Respiratory Infections (Peds-II)

PURULENT RHINITIS

syndrome in young infants associated with a persistent mucopurulent nasal discharge & an irregular fever (Group A streptococci & Streptococcus pneumoniae are frequent causative agents)

Pharyngitis: Bacterial (Group A Strep): TREATMENT

Penicillin, amoxicillin, cephalexin or erythromycin (Clindamycin recommended for treatment failures) (Children should be treated for 24 hours prior to return to school)

Bronchiolitis: PREVENTION

Prophylaxis with Synagis® • should not be given to infants with a gestational age of 29 weeks who are otherwise healthy • should be given to infants during the first year of life with hemodynamically significant heart disease or premature CLD (premature infants < 32 weeks who require >21% oxygen for at least the first 21 days of life) - max of 5 doses during the RSV season

Rhinosinusitis: RECURRENT/CHRONIC Rhinosinusitis TREATMENT

RECURRENT: -infections clear with antibiotic therapy but recur with subsequent URIs CHRONIC: -prolonged symptoms but no complications Imaging warranted TREATMENT (few clear recommendations): - prolonged antibiotic regimens: up to 28 days - treat any underlying conditions - specialist referral: allergy, ENT

Bronchiolitis

A syndrome of illness related to infection of smaller bronchi & bronchioles Results from inflammatory obstruction of these airways Occurs both sporadically & epidemically Young infants at increased risk b/c of immature immune systems & small airways Can be used as a non-specific term for 1st time wheezing with a viral respiratory infection

Otitis Media: RISK FACTORS

Certain ethnic groups - Alaskan Natives & Native Americans Day care attendance Parental history of ear infections Parental smoking Sibling with history of recurrent AOM Maxillofacial abnormalities HIV infection Trisomy 21

RHINOSINUSITIS

Suppurative infection of paranasal sinuses Anatomy & development: - maxillary & ethmoid sinuses fully formed at birth; pneumatized at 3-4 years - sphenoid sinuses not fully formed until 7-8 yrs - frontal sinuses not fully developed until early teens - ethmoid/maxillary disease most common in children Each sinus is drained via ostium which empties into a meatus. Obstruction of mucociliary flow, which maintains sterile environment, is the usual trigger for sinusitis.

Common Cold (Viral Rhinitis): EPIDEMIOLOGY

most common infectious disease entity 50% of URIs are colds (aka viral rhinitis) - Children have 6-7 episodes/year; some children have more. Incidence decreases as children get older - More prevalent in the winter months - Day care, school, parental smoking, low income and crowding increase the risk of catching a cold - Preschoolers are commonly responsible for household spread

Pneumonia: Etiology: Bacteria: <1 MONTH Old

(Neonatal period somewhat more likely to have bacterial pneumonia) - Group B streptococci - Staphylococcus aureus - gram negative enteric bacilli - T. pallidum - Listeria

Pneumonia: Bacterial: CLINICAL

(age plays important role in symptomatology as well) NEONATES: - fever without focal findings OLDER infants/children (rapid onset of illness): -cough, -dyspnea, -tachypnea! -nasal flaring, -grunting respirations (worrisome) -retractions -often toxic-appearing with a temp > 39°C

Rhinosinusitis: DIAGNOSIS

- Clinical - Sinus x-rays - CT scan

Pharyngitis: OTHER Bacteria ETIOLOGIES

- Fusobacterium necrophorum (FN) - groups C and G streptococci - Corynebacterium diphtheriae - Arcanobacterium haemolyticum - Neisseria meningitidis - Chlamydophila pneumoniae - Mycoplasma pneumoniae

Common Cold: PREVENTION

- Good handwashing and avoidance of environment contaminated with nasal secretions - Avoidance not practical - No role for multivitamins, vitamin C in pediatric populations - Breastfeeding may be protective

Common Cold: EVAL

- History • Symptoms & duration • Epidemiologic data - Physical exam • Vital signs • HEENT • Lungs & heart - Labs rarely needed

