Board ReviewID Bacteria Part 2

Pasteurella multocida Most commonly seen in cat or dog bites Will see erythema, swelling, tenderness, LAD Treatment of Choice – Penicillin

Alternative – Ampicillin, Augmentin, Cefuroxime PCN Allergy - Azithromycin, Bactrim

Borrelia burgdorferi Lyme Disease Usually don’t tell you about the tick Clinical symptoms

Fever, arthritis, rash Arthritis is usually pauciarticular – large joints Antibodies are not positive for 4-6 weeks so don’t

wait!! Lab Test – enzyme assay, Western blot Know that it can be confused with JRA Treatment of Choice – Doxycycline

Alternative Children < 8 – PCN and Erythromycin

A Hard One! Patient with Lyme Disease develops sepsis like

picture Fever, chills, hypotension

What is the name? Jarish-Herxheimer

What is the cause? Treatment causes lysis of organism and release of

endotoxin

Yersina Pestis Bubonic Plague is seen in Western US Presenting symptoms are fever and painful

lymphadenitis Tests

Confirmed with culture CDC has antibody assay

Treatment Streptomycin Gentamicin May need to drain abscesses

Previously healthy 7 year old went to a group picnic with chicken salad the day prior to developing watery loose stools, vomiting and fever.

Diagnosis – Salmonella

Treatment – Supportive

What if I took out “previously healthy” and said “patient with ALL getting chemo” Amoxil, Bactrim or cefotaxime

Salmonella Mode of transmission

Contaminated food Clinical Manifestations

Fever, diarrhea, abdominal cramps Increased WBC, blood, mucus and whites in stool Can have asymptomatic carriers

Lab testing Stool culture

Treatment of Choice Healthy children – supportive Immunosuppressed or very young (< 3mos)

Bactrim, Amoxil

Know that in an healthy individual you don’t have to treat!

Contact Precautions

Shigella Mode of transmission

Person to person Clinical symptoms

If you have it you will have symptoms Fever, SEIZURES Diarrhea – blood, mucus, whites Left shift on differential

Lab Tests Culture, PCR, DFA are available

Treatment Bactrim, Ampicillin

What about daycare?? Do we treat them?

Not unless they have symptoms.

Otherwise just strict hand washing!!!

What is the bug that mimics appendicitis????

Yersina

Yersina enterocolitica Mode of transmission

Contaminated pork Clinical symptoms

“mimic appendicitis” Fever and diarrhea

Lab Tests Stool cultures

Treatment None required Immunocompromised or septicemia – Bactrim,

Aminoglycocides Isolation

CONTACT

Diarrhea in child that lives on a farm????

Campylobacter

Campylobacter Clinical Features

Diarrhea, abdominal pain, fever, malaise Bloody stools

Transmission Chickens, turkeys, farm animals, unpasteurized milk

Tests Stool culture

Management Erythromycin or Azithromycin

* Family working on a farm

CONTACT

H pylori Chronic Gastritis

Epigastric pain, nausea, vomiting, hematemesis, heme + stools

Diagnosis Culture Histological – nodular antrum, lymphoid hyperplasia Urease breath test Serology

Stool antigen should disappear when treated

Treatment – Triple therapy 14 days PPI + Clarithromycin + ( Amoxil or Metronidazole)

Risk Factors Developing country, poor socioeconomic status, family

overcrowding

E ColiBLOOD??

STEC enterohemorrhagic

Hemorrhagic colitis and HUS

+/-

Enteropathogenic

Acute and chronic diarrhea in infants

Watery

Enterotoxigenic Infantile diarrhea in developing countries“Travelers diarrhea”

Watery

Enteroinvasive Diarrhea and fever all ages

Bloody

Enteroaggregative

Acute and chronic diarrhea in infants

Watery(sometimes bloody)

E Coli – enterohemorrhagic (STEC) Diagnosis

Shiga toxin in stool Culture

Remember can also cause ? HUS

Renal failure Thrombocytopenia Hemolytic anemia

Treatment Antibiotics were thought to increase risk of developing

HUS Recent studies have disputed this Most still don’t treat

Pseudomonas Otitis externa Hot tub folliculitis Puncture wound – nail in shoe Cystic Fibrosis Burns Immunocompromised patients

Treatment CEFTAZ

Treponema pallidum- acquired Clinical

manifestations Primary

Painless ulcer - chancre Secondary – 1-2 mos

later Rash, mucocutaneous

lesions, LAD Fever, malaise, sore

throat, arthralgia Latent

Seropositive, but no signs

Lab test Definitive diagnosis –

visualization of spirochetes on dark field mic.

Non-Treponemal RPR, VDRL, ART

Treponemal (+ for life) FTA-ABS , TP-PA

Don’t forget CSF!!! Check with untreated

syphilis > 1yr VDRL, FTA-ABS

Treatment PCN

Treponema pallidum - congenital IgG will cross the placenta

Clinical features Macular papular rash, HSM, peeling skin, LAD,

edema, hemolytic anemia, thrombocytopenia

If untreated – will seeSniffles, bullous lesions, osteochondritis, Hutchinson teeth, keratitis, frontal bossing, mulberry molars, saddle nose, 8th nerve deafness.

