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Common Outpatient Infections

Common Outpatient Infections. Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New Orleans. Otitis Media Sinusitis Pharyngitis Lymphadenitis Pneumonia Urinary tract infection Diarrhea. Impetigo/cellulitis Wounds/bites Infestations Fungal Parasites Herpes Exanthems.

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Common Outpatient Infections

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  1. Common Outpatient Infections Rodolfo E Bégué, MD Chief, Pediatric Infectious Diseases LSUHSC, New Orleans

  2. Otitis Media Sinusitis Pharyngitis Lymphadenitis Pneumonia Urinary tract infection Diarrhea Impetigo/cellulitis Wounds/bites Infestations Fungal Parasites Herpes Exanthems Common Outpatient Infections

  3. Otitis Media Diagnosis • Acute onset • Inflammation • Middle ear fluid Normal AOM

  4. Otitis Media Etiology • Streptococcus pneumoniae Penicillin-susceptible Penicillin-non susceptible • Haemophilus influenzae (non-typeable) • Moraxella catarrhalis

  5. Otitis Media Treatment • ~ 80% resolve spontaneouslyantibiotics increase resolution to ~ 95% • Priority to treat is children < 2 years and severe cases • Drug of Choice: AMOXICILLIN 80-90 mg/kg/d

  6. Otitis Media Failure: • Amoxicillin / clavulanate • Ceftriaxone (1-3 doses) • Tympanocentesis

  7. Otitis Media Alternatives: • Cefdinir (Omnicef) • Cefuroxime (Ceftin) • Cefpodoxime (Vantin) • Ceftriaxone • Azitromycin • Clarithromycin

  8. Recurrent Otitis Media • 3 episodes in 6 months4 episodes in 12 months • Check for environmental factors • Chemoprophylaxis: amoxicillin (20 mg/kg/d) sulfisoxazole (35-70 mg/kg/d) • Ventilating tubes

  9. Otitis Media with Effusion • Middle ear fluidNo inflammation • Must de differentiated from AOM AOM OME Normal

  10. Otitis Media with Effusion Management • Intervention only necessary if there is hearing deficit (bilateral and >20db in “best” ear) • First 3 months: watchful waiting (>95% will resolve) • After 3 months: hearing testing (> 20 db?) • > 4 months: discuss with ENTconsider ventilating tubes

  11. AOMT • Augmentin • Ciprodex Ciprofloxacin 0.3% Dexamethasone 0.1%Cipro HC Ciprofloxacin HCl 0.2% Hydrocortisone 1%Floxin Ofloxacin 0.3%

  12. Otitis Externa • Swimmer’s ear • Staphylococcus aureus, Pseudomonas spp • Cleansing, drying • Neomycin otic solution with polymyxin B and hydrocortisone (Cortisporin)Ciprofloxacin with hydrocortisone (Cipro HC Otic) Ofloxacin otic solution (Floxin Otic) • 2% acetic acidGentamicin ophthalmic (Garamycin)Tobramycin opthalmic (Tobrex)

  13. Diagnosis is clinical URI symptoms that persist > 10 days URI symptoms that get worse after 5 days Sinus pain uncommon Do not do plain films Do not abuse CT Sinusitis

  14. Etiology: Similar to AOM Treatment: Similar to AOM, except that duration is ~ 2 weeks (7 d after patient is free of symptoms) Sinusitis

  15. UNCOMMON Suspect Other etiologies (CF, anatomical) Other explanations (asthma, allergies environmental factors Chronic Sinusitis

  16. Pharyngitis • Viral most common (EBV, rhinovirus, etc) • Allergies • Bacterial: Group A Streptococcus Other Streptococcus

  17. Strept Pharyngitis Diagnosis: • Clinical > 2 years old, acute onset, fever, unilateral lymphadenitis, no URI • Rapid test • Culture (GAS only vs others) • Beware of carriers (need ASLO)

  18. Pharyngitis Treatment: • Penicillin V 250 mg PO bid x 10 daysamoxicillin 40 mg/kg/d div bid x 10 days • Alternatives:benzathine penicillin G, erythromycin, clindamycin, cephalexin, • Others:clarithromycin, cefuroxime, cefixime, ceftibuten, cefdinir, cefpodoxime, azithromycin