Laryngotracheobronchitis (Croup): EPIDEMIOLOGY

- Illness generally occurs in children ages 6 months to 3 years - It is more commonly seen during winter months - Males are more predisposed to croup - Recurrent infections are common - Family history plays a role

Bronchiolitis: EPIDEMIOLOGY

- Illness generally occurs in children less than 2 years of age with peak at 2-6 months - It is more commonly seen during winter months - More common in male infants - Ill family members are source of infection - Children with underling cardiopulmonary disease or immunodeficiency appear to be at higher risk of more serious disease

Pharyngitis: VIRAL

- Infectious mononucleosis (Epstein-Barr Virus) • exudative tonsillitis, cervical adenitis, fever, enlarged liver or spleen • atypical lymphocytosis & positive monospot • monospot frequently negative in children < 5 yrs; • rarely distinguishable from other viruses in children - Herpetic gingivostomatitis; aphthous stomatitis - Herpangina, hand foot and mouth disease - Pharyngoconjunctival fever (adenovirus) - CMV, parainfluenza, RSV, influenza, rhinovirus

Pneumonia: Etiology: VIRAL

- Overall viruses are the most common offending agents in children > 4 months of age • RSV • human metapneumovirus • PIVs • Influenza • Adenovirus • neonates: -consider CMV, Herpes, rubella

Common Cold: TREATMENT

- Saline nose drops (¼-½ tsp salt & 4-6 oz of water) - Nasal bulb suction device - Cool mist humidification of air - Vaporizer - Maintain hydration - Older children: • elevate head of bed • saline gargles or lozenges - Antipyretics - avoid aspirin - acetaminophen - ibuprofen (children ≥ 6 months of age) - Decongestants (for children ≥ 6 years of age) • oral : pseudoephidrine or phenylephrine • topical: phenylephrine or oxymetazoline (children over age 2) - Cough suppressants: dextromethorphan or narcotics - No role for antihistamines

Influenza: CLINICAL

- Sudden rise in temperature, rigors, myalgia, headache, lassitude and anorexia. - Sore throat, nasal congestion, conjunctivitis, nonproductive cough - GI upset not uncommon in pediatric patients - Illness lasts several days - Post-viral asthenia

Common Cold: COMPLICATIONS

- Younger children may have high fevers in absence of secondary infection - Bacterial secondary infections most common: • otitis media, sinusitis, adenitis, pneumonia, bronchitis, asthma exacerbations - Parents should be instructed to watch for any signs of difficult breathing & prolonged high fevers

Otitis Media: Treatment APPROACH

- based on certainty of diagnosis & severity of illness - conservative approach ("watchful waiting") now recommended for afebrile children ≥ 2 years • ~80% will clear infection without antibiotics ORAL ANTIBIOTICS: -recommended for febrile children & those < 2 years (children < 2 are at increased risk of treatment failure, persistent symptoms & recurrent OM)

Otitis Media: Oral Antibiotics CAVEATS

- children < 6 months of age should be treated - children 6-24 months of age should be treated - children ≥ 2 years can have observation if afebrile - children ≥ 2 years that appear toxic, have bilateral OM, persistent otalgia or fever ≥ 102.2° F for 48 hours should be treated - amoxicillin for nearly all children should be given at HD • children at increased risk of beta-lactam resistance • if observations fails after 72 hours use Augmentin-HD • if Augmentin-HD fails after 72 hours use IM ceftriaxone x 3 days PCN-allergic children: - difficult! - macrolides problematic but recommended with acknowledgement of therapeutic limitations - consider clindamycin + sulfisoxazole for moderate to severely ill children - trimethoprim/sulfamethoxazole - quinolones have been used

Pneumonia: RISK FACTORS

- congenital heart and/or lung disease, cystic fibrosis, asthma, sickle cell disease - immunodeficiency syndromes