Hutchinson Triad – Interstitial keratitisEight cranial nerve deafnessHutchinson teeth

Evaluation of Babies Know the serologic status for ALL babies prior to d/c If mom is +

Careful exam Nontreponemal test

Make sure to do the same one as the mom, so you can compare

** further eval if mom has 4 fold increase or if baby is 4 times mom

Workup Physical exam Nontreponemal test VDRL of CSF (include cell count and protein) Long bone xrays CBC

Do we tap everyone?? Anything on exam suggestive of Syphilis Nontreponemal test fourfold higher than

mom’s Positive darkfield or fluorescent antibody test

Pick your brain… You see a baby in the newborn nursery. When

looking at mom’s labs you notice she is +RPR. What are you thinking? What should you do?

Continuing to investigate you see mom’s FTA-ABS is negative. Do you want to test the baby? Should we give the baby PCN?

The baby’s RPR comes back +, now what FTA-ABS -

Clarify!!Nontreponemal

Test ResultTreponemal Test Result

Means What?

Mom Baby Mom Baby

- - - - No syphilis in mom or baby

+ + - - No syphilis in mom or baby (false positive)

+ - or + + + Maternal syphilis with possible infant infection; mother treated for syphilis during pregnancy, or mom with latent syphilis and possible infant infection

+ + + + Recent or previous syphilis in mom and possibly in infant

- - + + Mom treated successfully before or early in pregnancy

Quiz Infant born with congenital syphilis. Mom was

treated with Erythromycin 2 months prior to delivery. What if any treatment should the infant receive?

If mom treated > 1month prior to delivery no treatment of baby is required BUT – it has to be with PCN to cross the placenta

Treat the baby with Penicillin

Treat or not to Treat… Treatment of Choice – Penicillin G

ALWAYS: neruosyphilis, pregnancy, congenital Answer will be Desensitization (no alternatives)

Newborns Physical, labs, or radiologic evidence of active

disease Positive placenta or umbilical cord test using

darkfield Reactive VDRL in CSF Serum nontreponemal test that is fourfold higher

than mom’s Or if you can’t exclude infection - TREAT

Those who are Safe Healthy appearing babies who’s mom

completed the right dose of PCN greater than FOUR weeks before delivery

Mom had appropriate serological response to treatment

Infant has a nontreponemal titer the same or less than fourfold the maternal titer

Mom had no evidence of reinfection

Treat with a single dose of PCN or Follow PE and titers closely until they are

titers are negative

What if mommy didn’t get it exactly right? 1. Don’t know PCN dose 2. Mom got something other than PCN 3. Treatment given within 28 days of birth Asymptomatic babies with less than four fold

increase 2 choices:

1. Normal full workup: CSF, optho, xrays, blood counts Single dose of PCN G

2. Treat for 10 days with PCN G

Mycobacterium tuberculosis Transmission - airborn Clinical manifestations

Cough, fever, growth delay, wt loss, night sweats Lab test

Skin Test Xray- hilar/mediastinal LAD AFB

sputum > 5 years old Early morning gastric aspirate

Isolation Droplet

Check the BUMP…Induration > 5mm Induration > 10mm Induration > 15mm

Children in close contact with known or suspected contagious people with TB disease

Children at increased risk of disseminated disease Less than 4 years Other medical conditions (Hodgkin, lymphoma, DM chronic renal failure, malnutrition)

Children 4 years or older with no risk factors

Children suspected of having disease: Positive CXR Clinical evidence of TB

Children with increased exposure Born in high prev area Frequently exposed to adults HIV, homeless, illicit drug, institutionalized Traveled to high prev areas

Children receiving immunosuppressive tx or with immunosuppressive conditions (including HIV)

What if it is positive? What is the next step? CXR

If CXR is negative, do you treat? Yes With what? Isoniazid How long? 9 months

Remember! What is the deal with delayed immunizations

and TST???

Can’t give it with the measles vaccine. Why? Will decrease your response to TST

If you need to do TST – should delay vaccine 4-6 weeks No evidence to show you need to do it with

varicella, but you can assume you need to delay as well

My mommy has TBMommy’s Tests What to do with

baby?

TST CXR

+ normal No separationNo special eval or therapyCheck all household members

Abnormal(and mom has signs

or symptoms)

Evaluated baby for congenital TBInitial separation of mom and baby until: Mom and baby are on treatment Mom understands control measures(mask, etc)

Abnormal(mom has no signs or

symptoms)

No SeparationFollow CloselyTreat mom for LTBI

Baby Treatment: Isoniazid 3-4 mos Place PPD if + evaluate for active disease - continue therapy for 9 mos - and mom treated appropriately can stop baby meds

Extrapulmonary TB Meningitis Lymphadenitis Bones Joints Skin