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155829057111900015582907364095002438407364095Aetiology00Aetiology229616010007600N meningitidis > Strep pneumoniae In pneumonia: M pneumoniae > S pneumonaie > C pneumoniae > Hib/a > adenovirus > other viruses (also S aureus, Legionella)00N meningitidis > Strep pneumoniae In pneumonia: M pneumoniae > S pneumonaie > C pneumoniae > Hib/a > adenovirus > other viruses (also S aureus, Legionella)155067010007600>5yrs00>5yrs22961609347200N meningitidis > Strep pneumoniae > HibIn pneumonia: viruses > S pneumonaie > Hib > M pneumoniae > C pneumoniae (also S aureus, B pertussis)00N meningitidis > Strep pneumoniae > HibIn pneumonia: viruses > S pneumonaie > Hib > M pneumoniae > C pneumoniae (also S aureus, B pertussis)15506709347200<5yrs00<5yrs15582908796020<1yr00<1yr22967958796020In pneumonia: RSV > other viruses > strep pneumoniae > Hib > C trachomatis > mycoplasma pneumoniae 00In pneumonia: RSV > other viruses > strep pneumoniae > Hib > C trachomatis > mycoplasma pneumoniae 22961608196580N meningitidis > Hib > Strep pneumoniae > Gp B Strep > E coli > Listeria In pneumonia: Chlamydia trachomatis (develops in 3-16% exposed, conjunctivitis in 50%) > RSV > other viruses > Bordatella pertussis 00N meningitidis > Hib > Strep pneumoniae > Gp B Strep > E coli > Listeria In pneumonia: Chlamydia trachomatis (develops in 3-16% exposed, conjunctivitis in 50%) > RSV > other viruses > Bordatella pertussis 15582908196580<3/1200<3/1215506707364095Neonate00Neonate22967957364095Gp B Strep (30%) > E coli (30-40%) > N meningitidis > Hib > Strep pneumoniae > Listeria Vertical transmission more likely; higher mortality; pneumonia common; other G-ive 15- 20% (eg. Klebsiella), G +ive 10%; enterococci, C trachomatis, herpes simplex; enterovirus, RSV, influenza A00Gp B Strep (30%) > E coli (30-40%) > N meningitidis > Hib > Strep pneumoniae > Listeria Vertical transmission more likely; higher mortality; pneumonia common; other G-ive 15- 20% (eg. Klebsiella), G +ive 10%; enterococci, C trachomatis, herpes simplex; enterovirus, RSV, influenza A1558290963930002463805711825Definitions00Definitions15513056733540Simple febrile convulsion00Simple febrile convulsion335724567335416/12 - 5yrs; T >38.5°C; generalised seizure; short post-ictal period; 1 seizure / fever; duration <15 minutes; no focal neurological deficit afterwards006/12 - 5yrs; T >38.5°C; generalised seizure; short post-ictal period; 1 seizure / fever; duration <15 minutes; no focal neurological deficit afterwards33572456393180As above + hypotension (<65 infants, <75 children, <90 adolescent)00As above + hypotension (<65 infants, <75 children, <90 adolescent)15513056393180Severe sepsis00Severe sepsis15513055711190SIRS00SIRS33572455711825T >38°C / <36°C + HR >160 (infants) / >150 (children) + RR >60 (infants) / >50 (children) + WCC >12 / >10% band forms00T >38°C / <36°C + HR >160 (infants) / >150 (children) + RR >60 (infants) / >50 (children) + WCC >12 / >10% band forms243840963930Pyrexia00Pyrexia15513051536065<1/1200<1/1215582902174240<3/1200<3/12155829028301953-6/12003-6/1222193254125595WCC >15 + fever00WCC >15 + fever222631044729403-36/12 + febrile + appears well003-36/12 + febrile + appears well22123403171190T <38.9°C00T <38.9°C22123403487420T >39°C00T >39°C22193253809365T > 40°C00T > 40°C22263102174240Appears ill00Appears ill22263102490470Appears well00Appears well22193251536065Appears ill00Appears ill22193251852295Appears well00Appears well3364230380936510% bacteraemia0010% bacteraemia3371850412559510% bacteraemia0010% bacteraemia337185044729400.5-0.7% sepsis000.5-0.7% sepsis336486534874203% bacteraemia003% bacteraemia33648652830195<1% SBI00<1% SBI3357880153479513-21% SBI0013-21% SBI33578801851025<5% SBI00<5% SBI3364865217297013-21% SBI0013-21% SBI33648652489200<5% SBI00<5% SBI335788031711901% bacteraemia001% bacteraemia45980352830195UTI