Otitis Media: RECURRENT

- defined as return of signs and symptoms of acute OM after successful treatment - be sure this is not persistent effusion which may last for 6-8 weeks TREATMENT if WITHIN 30 days of previous episode: • ceftriaxone 50 mg/kg per day IM or IV x 3 days or every 36 hours for 2 doses • levofloxacin 10mg/kg po twice daily for 10 days for children 6mos-5 years; 10 mg/kg po once daily for 10 days (not to exceed 750 mg/day) TREATMENT >30 days of previous of episode: • treat with high dose amoxicillin/clavulanate

Laryngotracheobronchitis (Croup): ETIOLOGY

- most common offending agent is one of parainfluenza viruses (PIVs) - PIV types 1 and 2 commonly cause outbreaks of croup during the fall of year - PIV type 3 can occur sporadically throughout year - Other viral causes of croup include influenza, respiratory syncytial virus & human metapneumovirus

Bronchiolitis: ETIOLOGY

- most common offending agent is respiratory syncytial virus (RSV) - RSV generally occurs during the winter months & pediatric hospitalizations for bronchiolitis & pneumonia generally peak during RSV season Other etiologies: -rhinovirus, -PIVs 1 &2, -influenza virus -corona virus - hMPV (human metapneumovirus) is emerging pathogen

Common Cold: CLINICAL

- nasal irritation - nasal congestion - watery nasal discharge - sneezing - scratchy throat - fever - malaise - conjunctivitis - headache - myalgia (Symptoms generally resolve in 5 to 7 days, but may persist for up to 10 days)

Rhinosinusitis: INDICATIONS for REFERRAL

- need for surgical drainage - need for polypectomy - recurrent sinusitis • especially with exacerbation(s) of asthma - isolation of rare or resistant microbe as etiology - intracranial or orbital complications - suspected immunodeficiency

Rhinosinusitis: COMPLICATIONS

- orbital cellulitis • (commom presentation/complication of ethmoid sinusitis) - dural sinus thrombosis - brain abscess - osteomyelitis (complication of frontal sinusitis aka Pott's puffy tumor) - asthma exacerbations

Pertussis (aka "Whooping cough")

- strictly human disease ETIOLOGY: -Bordetella pertussis - infection in infants has increased steadily since 1980s - incubation period is ~6 days - clinical disease has 3 stages that last ~8 weeks: 1)catarrhal stage: -low grade fever, runny nose 2)paroxysmal stage: -cough with inspirational "whoop" 3)convalescent stage: -gradual symptom resolution peak incidence of pertussis in infants in US occurs in those less than 4 months of age - immunization not completed - at risk for most severe complications Infants are most likely to have atypical symptoms - apneic spells are most common DIAGNOSIS: -culture, -PCR, -fluorescent antibody staining LABS: -↑ WBC with lymphocytosis; CXR: -segmental atelectasis, -perihilar infiltrates TREATMENT: -macrolides, -azithromycin in neonates

Laryngotracheobronchitis (Croup): TREATMENT

- supportive but may also include: • cool mist humidification of the environmental air • inhaled racemic epinephrine for more severe airway compromise • IM or po steroids - Children should be kept calm - Children with stridor at rest may require hospitalization

Influenza: TREATMENT (Influenza A)

1)Amantadine 2)Rimantadine (fewer side effects but FDAapproved only for prevention) 3)Newer drugs (neuraminidase inhibitors): Tamiflu® is now approved for children >1 year of age • resistance of strains of influenza A & B 1st reported in 2005 • resistance is increasing, includes H1N1

Otitis Media: ORAL ANTIBIOTICS

1)Amoxicillin: high dose (HD) now considered standard - 90 mg/kg/d in two divided doses - concentration in middle ear inhibits 98% of all pneumococcal isolates 2)Augmentin®: high dose (HD) - 90 mg/kg/day (of amoxicillin component) in 2 divided doses - use ES suspension (600mg/5ml) MILD PCN Allergy: -Cefdinir (Omnicef®) -cefpodoxime (Vantin®) -cefuroxime (Ceftin®) SEVERE PCN Allergy: -Clarithromycin (Biaxin®) -azithromycin (Zithromax®)