  19. Generalized Viral (EBV) Toxoplasmosis Syphilis Single Acute:Staph / Strep Chronic:Bartonella henselaeMycobacteria Lymphadenitis

  20. Acute Lymphadenitis • Clindamycin, cephalexin, macrolide • US  Aspiration Gorup A Streptococcus Staphylococcus aureus

  21. Chronic (sub-acute) lymphadenitis • To consider: CBC, EBV, PPD, B. henselae titers, Toxo, others depending on risk factors • Can treat as for “acute” first • Watch for 2-3 w and re-evaluate • If all negative and not any better, consider wait vs re-test vs aspiration/incision/excision B. henselae MAIC M. tuberculosis

  22. Etiologies ViralRSVInfluenza BacterialStrep pneumoniae AtypicalMycoplasmaChlamydiaTuberculosis Treatment Amoxicillin (2m- 5 yrs) MacrolideErythromycinAzithromycin Antivirals(Oseltamivir) CA Pneumonia

  23. Urinary Tract Infection • Not difficult to treat, only difficult to diagnose but the implications of a missed diagnosis may be terrible • Always suspect in febrile children < 2 yrs of age • Dx of UTI requires a UCx (bag-specimen not good) • UA (WBC), dipstick OK as a guide, especially in combination

  24. Etiology Escherichia coli Enterococcus Treatment Amoxicillin TMP / SMX Cefixime Quinolone Urinary Tract Infection • Follow-up • US, VCUG • DMSA scan • Consider prophylaxis

  25. Acute Gastroenteritis • “Always” infectious • Viruses: rotavirus, calicivirus, others • Bacteria: Campylobacter, Shigella, Salmonella, Yersinia, E. coli • Antibiotics usually not required, unless diarrhea is dysenteric TMP/SMX, Azithromycin, Quinolones • Clostridium difficile

  26. Impetigo / cellulitis • Etiology:Group A Streptococcus Staphylococcus aureus (MRSA) • Treatment:Bacitracin, Mupirocin, RetapaluminCephalexin, clindamycin, TMP/SMX, erytho, linezolid Drain any abscess

  27. Etiology Staph aureus (~ 3 d) Pseudom spp (~ 7 d) Mycobacteria (~ 2-4 w) Treatment Wound careTetanus vaccineAnti-Staph antibiotics If no responseSurgical exploration  cultureCeftazidime  ciprofloxacin (for 2 w) Puncture wounds (foot)

  28. Etiology Pasteurella multocida Eikenella corrodens Streptococcus spp / Staphylococcus spp Neisseria spp / Corynebacterium spp Anaerobes Polymicrobial Prophylaxis and Treatment Wound careTetanus shotRabies prophylaxis (?) Amoxicillin / clavulanate clindamycin + TMP/SMX Bites

  29. Fungal Infections • Oral candidiasisoral nystatin or clotrimazolefluconazole 3 mg/kg qd x 7d • Tinea corporistopical clotrimazole or terbinafine bid 2-3 w+ fluconazole 3 mg/kg/w x 2-3 w • Tinea capitisgriseofulvin 10 mg/kg qd x 4-8 wterbinafine 125 mg qd x 4 w (Lamisil)

  30. Worms Enterobius vermicularis(Ascaris) Scotch tape test Mebendazole 100 mg Pyrantel pamoate 11 mg/kgAlbendazole 400 mg All repeat in 1 w Protozoans Giardia (Cryptosporidium) Metronidazole 5 mg/kg q8h x 5-10dFurazolidone 2 mg/kg q6h x 7-10dAlbendazole 400 mg/d x 5d(Nitazoxanide) Parasites • Taeniasis • Praziquantel, different doses Uncertain significance Entamoeba coli, Endolimax nana, Iodamoeba butschlii Blastocystis hominis, Dientamoeba fragilis

  31. Standard: Permethrin: 1% Nix (Tx of choice) Pyrethrins: RID, A-200, R&C, Pronto, Clear Lice System Lindane 1%: Kwell Upgrade: Permethrin 5%: Elimite Malathion 0.5%: Ovide Crotamiton 10%: Eurax TMP/SMX PO Ivermectin PO200 g/kg Head Lice

  32. QUESTIONS ?

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