in 3-8%00UTI in 3-8%45980351534795Neonates have 2x risk of SBI than 4-8/5200Neonates have 2x risk of SBI than 4-8/52155130531711906/12 – 2yrs006/12 – 2yrs45967653171190UTI most common cause of fever without focus00UTI most common cause of fever without focus15582904994275Any fever00Any fever3357880499491010% SBI0010% SBI15582905345430T >40°C00T >40°C3357880534543010% SBI0010% SBI46005755344795UTI most common cause00UTI most common cause1551305963295Axillary 1°C lower than core; tympanics unreliable; Height of fever irrelevant; may be hypothermic; concern if >38°C; those <3/12 with viral illness have significant incidence of UTI, so still need to do urine00Axillary 1°C lower than core; tympanics unreliable; Height of fever irrelevant; may be hypothermic; concern if >38°C; those <3/12 with viral illness have significant incidence of UTI, so still need to do urine24638011990705Management00Management155575012051665Meropenem 1g TDS (use penicillin / cepahzolin instead if Strep pyogenes) + clindamycin; can use antitoxins if clostridium; debridement; HBOIn Fournier’s gangrene: ceftriaxone 2g IV + metronidazole 500mg IV + gentamicin 5mg/kg00Meropenem 1g TDS (use penicillin / cepahzolin instead if Strep pyogenes) + clindamycin; can use antitoxins if clostridium; debridement; HBOIn Fournier’s gangrene: ceftriaxone 2g IV + metronidazole 500mg IV + gentamicin 5mg/kg246380330200Fever in Children00Fever in Children2438405501005Urinary Tract Infections00Urinary Tract Infections15506705499735Epidemiology: incidence 5% in children aged 3-24/12 with fever; affects 1% boys, 3% girls before puberty; females:males 3:1 (except in neonates); circumcised:uncircumcised 10:1; most common SBI; present in 3-8% young children presenting with fever and no obvious source; 5-10% with symptomatic UTI will develop renal scarring ( HTN, CRF, eclampsia) and bacteraemia; systemic sepsis in 30% 1- 3/12, 5% >3/12; 2% children have asymptomatic bacteruria which is not cause for presentation; pyelonephritis suggested if T >39°C and +ive urine; 10% young infants with UTI have sterile WCC in CSFPathophysiology: haematogenous seeding in neonates; ascending otherwise; cystitis can cause vesicoureteric refluxBacteria: 84% E coli, 6% proteus, 5% klebsiella, 3.5% enterococcus; G+ives in older boys and children with underlying medical conditionsInvestigation: Urine: always send for culture if suspect UTI; always send for microscopy regardless of result of dipstick (unless low risk and negative dipstick); do repeat urine at 10/7 to ensure clearance Nitrites: 40% sensitivity (doesn’t develop with G+ives) 95-99% specificity WBC dipstick: 70-80% sensitivity80-90% specificity Gram stain 80-97% sensitivity; sensitivity ? if <2yrs WBC: 50-90% sensitivity 50-90% specificity Bacteria: 50-90% sensitivity 10-90% specificity Microscopy – 15% false negative rate; significant number missed; may get moderate leucocytess in 40% febrile children without UTI MSSU: good sensitivity, positive if WCC >5-10 Bag spec: unreliable; if negative still needs to be sent for culture; can be used if pre-test probability low Catheter spec: positive if WCC >1-5 SPA: positive if WCC >0; must have at least 15ml on USS, go 1cm superior to pubic symphysis with 23G needle; 50% success rate blind, 95% with USS guidance) Blood: do blood culture if positive urine and <1yr, or ill enough to require admission LP: consider if <1/12 Renal USS: do in all children with 1st UTI, 3-6/52 after infection; also do if sibling of child with VUR; abnormalities found in 40%; obstructive lesions found more commonly in young (<3/12)00Epidemiology: incidence 5% in children aged 3-24/12 with fever; affects 1% boys, 3% girls before