Rhinosinusitis: ACUTE Rhinosinusitis TREATMENT

1)Antibiotics: For MILD-MODETATE (no risk factors): - amoxicillin: low dose/high dose - 10-14 day regimen (or 7 days after symptom resolution) - PCN allergy: second or third gen cephalosporin OR macrolide For SEVERE (or RISK FACTORS): - Augmentin® - cephalosporins (cefprozil, cefuroxime, cefdinir) 2)Topical and/or oral decongestant 3)Saline irrigation 4)Nasal/oral steroids 5)Mucolytics (Failure to improve after 72hrs suggests complication or resistant microbes. Consider imaging, IM or IV therapy, ENT referral)

Bronchiolitis: AAP Guidelines (2014)

1)Diagnosis, treatment and prevention • Dx: distinguish bronchiolitis from other viral infections & identify severe disease • no role for CXR in making diagnosis 2)Treatment remains supportive; new changes: • no role for albuterol, epinephrine or nebulized hypertonic saline* • no role for systemic steroids 3)A pulse oximeter may be helpful in assessing the degree of hypoxemia but doesn't correlate well with respiratory distress • no role for continuous pulse oximetry • supplemental oxygen if pO2 < 90%; clinicians "may choose not to administer" supplemental oxygen if saturation > 90%

Rhinosinusitis: PRE-DISPOSING FACTORS

1)Infectious: -URI(most common), -dental infections 2)Inflammatory: -allergic rhinitis, -vasomotor rhinitis, -allergic fungal sinusitis, -GERD 3)Anatomic: -nasal polyps, -deviated septum, -cleft palate, -adenoidal hypertrophy 4)Foreign body 5)Systemic -immune deficiency, -cystic fibrosis, -immotile cilia syndrome

Influenza: PREVENTION

1)Vaccine: inactivated and live, attenuated (≥ 2 years) • now recommended for all children 6 months to 18 years - cardiovascular disease - respiratory disease, e.g. asthma, CF - immunosupression - sickle-cell disease - live attenuated vaccine is preferred form for healthy children ages 2-8 years 2)rimantadine (Flumadine®) 3)oseltamivir (Tamiflu®)

Otitis Media: SURGICAL

1)tympanocentesis 2)myringotomy/tympanostomy tubes • INDICATIONS: - bilateral effusion for a total of 3 months & a bilateral hearing deficiency - ≥ 3 documented episodes of AOM in six months OR ≥ 4 episodes in 12 months • use of pneumococcal conjugate vaccine has decreased incidence of surgery for tube placement by 25%

PNEUMONIA

A syndrome of illness related to infection of smaller airways & parenchyma with consolidation of aveloar spaces Signs & symptoms: - increased respiratory rate - decreased breath sounds - dullness to percussion - rales or fine crackles - fever, high with bacterial etiology

Rhinosinusitis: ETIOLOGY

ACUTE: • Streptococcus pneumoniae (45%) • Haemophilus influenzae (25%) • Moraxella catarrhalis (20%) CHRONIC: • £-hemolytic streptococci • Staphylococcus aureus • anaerobes

Rhinosinusitis: CLINICAL

ADULTS: -headache, -facial pain, -fever CHILDREN (2 presentations): 1) ≥10 days of nasal congestion, purulent nasal drainage and/or persistent cough 2) abrupt onset with fever > 101 °, facial pain & purulent nasal drainage

Otitis Media: ETIOLOGY

BACTERIA: • H influenzae (↑33%) • M. catarrhalis (↑39%) • S. pneumoniae (↓28%) • Group A strep (rare) VIRUS: -RSV, -rhinoviruses, -CMV, -influenza

Common Cold: TRANSMISSION

Children are main reservoir of cold viruses; -their infection then introduces virus into home ROUTES: - Hand contact of contaminated objects - Inhalation of airborne droplets (droplet infection) Incubation period 2-5 days but can be as long as 8 days

Pharyngitis: Fusobacterium necrophorum (FN)

