bacterial infections - pediatrics part 2

8/14/2019 Bacterial infections - Pediatrics part 2

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Bacterial Infections(Part 2)

Ma.AnnaP.Baez,M.D.

DepartmentofChildHealth

Neisseria gonorrheae

Nonmotile,aerobic,

nonsporeforming,

gramnegative,

intracellular

diplococcus with

flattenedadjacent

surfaces

Epidemiology Infectiononlyinhumans

Transmission: intimatecontact; rarely,fomites

Infectioninnewborngenerallyacquiredduringdelivery

Acuteinfectionbegins25daysafterbirth

MostcommonSTIinsexuallyabusedchildren

Pathogenesis InfectsprimarilyColumnarEpithelium

Mucosalinvasion localinflammatoryresponse

purulentexudate (PMN,serumanddesquamatedepithelium)

Gonococcal LipoOligosaccharide(Endotoxin)exhibitsdirectcytotoxicity ciliastasisandsloughingofciliatedepithelialcells

Gonococcustransversesthemucosalbarrier,thelipooligosaccharidebindsbactericidalIgM antibodyandserumcomplement acuteinflammatoryresponseinthesubepithelialspace

TNFandothercytokinesarethoughttomediatethecytotoxicity ofgonococcal infections

ClinicalManifestations

AsymptomaticGonorrhea Pharyngealgonococcal infection

Rectalcarriage

(40

60%)

Clinical Manifestation Uncomplicatedgonorrhea

Genital

Primaryinfectionin urethrainmales,vulvaand

vaginainprepubertalfemales,cervixpostpubertal

females

IP25days

in

men;

510

days

in

females

Urethritis

Purulentdischarge,dysuria withouturgencyor

frequency

Untreatedcasesresolvespontaneouslyinseveral

weeksorcomplicatedbyepididymitis,penileedema,

lympangitis,prostatitis,seminalvesiculitis


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Vulvovaginitis:

Purulentvaginaldischargewithswollen,erythematous,

tender,andexcoriatedvulva

Dysuria,dyspareunia,intermenstrual bleeding

Cervixmaybeinflamedandtender

Purulentmaterialcanbeexpressedfromurethraor

ductsofBartholin gland

Rectalgonorrhea:

Oftenasymptomatic

Maycauseproctitis withsymptomsofanaldischarge,

pruritus,bleeding,pain,tenesmus andconstipation


Gonococcal Ophthalmitis

Unilateralorbilateral

Occur14daysafterbirth

Beginswithmildinflammationanda

serosanguinous discharge Within24hours thickand

purulent,tenseedemaoftheeyelidsandmarkedchemosisoccur

Withouttreatment cornealulceration,ruptureandblindness

Clinical Manifestation Disseminated Gonococcal Infection

13%ofgonococcal infection

Afterasymptomaticprimaryinfectioninwomen

Begin730daysafterinfectionandwithin7daysaftermenstruation

Aspolyarticular septicarthritisinneonate

CommonManifestation:

Acutepolyarthralgia andfever(mostcommon)

Skinlesionsin25%(acral petechiae /pustular)

Tenosynovitis

Suppurative arthritis

Rarely

carditis,

osteomyelitis,

and

osteitis

Clinical Manifestation Disseminated Gonococcal Infection

Tenosynovitis DermatitisSyndrome

Morecommon

Fever,chills,skinlesions,andpolyarthralgias

predominantlyinvolvingthewrist,handsand

fingers

BCS(+)3040%

Synovial fluidCSalmostuniformlynegative

Suppurative ArthritisSyndrome

Systemicsignsandsymptomsarelessprominent

Monarticular arthritis ofteninvolvingtheknee

Synovial fluidCS(+)in4555%

BloodCS

()

Diagnosis

Dependsonisolationoforganism

Urethritis

Gram()intracellulardiplococci

PRESUMPTIVEDXinsymptomaticmales

Not

sufficient

in

females;

similar

to

Mimapolymorpha &Moraxella

Otherinfectionswithpurulence:

C.trachomatis,M.hominis,T.vaginalis,C.albicans

Evaluateforconcurrentsyphilis,hepatitisB,HIVandC.trachomatis infection

Treatment

Dueto increaseprevalenceofpenicillin

resistantN.gonorrheae,Ceftriaxone isrecommendedasinitialtherapyforallages

Patientbeyond

the

neonatal

period

should

also

betreatedpresumptivelyforC.trachomatis


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Treatment Infant and

UncomplicatedInfection

Ceftriaxone 50mg/kg/insingledoseIM;maximum

125mg

Bacteremia orArthritis

Ceftriaxone 50mg/kg/24hrforaminimumof7days

>45kgs 10

14

days

Meningitis

Ceftriaxone 50mg/kg/doseq12hr1014days

Ophthalmia Neonatorum

Ceftriaxone 50mg/kg/insingledoseIM;maximum

125mg

Cefotaxime 100mg/kg/daysingledoseIM

Pediatric Infections

Endocarditis

Ceftriaxone 50mg/kg/doseq12hr28days

NeonatalSepsis

Should

be

treated

parentally

for

minimum

of

7days

Cefotaxime isrecommendedforpatientwith

hyperbilirubinemia

Treatment Infant and

Pediatric Infections

Treatment for Adolescent and

Adult Infection

Singledoseofceftriaxone 125mgIM

eradicatespharyngealanduncomplicated

urogenital infections

Safeinpregnantwomen

Otheralternatives:

Cefixime 400mgPOassingledose

Ciprofloxacin500mgassingledose

Ofloxacin 400mgPO

Regardlessofregimenchosen,treatment

shouldbefollowed byregimenactive

againstC.trachomatis

Doxycycline 100mgBIDx7days

Azithromycin 1gminsingledosepo

Erythromycin forpregnantwomenx710day

Treatment for Adolescent and

Adult Infection

DisseminatedGonococcal Infection

Ceftriaxone 1gram/24hrIVrecommendedasinitialtherapy

Alternativeregimen

Cefotaxime 1gmIVq8

Ciprofloxacin500mg/IVq12

Ofloxacin 400mg/IVq12

Spectinomycin 2

gm

q12

Examineforclinicalsignsofmeningitisandendocarditis

Switchtooral2448hrsafterimprovement:

Cefixime 400mgbid

Ciprofloxacin500mgbid x7days

Ofloxacin 400mgbid

Gonococcal Conjunctivitis

Ceftriaxone 1gmIM,singledose

Treatment for Adolescent and Adult Infection

Complications

PelvicInflammatoryDisease

Aspectrumofinfectiousdiseasesofuppergenital

tractduetoN.gonorrhea,C.trachomatis and

endogenousflora(Streptococci,Anaerobes,gram

()bacilli

RecommendedRegimen:

Cefoxitin 2gIVq6orCefotetan 2gq12+

Doxycycline

AlternativeRegimen:

Clindamycin +Gentamycin +Doxycycline


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Other Complications

PID

Endometritis

Ectopic regnancy

Perihepatitis Chorioamnionitis

Septicabortion

p

Prevention

Education

Useofbarriercontraceptive

Earlyidentificationandtreatment

Gonococcal Ophthalmia Neonatorum

2drops

1%

solution

of

silver

nitrate

into

eachconjunctival sacshortlyafterbirth

Erythromycin(0.5%)

TetracyclineOphthalmicointment

Syphilis Treponema pallidum:thin,motile,fastidiousspirochete

CongenitalSyphilis

viatransplacental transmission,atanytimeduring

pregnancyoratbirth

Moistsecretionsarehighly infectious

AcquiredSyphilis

sexualcontact;suspectsexualabuseinachild(+)for

acquiredSY

IP:3wks(1090d)

Openmoistlesionsof1o &2o stagesarehighly

infectious

Congenital Syphilis

Up100%transmissionrateduringpregnancy

Fetalorperinatal deathin40%ofaffected

infants

EarlySigns:

1st 2yearsoflife

Transplacental spirochetemia,analogousto

secondarystageofAcquiredSyphilis

2/3asymptomatic,identifiedthruscreening

Congenital Syphilis EarlySigns

Hepatosplenomegaly

Jaundice

Diffuselymphadenopathy

Coombs negativehemolyticanemia

Thrombocytopenia

Osteochondritis:painful,multiple,causingirritabilityandpseudoparalysis ofParrot

Periostitis oflongbone

Erythematous maculopapular &bullous lesionswithdesquamationonhandsandfeet

Mucouspatches,rhinitis(snuffles),condylomatous lesions

CNSabnormalities,failuretothrive,chorioretinitis,nephritisandnephrotic syndrome

Congenital SyphilisLateSigns Secondarytochronicinflammationofbone,teethandCNS

FrontalbossofParrott

Shortmaxilla

Highpalatalarch

Hutchinsons Triad:hutchinson teeth,interstitialkeratitis,8th nerve

deafness

Saddlenose

Mulberry

molars Higoumenakis sign

Relativeprotruberance ofthemandible

Rhagades linearscarsfrompreviousmucocutaneous fissureson

mouth,anusandgenitalia

Sabershin

Scaphoid scapulae

Clutton joint

JuvenileParesis adolescenceasbehavioralchanges,focalseizure,

lossofintellectualfunction

JuvenileTabes rare,spinalcord&CVinvolvementwithaortitis


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Acquired Syphilis: 3 Stages Primary:painlessindurated ulcers(chancres)on

genitalia

Secondary:begins12mos later

Mucocutaneous lesions,lymphadenopathy

Rash:maculopapular,generalized

Condylomata lata (graywhite/erythematous plaquesaroundanusorvagina)

Latent:period

after

infection

when

seroreactive but

asymptomatic

EarlylatentSyphilis:acquiredwithintheprecedingyear

Late latentSyphilis:asymptomatic

Tertiary:latelatentbutsymptomaticwithcardiovascular&gummatous lesions(granuloma ofskinandmusculoskeletalsystem)

Neurosyphilis

InfectionoftheCNS

OccuratanystageespeciallyinHIVpatients

Acquired Syphilis: 3 Stages Diagnosis Demonstratedbydarkfieldmicroscopy

Serology:principalmeansfordiagnosis

NonTreponemal Tests

VDRL,RPR

Detectantibodiesagainstacardiolipincholesterollecithincomplex

notspecificforSyphilis

Correlatew/diseaseactivity:forscreening

Nonreactivew/in1yearoftreatmentforprimarysyphilis,2yearsforsecondarysyphilis,fewmonthsincongenitalsyphilis

False

(+)in

autoimmune

diseases

Diagnosis

SpecificTreponemal AntibodyTests

Confirmatorybutremainpositiveforlife

T.pallidum immobilization(TPI)

Fluorescent

treponemal antibody

absorptiontest(FTAABS)

Microhemagglutination assayfor

antibodiestoT.pallidum (MHATP)

FTAABS19SIgM

Stage TreatmentandDosage AlternativesPrimary,secondary,or

earlylatent(1yr),

latentofunknown

duration,ortertiary

(gumma or

cardiovascularsyphilis)

PenicillinGbenzathine (2.4millionU

IM)weeklyfor3doses

Tetracycline(500 mgPOqid

for4wk)ordoxycycline

(100mgPObidfor4wk)

Neurosyphilis AqueouscrystallinepenicillinG(1224

millionU/24

hr

IV

given

as

2.4

million

Uevery4hr)for1014daysFor

children:Aqueouscrystallinepenicillin

G(200,000300,000U/kgeveryday

IV,givenevery46hr)for1014days

PenicillinGprocaine(2.4

millionU/day

IM)

plus

probenicid (500 mgPOqid).

Bothfor1014days

Congenitalsyphilis AqueouscrystallinepenicillinG

(100,000150,000 U/kg/24hr,givenas

50,000U/kgIVevery12hrforthefirst

7daysandevery8hrthereafter)for

1014daysorProcainepenicillinG

(50,000U/kgIMdailyinasingledose)

for1014days

*Enlargedtable,seelastpage


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SalmonellaInfections

Gramnegativebacilli

Incubationperiod

Gastroenteritis:648hrs

Entericfever:360days(usually714days)

>2460Salmonella

serotypes:most humandiseasecausedbyGroupsAE

SerotypeTyphi isclassifiedinSerogroup D

Salmonella Infections NonTyphoidal Salmonella

Reservoirs:poultry,livestock,reptiles,pets

Vehiclesoftransmission:poultry,beef,fish,eggs,dairyproducts,fruits,vegetables,bakeryproducts

Othermodesoftransmission:ingestionofcontaminatedwater,contactwithreptiles,contaminatedmedications,dyes,medicalinstruments

