention

• Standard childhood vaccines

  • Respiratory syncytial virus (RSV)

  • Pneumococcal conjugate (PCV-20)

  • Haemophilus influenzae B (Hib)

• Annual Vaccines

  • Influenza

CAP Fully immunized, not in ICU

Ampicillin 150-200 mg/kg/day IV divided q6h or Amoxicillin 90 mg/kg/day PO divided q8 or q12

alt: second or third generation cephalosporin

CAP not fully immunized

Ceftriaxone 50-100 mg/kg/day IV divided q12-24h

CAP fully immunized, requiring invasive ventilation/ICU

Ceftriaxone 50-100 mg/kg/day IV divided q12-24h

alt: vancomycin

CAP suspicion of atypical pathogen

Azithromycin 10 mg/kg IV/PO once daily x1 day, then 5 mg/kg IV/PO once daily x4 days

CAP suspicion for S. aureus infection (lung abscess, empyema, necrotizing pneumonia)

Vancomycin OR clindamycin 30-40 mg/kg/day divided q8h

alt: linezolid can be used for MRSA coverage

CAP duration of therapy

o   IDSA guidelines suggest 10 days total for uncomplicated CAP

§  Studies show shorter DOT of 5 days are equally effective

o   Atypical pneumonia: 5 days

o   Severe infections may require ≥10 days

o   Use oral therapy when possible

CAP prevention

• Standard childhood vaccines

  • Respiratory syncytial virus (RSV)

  • Pneumococcal conjugate (PCV-20)

  • Haemophilus influenzae B (Hib)

  • Pertussis (DTaP/Tdap)

  • Measles (MMR)

  • Varicella

• Annual Vaccines

  • Influenza

  • COVID-19

GAS treatment

Agent	Dose & Duration
Amoxicillin​ (PO)	50 mg/kg once daily​ (or 25 mg/kg twice daily) x 10 days ​[max 1000 mg/day]
Penicillin V​ potassium (PO)	≤ 27 kg: 250 mg q8-12h PO x 10 days​ > 27 kg: 500 mg q8-12h PO x 10 days​
Penicillin G​ benzathine (IM)	≤ 27 kg: 600,000 units IM​ once >27 kg: 1.2 million units IM​ once

GAS alternatives

Agent (PCN Allergy)	Dose & Duration
Cephalexin (PO)	20 mg/kg q12h x 10 days
Clindamycin (PO)	7 mg/kg/day q8h x 10 days​
*Azithromycin (PO)	12 mg/kg once, then 6 mg/kg daily x 4 days (or 20 mg/kg once daily x 3 days)​
*Clarithromycin (PO)	7.5 mg/kg q12h x 10 days ​

*Resistance rates to macrolides differ geographically

EOS antibiotic

Ampicillin + gentamicin (or ampicillin + ceftazidime)

o   Use ceftazidime or cefepime if CNS coverage needed (i.e. meningitis)

LOS antibiotic

Ampicillin (vancomycin or linezolid if MRSA suspected) + gentamicin

o   Use ceftazidime or cefepime if CNS coverage needed (i.e. meningitis)

Risks of antibiotic overuse

o   Necrotizing enterocolitis

o   Bronchopulmonary dysplasia

o   Fungal infections

o   Antimicrobial resistance

o   Increased mortality

inappropriate antibiotics

• nitrofurantoin

• ceftriaxone, sulfonamides (Bacrim)

• fluoroquinolones

• tetracyclines

risk of nitrofurantoin

§  Risk: hemolytic anemia in neonates (0-28 days)

risk of ceftriaxone, sulfonamides (Bactrim)

§  Risk: kernicterus in neonates (0-28 days)

risk of fluoroquinolones

§  Should not be used routinely as first-line agents in children < 18 years except when specific indications exist or if are no alternative agents

§  Risks: musculoskeletal adverse effects

tetracycline risk

§  Risk: permanent tooth discoloration and enamel hypoplasia in children < 12 years

§  Risk factors: duration of therapy > 21 days, higher doses

Beta lactam allergies

o   Penicillin allergy is the most common allergy reported by patients

o   > 90% of patients who report a penicillin allergy can tolerate penicillin-based agents without a reaction

o   Cross-reactivity is not a beta-lactam class effect but an allergic reaction to antibiotics with similar side chains

allergy delbeling

o   Patients can be screened for risk of penicillin allergy

o   Penicillin allergy screening

§  Low/moderate risk: reaction ≥10 years ago + mild reaction (hives)

§  Severe risk (no desensitization): history of type IV allergic reaction (SJS, TEN, DRESS)

o   For patients determined to have low or moderate risk of penicillin allergy, can proceed with penicillin allergy challenge under provider supervision

o   Penicillin allergy challenge: Supervised administration of amoxicillin (up to 1 hour)

o   If patient passes challenge, can delabel allergy