F. necrophorum, a Gram negative anaerobe, causes endemic pharyngitis in adolescents & young adults (15-30) accounts for approximately 10% of cases of pharyngitis in this age group. -More importantly, its suppurative complications, inc. Lemierre's syndrome, occur at a higher rate than rheumatic fever & cause much greater morbidity & mortality normal flora of oropharynx , also a pharyngeal pathogen lives in tonsillar crypts; major pathogen in peritonsillar infections dramatic increase in US (and worldwide) in past decade affects all ages but adolescents/young adults at increased risk of severe infection, complications (Lemierre's syndrome) acute presentation: severe pharyngitis, cervical adenopathy, headache, ± fever Lemierre's syndrome typically develops 1 -2 weeks after acute pharyngitis Lemierre's syndrome (LS) is septic thrombosis of internal jugular vein that results from extension of F. necrophorum from oropharynx to IJV It results in seeding of distant organs (usually lungs) by septic emboli and is associated with significant morbidity and mortality Suspect in susceptible patients with persistent sore throat, unilateral neck pain/swollen neck Treat non-Group A strep bacterial pharyngitis aggressively in adolescents with PCN + clindamycin (antibiotic therapy must provide anaerobic coverage)

Otitis Media: CLINICAL

INFANTS: -fever, irritability & poor feeding (pulling at ears can be unreliable) OLDER CHILDREN: -fever & otalgia - often follows URI - bulging, erythematous, immobile TM - TM may rupture spontaneously (otorrhea) - if associated with conjunctivitis, think of H. influenzae as likely etiologic agent

Laryngotracheobronchitis (Croup)

Inflammation of subglottic trachea Most common clinical manifestation of acute upper airway obstruction Signs & symptoms: - stridor (intermittent at 1st but increases as obstruction increases) - hoarseness - "barking seal" cough - low-grade fever - symptoms usually worse at night

INFLUENZA: ETIOLOGY

Influenza type A, Influenza type B

Pneumonia: Etiology: Bacteria: >5 YRS Old

MOST COMMON: -Mycoplasma pneumoniae! OTHERS: -"atypicals" also likely (associated with wheezing) -Streptococcus pneumoniae -S. aureus (increasing in incidence) -Pertussis (unimmunized or incompletely immunized) -M. tuberculosis (esp from countries where endemic)

Pneumonia: Etiology: Bacteria: 1-4 MONTH Old

MOST COMMON: Chlamydia trachomatis OTHERS: - H. influenzae (both type B and non-typeable strains) - S. pneumoniae - Group A streptococci - S. aureus (including MRSA) - Mycoplasma pneumoniae

Common Cold: ETIOLOGY

Over 200 viruses: - Rhinoviruses (100 serotypes) - Coronaviruses -Parainfluenza viruses, -respiratory syncytial virus, -adenoviruses, -influenza viruses, -enteroviruses; -human metapneumovirus

Influenza: EPIDEMIOLOGY

Spread of virus is caused by the formation of virus-laden aerosol droplets when an infected individual coughs or sneezes. Individuals in immediate vicinity inhale particles. efficiency of aerosol spread is high & in closed communities can approach 90%. Illness usually occurs 1 -4 days after exposure

OTITIS MEDIA

Suppurative infection of middle ear space - 20% -30% of annual visits to primary care PATHOPHYSIOLOGY: -eustachian tube dysfunction creates negative pressure in middle ear allowing reflux of upper respiratory bacterial flora Peak incidence bet 6 months-3 years (most bet 6-15 mo.) - this age group accounts for 75% of all infections - second peak at 5 years MORE COMMON IN: - young age - bottle-fed infants - winter months

Special Note on Fever

You will see children with respiratory infections (colds, otitis media, pharyngitis, etc.) every day. Many of them will have fever. Most of their infections will be fairly easy to diagnose and treat. But... a child under 3 months of age with a fever > 101°F (38.3°C) has a potentially lifethreatening bacterial infection (SBI) & requires immediate, thorough, aggressive evaluation and treatment