S

Serotype

Typhi:

found

only

in

humans Infection:direct/indirect contactwithaninfected

person

MOT:Ingestionofwater/foodcontaminatedwithhumanfeces

Highinoculum 106108requiredtocausedisease,contaminatedfoodamajorsourceofhumaninfections

Persontopersontransmissionbydirectfecaloralspreadisunusual,mayoccurinyoungchildren

Salmonella Infections Riskoftransmission:throughouttheduration

offecalexcretionoforganism

ChronicCarrier:1%ofpatientscontinueto

excreteSalmonella for>1yr

Clinical Manifestation of

Non-Typhoidal SalmonellosisAcuteGastroenteritis

Mostcommonpresentation

IP:672hrs(mean,24hrs)

Abruptonsetofnausea,vomiting,

abdominalcrampsfollowedbywateryor

bloody,mucoid diarrhea

70%withTemp38.539C

Stoolexam:moderatePMNandoccultblood

Recoveryin27days

Clinical Manifestation of

Non-Typhoidal SalmonellosisBacteremia

RiskFactors:

Neonatesandyounginfants


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Enteric Fever or Typhoid Fever

Insidiousonsetwithfever,malaise,anorexia,

myalgia,headacheandabdominalpainover 23

days

Diarrheaorconstipation

Cough,epistaxis

Temperatureincreases,becomingunremitting,highwithin1wk

On2nd wk,highfever,fatigue,anorexia&abdominal

symptomsincrease

Appearill,disoriented,lethargic

Enteric Fever or Typhoid Fever

Relativebradycardia,hepatosplenomegaly,

abdominaldistentionandtenderness

Rosespotsonlowerchestandabdomen

Ifuncomplicated,symptomsandPEfindings

graduallyresolvein24wks

Malaiseandlethargyfor12months

Complications mayoccurafter1st weekasintestinal

hemorrhageorperforation

Othercomplications:hepatitis,cholecystitis,

pyelonephritis,nephrotic syndrome,meninigitis,

endocarditis

Diagnosis Culture:blood,stool,urine

Blood:40%(+)in1st week

UrineandStool:highly(+)afterthe1st

week

BoneMarrow:singlemostsensitivetest (+)in8590%

Lessinfluencedbypriorantimicrobialtherapy

Enzymeimmunoassay,latexagglutination,DNAprobesandmonoclonalantibodieshavebeendeveloped&areinuseinsome

laboratories

Treatment for Non-Typhoidal

Salmonella Infection AntibioticsNOT recommendedforuncomplicated

gastroenteritiscausedbyNontyphoidal species

prolongsdurationofcarriage

AntimicrobialTreatment

Inpatientswithincreasedriskofinvasivedisease:

infants/=3monafterinfection

~15%;Lowriskinchildren,highdoseIVAmpicillinororalAmoxicillin withProbenecid x46weeks

Foradultcarriers:Ciprofloxacin isdrugofchoice

Cholecystectomy: indicatedin

which

gallstones

provideanidus forresistancetomedicaltreatment

Steroids:

(+)delirium,obtundation,stupor,comaorshock

Dexamethasone:1mg/kq6hrx2days


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\\\\\\\\\

Relapse

Afterinitialclinicalresponseoccursin48%

nottreatedwithantibiotics

Fortreatedpatients,apparent~2wkafter

stoppingantibiotic;milderandshorter

duration;maybemultiple

Prevention:

Improvedsanitationandclean,runningwater

Personalhygiene,handwashing

Vaccination:

Oral,liveattenuatedty21astrain(Vivotif)

4enteric

coated

at

>/=6

yo q

5yrs;

6782%efficacy

Vicapsularpolysaccharidevaccine(Typhim Vi)

GivenIMq2yrsfor>/=2yo

Shigella Gramnegativebacilliwith>40serotypes

4speciesresponsibleforillness:

S.dysenteriae (Serogroup A)

S.flexneri (Serogroup B)

S.boydii (Serogroup C)

S.sonnei (Serogroup D)