puberty; females:males 3:1 (except in neonates); circumcised:uncircumcised 10:1; most common SBI; present in 3-8% young children presenting with fever and no obvious source; 5-10% with symptomatic UTI will develop renal scarring ( HTN, CRF, eclampsia) and bacteraemia; systemic sepsis in 30% 1- 3/12, 5% >3/12; 2% children have asymptomatic bacteruria which is not cause for presentation; pyelonephritis suggested if T >39°C and +ive urine; 10% young infants with UTI have sterile WCC in CSFPathophysiology: haematogenous seeding in neonates; ascending otherwise; cystitis can cause vesicoureteric refluxBacteria: 84% E coli, 6% proteus, 5% klebsiella, 3.5% enterococcus; G+ives in older boys and children with underlying medical conditionsInvestigation: Urine: always send for culture if suspect UTI; always send for microscopy regardless of result of dipstick (unless low risk and negative dipstick); do repeat urine at 10/7 to ensure clearance Nitrites: 40% sensitivity (doesn’t develop with G+ives) 95-99% specificity WBC dipstick: 70-80% sensitivity80-90% specificity Gram stain 80-97% sensitivity; sensitivity ? if <2yrs WBC: 50-90% sensitivity 50-90% specificity Bacteria: 50-90% sensitivity 10-90% specificity Microscopy – 15% false negative rate; significant number missed; may get moderate leucocytess in 40% febrile children without UTI MSSU: good sensitivity, positive if WCC >5-10 Bag spec: unreliable; if negative still needs to be sent for culture; can be used if pre-test probability low Catheter spec: positive if WCC >1-5 SPA: positive if WCC >0; must have at least 15ml on USS, go 1cm superior to pubic symphysis with 23G needle; 50% success rate blind, 95% with USS guidance) Blood: do blood culture if positive urine and <1yr, or ill enough to require admission LP: consider if <1/12 Renal USS: do in all children with 1st UTI, 3-6/52 after infection; also do if sibling of child with VUR; abnormalities found in 40%; obstructive lesions found more commonly in young (<3/12)2438402040890Febrile Convulsions00Febrile Convulsions15506702040255Epidemiology: in 3-5% children; 30-40% recurrent especially if <1yr; ; 3% go on to suffer epilepsy; have no effect on CSF WCCLP in first febrile convulsion: if you think it’s meningitis, treat and do LP when improve Pros: mental state difficult to assess post-ictally; fulminant infections require early diagnosis; quick Cons: <5% have meningitis; traumatic to child / family; may cause meningeal seeding if bacteraemia; coningManagement: seek cause of fever; seek concurrent antibiotics; investigate as per usual fever; consider need for cancer / glucose / pyridoxineRemember: weight = (age + 4) x 2 or >10yrs = age x 3Diazepam 0.25mg/kg IV / 0.5mg/kg PR or Midazolam 0.15mg/kg IV / IM / buccalRepeat after 5minsPhenytoin 18mg/kg over 30mins (will be slow at controlling seizures)Or Phenobarbitone 18mg/kg over 30minsThiopental 5mg/kg IV + RSIIf no IV access: paraldehyde 0.3mg/kg PR (good if mentally handicapped / recurrent seizures)Prognosis: ? risk of febrile convulsion recurrence if: repetitive seizures, focal features, onset <1yr, brief duration between fever onset and seizure; FHDifferential diagnosis: Infantile spasm: sudden brief flexion of arms, head and trunk, occurring in clusters Breath-holding spells: noxious stimulus; after brief cry / vigorous crying Benign neonatal sleep myoclonus / Benign focal epilepsy of childhood / Nocturnal frontal lobe seizures / Night terrors00Epidemiology: in 3-5% children; 30-40% recurrent especially if <1yr; ; 3% go on to suffer epilepsy; have no effect on CSF WCCLP in first febrile convulsion: if you think it’s meningitis, treat and do LP when improve Pros: mental state difficult to assess post-ictally; fulminant infections require early diagnosis; quick Cons: <5% have