Laryngotracheobronchitis (Croup): CLINICAL

hoarseness, barky cough, inspiratory stridor - elevated respiratory rate - retractions - rales, ronchi & wheezing - x-ray: subglottic narrowing of trachea ("steeple sign")

Pneumonia: ETIOLOGY

mostly viral & bacterial - S. pneumoniae is the most common cause of bacterial pneumonia in children of all ages - fungal (Aspergillus, Histoplasma) & parasitic (Pneumocystis) etiologies not uncommon in children who are immunocompromised - the most common etiologies of pneumonia in children are age dependent

Common Cold: FDA Official Advisory

no cough, cold medications recommended for children under 2 AAP issued similar statement in January 2008 •"children metabolize and react to medications differently than adults" •difficulty: finding correct dose •more than 14 OTC cough and cold medicines removed from market •awaiting FDA recommendations for 5-11 year olds ("not yet complete")

Bronchiolitis: CLINICAL

wheezing, retractions, tachypnea, & rales - children usually have accompanying upper respiratory tract infections, sometimes including conjunctivitis & OM - low-grade fever; irritability with increased WOB - young babies, in particular those born prematurely, may have apneic spells as their presenting manifestation of RSV illness - X-ray may show hyperinflation, atelectasis & infiltrates - diagnosis can be made on clinical grounds - confirmation of an etiologic agent can be made by antigen testing or culture of nasal secretions

Bronchiolitis: Etiology: Human metapneumovirus (hMPV)

• "discovered" in 2001 • causes wide spectrum of respiratory disease from mild URIs to severe lower disease requiring hospitalization; accounts for approximately 3% of RIs in immunocompetent adults & ~6% of RIs in children < 5 yrs • causes a bronchiolitis in children < 2 years of age that is clinically indistinguishable from RSV • immunocomprimised and frail elderly also at increased risk of more severe hMPV infections

Pneumonia: Labs/Imaging: BACTERIAL

• CXR: -segmental infiltrates -atelectasis -sometimes pleural effusions. -Empyema may develop • WBC count usually elevated -predominance of neutrophils • Blood cultures positive in 10-15%

PHARYNGITIS: Bacterial (Group A Strep): CLINICAL

• Sudden onset of illness, with sore throat, fever, headache & abdominal pain; -sore throat may be minor complaint or absent • More often seen in children 5-10 years of age, year-round incidence with peaks in spring and winter months •Often a lack of other respiratory symptoms • Physical exam varied: oropharynx may be beefy red, petechiae may be present; ± exudate • anterior cervical lymph nodes are frequently tender and enlarged • A scarletinaform rash may be apparent (scarlet fever)

Pneumonia: Treatment: VIRAL

• Supportive -nebulized albuterol, -ipratropium or epinephrine - ± steroids • Hydration • Antipyretics & analgesics •Oxygen saturation <95% should be treated with supplemental oxygen

Pharyngitis: Bacterial (Group A Strep): COMPLICATIONS

• Suppurative: - peritonsilar abscess - otitis media - rhinosinusitis - cervical lymphadenitis • NON-suppurative: - rheumatic fever - glomerulonephritis

Pneumonia: Treatment: BACTERIAL

• Therapy usually empiric without a known pathogen • Cover for atypicals & S. pneumoniae unless history & PE provide etiologic clue(s) • If pathogen is known, direct therapy towards specific pathogen • Be aware of drug-resistance of Streptococcus pneumoniae in your community

Pharyngitis: Bacterial (Group A Strep): DIAGNOSIS

• Throat culture and/or rapid antigen detection test • Rapid strep tests are specific but lack sensitivity - no false positives but quite a few false negatives

Pneumonia: Labs/Imaging: VIRAL

• WBC normal (or slightly elevated) -predominance of lymphocytes • CXR: -diffuse interstitial infiltrates, -increased interstitial markings -hyperinflation • Rapid antigen detection tests may be useful • CRP -may help in distinguishing viral from bacterial