Humansarethenaturalhost

Incubationperiod:17days

Transmission Fecaloralroute,ingestionofcontaminated

foodorwater,contactwithinanimateobject,

sexualcontact

Transmissionrequiresasfewas10to200

organismforinfectiontooccur

Carrierstateceaseswithin4weeksofonsetof

illness;chroniccarrierstateisrare

Clinical Manifestations

Primarilyinfectsthelargeintestine

Symptomsrangefromloosestoolswithminimalconstitutionalsymptomstomoreseveresymptomsfever,abdominalcramps,tenesmus,mucoid stoolswithorwithoutblood

Extraintestinal Manifestations

Neurologic ngsin40%hospitalizedchildren:convulsions,headache,lethargy,confusion,nuchal rigidity,hallucinationsbeforeorafterdiarrhea

NOT

findi

duetoShigatoxin

Complications:

Dehydration(mostcommon)

Bacteremia (uncommon)

Reitersyndrome(S.flexneri infection),

HUS(S.dysenteriae type1),

Toxic

megacolon and

perforation

Toxicencephalopathy(Ekiri syndrome)


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Diagnosis

StoolCulture

(+)fecalleukocytesonMethyleneBluestainedstoolsmear sensitivebutnotspecific

EnzymeimmunoassayforShigatoxin for

detectionof

S.

dysenteriae type

1in

stool

Bloodculture:inseverelyill,immunocompromised,malnourishedpatients

Othertests:fluorescentantibodytest,PCRassay,enzymelinkedDNAprobes

Treatment

Forsusceptiblestrains:Ampicillin and

Cotrimoxazole,Nalidixic acid

Forresistantstrains:Ciprofloxacin,Ceftriaxone

CurrentWHOrecommendation:

TreatforShigellosisinachildwithbloody

diarrhea DOC:Ciprofloxacin:15mg/kgbidx3days

AlternativeDrugs:

Ceftriaxone 50100mg/kg/dayIM/IVx25days

Azithromycin 610mg/kgODx35days

Vibrio cholerae Gram(),curved,motilebacillus

Serogroup O1havecaused

epidemics

2SerotypesofV.cholerae O1:

Inaba &Ogawa

2biotypes:ClassicalandEltorr

(predominant)

Serogroup 0139Bengal:epidemic

cholerainIndiansubcontinent&

southeastAsia

Otherserogroups &nontoxigenic

strainscausesporadic (not

epidemics)diarrhea

Vibrio cholerae ModeofInfection: ingestionofcontaminated

waterorfood(raworundercookedshellfish)

Humansnaturalhost

Directpersontopersonspread notdocumented

Peoplewithlowgastricacidity:increasedriskofinfection

Incubationperiod:13days(Range:fewhours 5days)

Clinical Manifestation Majorityofinfectedpatientsareasymptomatic


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Diagnosis

StoolCulture

Serology:4foldincreaseinvibriocidal

antibodytitersbetweenacute&convalescent

Clinical:suspectedinanychildwithsevere,

waterydiarrheaandahistoryofrecenttraveltoanendemicarea

Treatment

AntimicrobialTherapy

Shortensdurationofillness,reducesperiodofexcretion,decreasesfluidrequirements

DOC:OralDoxyclycline orTetracycline

AlternativeDrugs:Cotrimoxazole,Erythromycin, Furazolidone,Orciprofloxacin /Ofloxacin (>/=18yo)

DurationofTreatment:3days

Escherichia coli Associated with

Diarrhea Enterotoxigenic E.coli (ETEC)

Producesecretory enterotoxins

Majorcauseofinfantilediarrheaindeveloping

countries

Importantetiologicagentsoftravellers

diarrhea

Explosive,watery,nonmucoid,nonbloody

diarrhea,abdominalpain,nausea,vomiting&

littleor

no

fever

Enteroinvasive E

.coli

(EIEC)

UsuallywaterysimilartoETEC

Minority,dysenterylikeillnesswithbloody,

mucoid stoolsandfecalleucocyteswithfever,

systemictoxicity,abdominalcramps,

tenesmus

Enteropathogenic E.coli(EPEC)

Generallycauseacutediarrheabutsevere

casesleadtoprotracteddisease

Causechronicdiarrheaandmalnutritionin

infantsindevelopingcountries

Breastfeedingisprotective

ShigatoxinproducingE.coli(STEC)

Enterohemorrhagic E.coli(EHEC)