meningitis; traumatic to child / family; may cause meningeal seeding if bacteraemia; coningManagement: seek cause of fever; seek concurrent antibiotics; investigate as per usual fever; consider need for cancer / glucose / pyridoxineRemember: weight = (age + 4) x 2 or >10yrs = age x 3Diazepam 0.25mg/kg IV / 0.5mg/kg PR or Midazolam 0.15mg/kg IV / IM / buccalRepeat after 5minsPhenytoin 18mg/kg over 30mins (will be slow at controlling seizures)Or Phenobarbitone 18mg/kg over 30minsThiopental 5mg/kg IV + RSIIf no IV access: paraldehyde 0.3mg/kg PR (good if mentally handicapped / recurrent seizures)Prognosis: ? risk of febrile convulsion recurrence if: repetitive seizures, focal features, onset <1yr, brief duration between fever onset and seizure; FHDifferential diagnosis: Infantile spasm: sudden brief flexion of arms, head and trunk, occurring in clusters Breath-holding spells: noxious stimulus; after brief cry / vigorous crying Benign neonatal sleep myoclonus / Benign focal epilepsy of childhood / Nocturnal frontal lobe seizures / Night terrors243840563245Aetiology(cntd)00Aetiology(cntd)1550670574040Immunocompromised, neurosurgery, trauma: Staph, gram negativess, cryptococcus neoformansDeveloping countries: mycoplasma TBBrain abscess: strep viridans, anaerobes, G negatives, staph aureusViral: enterovirus, HSV, VZV, CMV, EBVChronic lung disease (pneumonia): Cystic fibrosis: S aureus, pseudomonas Sickle cell anaemia: encapsulated Immunocompromised: pneumocystis, aspergillis, histoplasma (nodular on CXR), CMV, fungi 00Immunocompromised, neurosurgery, trauma: Staph, gram negativess, cryptococcus neoformansDeveloping countries: mycoplasma TBBrain abscess: strep viridans, anaerobes, G negatives, staph aureusViral: enterovirus, HSV, VZV, CMV, EBVChronic lung disease (pneumonia): Cystic fibrosis: S aureus, pseudomonas Sickle cell anaemia: encapsulated Immunocompromised: pneumocystis, aspergillis, histoplasma (nodular on CXR), CMV, fungi 265430713676500399415010374630+/-00+/-303847510374630+00+26543010382885Gram stain00Gram stain66040009175115? ?00? ?66040009465945? late00? late66008258867775? late00? late66040008559800? early00? early66040007136765TB00TB66040007956550100-50000100-50049231559465310Normal00Normal492315591700350.4-1000.4-156191158877935?00?56197508568690<10000<10056197507956550<50000<50056191157136765Encephalitis00Encephalitis49377597136765Viral00Viral16065508867775<2000<202654308867775MMN (lymphocytes)00MMN (lymphocytes)2654309170035Protein00Protein23317208867775<500<523317209170035<0.400<0.416065509170035<0.300<0.330518108877935<10000<10030518109180195?00?39757358877935?00?39757359180195Normal/?00Normal/?39757359465310Normal/?00Normal/?30518109465310?00?23317209455150>2.500>2.516065509455150>2.500>2.52654309465310Glucose00Glucose233172010066655<200<226543010066655RBC00RBC160655010056495<200<21606550976185550005023317209761855>4000>402654309773285Glucose % in serum00Glucose % in serum49231558877935>10000>10049231558568690<10000<10049231557956550100-70000100-70039941507956550200-500000200-500039757358578850>10-10000>10-10039941507136765Partially treated00Partially treated30518107136765Bacterial00Bacterial30518107948295200-500000200-500030511758578850>100-10,00000>100-10,0002331720856869000002654308568690PMN (neutrophils)00PMN (neutrophils)16065508568690<500<52654308250555% PMN’s00% PMN’s16065508250555<200<22331720825055500002654307938135WCC00WCC16065507938135<3000<3023317207938135<5-1000<5-10233172076231758.5008.516065507623175500523317207136765Normal child00Normal child15976607136765Normal neonate00Normal neonate2654307623175Opening pressure00Opening pressure2654301797685Meningitis00Meningitis15582901797050Epidemiology: 90% occur <5yrs; 5% mortality; 10-20% intellectual / auditory complications; asymptomatic N meningitidis nasal carriage in 10%; meningococcal sepsis bimodal (0-4yrs, 15-25yrs); <3/12 + febrile = 1% incidencePathophysiology: usually haematogenous spread from URTI; can also be direct (eg. Otitis media), injuryRisk factors: young, male, low SEG, congenital abnormalities, shunt, trauma, immunocompromisedAssessment: may be afebrile / hypothermic; bulging fontanelle is late finding and masked by dehydration; signs of meningeal irritation may be absent <18/12; focal neurological deficit in 15% (30% pneumococcus); seizures in 30% (with worse than expected mental status after); 15-20% ? LOC (more in pneumococcus); subdural effusion / empyema (30% in Hib, 20% in strep); may deteriorate after antibiotics (bacteriolysis inflammation); beware partially treated meningitis (more frequent vomiting, longer duration of symptoms); suspect encephalitis if seizures / altered LOC / behaviour; early purpura may just be erytematous maculesLP: consider pre-oxygenation before LP; use non-styleted needle in small infants; neck in mid-flexionCSF interpretation: CSF protein ? 0.01g for every 1000 RBC; lymphocytes >50% in 10% bacterial meningitis; Gram stain 80% sensitivity (50% if pre-treated); may mistake G+ive for G-ive if pre-treated; nearly 100% mononuclear when viral (may be more PMN’s if <48hrs; monocytes are most common WBC in viral); visible budding MO’s on Indian ink staining = cryptococcal; CSF antigen tests have high sensitivity and specificity (especially for Hib and N meningititis)CT before LP if: FND, ? LOCContraindications to LP: signs of ? ICP, coma, FND, focal seizures, seizures >30 minutes, haemodynamically unstable, significant respiratory compromise, purpura, coagulopathy, ? platelets, localised skin infectionOther Investigations: bloods; meningococcal PCR; antigen studies on blood and urine; throat swab for N meningitidisManagement: if shocked, 10-20ml/kg N saline; SIADH in 30% so use 50% maintenance after resus; treat seizure, fever, hypoglycaemia, hyponatraemia (fluid restriction if Na <135), ? intracranial pressureAntibiotics: give antibiotics before LP if there will be >20min delay to LPDexamethasone: 0.25mg/kg (max 10mg) IV/IM Q6h for 48hrs; use if >1/12 to ? host response to bacteria and ? deafness; give at least 15-30mins before (or within 1hr of antibiotics); best in HibContact prophylaxis: meningococcus / Hib – give rifampicin 10mg/kg BD x4 (contraindicateded in pregnancy and liver disease; ceftriaxone IM or ciprofloxacin PO if contraindicated); contact = family and household contacts, those exposed to oral secretions, sexual partners, health care workers, staff and children at pre-school in last 10/700Epidemiology: 90% occur <5yrs; 5% mortality; 10-20% intellectual / auditory complications; asymptomatic N meningitidis nasal carriage in 10%; meningococcal sepsis bimodal (0-4yrs, 15-25yrs); <3/12 + febrile = 1% incidencePathophysiology: usually haematogenous spread from URTI; can also be direct (eg. Otitis media), injuryRisk factors: young, male, low SEG, congenital abnormalities, shunt, trauma, immunocompromisedAssessment: may be afebrile / hypothermic; bulging fontanelle is late finding and masked by dehydration; signs of meningeal irritation may be absent <18/12; focal neurological deficit in 15% (30% pneumococcus); seizures in 30% (with worse than expected mental status after); 15-20% ? LOC (more in pneumococcus); subdural effusion / empyema (30% in Hib, 20% in strep); may deteriorate after antibiotics (bacteriolysis inflammation); beware partially treated meningitis (more frequent vomiting, longer duration of symptoms); suspect encephalitis if seizures / altered LOC / behaviour; early purpura may just be erytematous maculesLP: consider pre-oxygenation before LP; use non-styleted needle in small infants; neck in mid-flexionCSF interpretation: CSF protein ? 