Abdominalpainandinitially,waterydiarrhea

bloodstreakedtobloody

Feverisuncommon

510%developsystemiccomplications:

o Hemolyticuremic syndrome

(renal

failure,

hemolytic

anemiaandthrombocytopenia)orthrombotic,

thrombocytopenicpurpura

Shigatoxin E.coli O157:H7 theprototype&most

virulentmemberoftheE.coli pathotype

Poorlycookedhamburgersacommoncauseoffood

borneoutbreaks


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Associatedwithpersistentdiarrhea(>14days)

indevelopingcountriesespeciallyin>12mos

old

Occasionally,bloody

Associatedwithgrowthretardationininfants

andmalnutrition

CauseAIDSassociatedchronicdiarrheaand

travelersdiarrhea

Enteroaggregative E.coli (EAggEC) Treatment Mainstay:fluid&electrolytetherapy

SpecificantimicrobialtherapyofdiarrheogenicE.coli isproblematicbecauseofdifficultyinmakingaccuratediagnosis&unpredictabilityofantibioticsusceptibility

TMP

SMZ:

appropriate

choice

for

ETEC,EPEC,EIEC EIECareusuallytreatedbeforecultureresults

becauseofsuspicionofshigellosis

AntibioticmayincreaseriskofHUSinSTECdiarrhea

Ciprofloxacin:forEAggEC travelersdiarrhea

E. coli and Other Gram Negative Bacilli

(Neonatal Sepsis and Meningitis )

E.colistrainswiththeK1capsularpolysaccharideantigen cause40%ofsepsisand80%ofcases

OtherGramnegativebacillicausingneonatalsepsis:nonK1strainsofE.coli,Klebsiella,Enterobacter,Proteus,Citrobacter,Salmonella,Pseudomonas,andSerratia sp.

Nontypable H.influenzae,andanaerobicgramnegativebacillirare

E. coli and Other Gram Negative Bacilli

(Septicemia and Meningitis in Neonates)

Difficultdifferentiateclinicallyneonatalsepticemiaor

meningitissecondarytoE.coli&othergramnegative

bacilli

SignsandSymptoms:fever,temperatureinstability,

heartrateabnormalities,gruntingrespirations,apnea,

cyanosis,lethargy,irritability,anorexia,vomiting,

jaundice

Meningitiscanoccurwithoutovertsigns

Citrobacter koseri,Enterobacter sakazakii &Serratia

marcesens maycausebrainabscessassociatedwith

meningitis

Source:maternalgenitaltract

Nosocomial,throughpersontopersontransmissionamongpersonnel&

environmentalsites

such

as

sinks,

solutions,

etc.

PredisposingFactors:

Intrapartum infection,


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Campylobacter Predominantsymptoms:diarrhea

(visibleoroccultbloodinthestool),

abdominalpain,malaise,fever

Milddiseaseresemblesviral

gastroenteritis

Severeinfectionmimicacute

inflammatorybowel

disease

Immunoreactive complications

occurduringconvalescence:GBS,

reactivearthritis,Reitersyndrome,

erythema nodosum

Tx:Erythromycin,Azithromycin,

Doxycycline orQuinolones

The End

Lord, thank you for everything,

I cant name them all but it all comes from You,everyday I am very grateful for everything!

Stage TreatmentandDosage AlternativesPrimary,secondary,or

earlylatent(1yr),

latentofunknown

duration,ortertiary

(gumma or

cardiovascularsyphilis)

PenicillinGbenzathine (2.4millionU

IM)weeklyfor3doses

Tetracycline(500 mgPOqid

for4wk)ordoxycycline

(100mgPObidfor4wk)

Neurosyphilis AqueouscrystallinepenicillinG(1224

millionU/24hrIVgivenas2.4million

Uevery4hr)for1014daysFor

children:Aqueouscrystallinepenicillin

G(200,000300,000U/kgeveryday

IV,givenevery46hr)for1014days

PenicillinGprocaine(2.4

millionU/dayIM)plus

probenicid (500 mgPOqid).

Bothfor1014days

Congenitalsyphilis AqueouscrystallinepenicillinG

(100,000150,000 U/kg/24hr,givenas

50,000U/kgIVevery12hrforthefirst

7daysandevery8hrthereafter)for

1014days

or

Procaine

penicillin

G

(50,000U/kgIMdailyinasingledose)

for1014days

Edited by: K.D. Espino, 2009

bacterial infections - pediatrics part 2

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