0.01g for every 1000 RBC; lymphocytes >50% in 10% bacterial meningitis; Gram stain 80% sensitivity (50% if pre-treated); may mistake G+ive for G-ive if pre-treated; nearly 100% mononuclear when viral (may be more PMN’s if <48hrs; monocytes are most common WBC in viral); visible budding MO’s on Indian ink staining = cryptococcal; CSF antigen tests have high sensitivity and specificity (especially for Hib and N meningititis)CT before LP if: FND, ? LOCContraindications to LP: signs of ? ICP, coma, FND, focal seizures, seizures >30 minutes, haemodynamically unstable, significant respiratory compromise, purpura, coagulopathy, ? platelets, localised skin infectionOther Investigations: bloods; meningococcal PCR; antigen studies on blood and urine; throat swab for N meningitidisManagement: if shocked, 10-20ml/kg N saline; SIADH in 30% so use 50% maintenance after resus; treat seizure, fever, hypoglycaemia, hyponatraemia (fluid restriction if Na <135), ? intracranial pressureAntibiotics: give antibiotics before LP if there will be >20min delay to LPDexamethasone: 0.25mg/kg (max 10mg) IV/IM Q6h for 48hrs; use if >1/12 to ? host response to bacteria and ? deafness; give at least 15-30mins before (or within 1hr of antibiotics); best in HibContact prophylaxis: meningococcus / Hib – give rifampicin 10mg/kg BD x4 (contraindicateded in pregnancy and liver disease; ceftriaxone IM or ciprofloxacin PO if contraindicated); contact = family and household contacts, those exposed to oral secretions, sexual partners, health care workers, staff and children at pre-school in last 10/7265430505460Urinary Tract Infections(cntd)00Urinary Tract Infections(cntd)1558290504190 DMSA scan: do after 6/12 or at age 3-4yrs to look for scarring if required hospitalisation MCU: do if <3/12 or if abnormal USS Admit if: <6/12, septic, significant underlying disease, urinary obstruction, pyelonephritis, failure to respond to PO’sProphylaxis: give if recurrent UTI’s, <3/12 awaiting MCU, known VUR or other renal abnormality; continue until after USS; give 2mg/kg co-trimoxazole or 3mg/kg nitrofurantoin nocte or 5-10mg/kg cefaclor nocte00 DMSA scan: do after 6/12 or at age 3-4yrs to look for scarring if required hospitalisation MCU: do if <3/12 or if abnormal USS Admit if: <6/12, septic, significant underlying disease, urinary obstruction, pyelonephritis, failure to respond to PO’sProphylaxis: give if recurrent UTI’s, <3/12 awaiting MCU, known VUR or other renal abnormality; continue until after USS; give 2mg/kg co-trimoxazole or 3mg/kg nitrofurantoin nocte or 5-10mg/kg cefaclor nocte2654307260590Investigation of the Febrile Child00Investigation of the Febrile Child155829072605900015582909472295Septic screen: do if: 3/12 or under Concurrent antibiotic use and fever without focus Toxic appearanceBloods: WCC, ANC, CRP, procalcitonin improve prediction of SBI; CRP 75% sensitivity and specificity for SBI00Septic screen: do if: 3/12 or under Concurrent antibiotic use and fever without focus Toxic appearanceBloods: WCC, ANC, CRP, procalcitonin improve prediction of SBI; CRP 75% sensitivity and specificity for SBI33528009152255Admit and treat00Admit and treat15538459154160Appears unwell, any age00Appears unwell, any age22256758846185Appears well00Appears well15544808846185>3/1200>3/1233534358846185Urine; discharge if negative00Urine; discharge if negative15544807779385<3/1200<3/1233534358526145Still need to do urine and bloods00Still need to do urine and bloods22256758526145?viral00?viral22256758251190?bronchiolitis00?bronchiolitis33534358251190Still need to do urine00Still need to do urine22256757782560Appears well00Appears well33528007780020As above; but can discharge if WCC <15, urine –ive, CSF WBC <10 and normal CXR; admit otherwise00As above; but can discharge if WCC <15, urine –ive, CSF WBC <10 and normal CXR; admit otherwise15582907260590<1/1200<1/1222256757260590Appears well00Appears well33528007260590FBC, blood culture, urine, CSF, CXR; stool if diarrhea; admit and give antibiotics00FBC, blood culture, urine, CSF, CXR; stool if diarrhea; admit and give antibiotics2654305711190Assessment of the Febrile Child00Assessment of the Febrile Child15582905711190If find source, still do extensive search especially if <3/12; after fever reduction, no difference between appearance of bacteraemic and non-bacteraemic child (fever reduction may mask signs of severe infection); ask about birth history, peri- or neonatal complications; all criteria missed SBI in those <1/12Rochester Criteria: if <60d and well looking, no peri-partum or prior illness, normal FBC, urine and CXR– SBI excluded; will miss 1% SBI; least sensitive of the 3Philadelphia Protocol: if 29-56d and well looking, no immunodeficiency, normal RBC, urine, CXR and CSF; sensitivity 98%, specificity 44%Boston Criteria: if 28-89d and well looking, no recent immunisations / antibiotics, WBC <20, normal urine, CXR and CSF; >99% sensitivity00If find source, still do extensive search especially if <3/12; after fever reduction, no difference between appearance of bacteraemic and non-bacteraemic child (fever reduction may mask signs of severe infection); ask about birth history, peri- or neonatal complications; all criteria missed SBI in those <1/12Rochester Criteria: if <60d and well looking, no peri-partum or prior illness, normal FBC, urine and CXR– SBI excluded; will miss 1% SBI; least sensitive of the 3Philadelphia Protocol: if 29-56d and well looking, no immunodeficiency, normal RBC, urine, CXR and CSF; sensitivity 98%, specificity 44%Boston Criteria: if 28-89d and well looking, no recent immunisations / antibiotics, WBC <20, normal urine, CXR and CSF; >99% sensitivity265430566420Pneumonia00Pneumonia1558290565785Epidemiology: up to 40% are mixed; viral more common than bacterial; strep pneumoniae most common bacterial cause (especially <5yrs); mycoplasma up to 30%History: if neonate, ask about mother’s pre- and perinatal health including infections and fever, premature rupture of membranes, peripartum complications, meconium; wheeze in young infant = bronchiolitis, in child = mycoplasmaAtypical pneumonias (eg. Mycoplasma, C pneumoniae) non-specific appearanceStaph rapidly progressive symptoms high fever, toxic, abscesses, cavitations, pleural effusions C trachomatis staccato cough, diffuse rales, no fever, sore throatMycoplasma hacking dry cough, arthralgia, rash (in 10%), indolent course, Kawasaki syndrome, erythema multiforme, Guillian Barre syndromeB pertussis paroxysmal coughing, gasping, colour change, URTIPneumococcal round pneumonia (should have FU to ensure resolution)If severely unwell: ?staph aureus, grp B strepIf underlying lung disease: ?HibApnoeas: more common in RSV, chlamydia, B pertussisEffusions: strep pneumoniae most common cause; also mycoplasma, HibEmpyema, pneumatocoele, cavitation: staph aureusExamination: toxic appearance has better sensitivity than other parts of exam; SaO2 <90% on air ? risk of treatment failure with PO amoxicillin; fever + ? RR / ? BS / fine crackles predicts XR positive pneumonia with 93-96% sensitivity; fever + all 3 = 98% sensitivity; absence of ? RR, respiratory distress, rales and ? BS excludes pneumonia in 100%; SOB is best sign to rule outBloods: blood culture +ive in <5%; NPA helpful to identify virus in younger, mycoplasma in older; mycoplasma cold agglutinins 72-92% sensitivityCXR: cons: may be false –ive / +ive; may be poor quality image; cost; delay; exposure to radiation; can’t distinguish between bacterial and viral Indications for CXR: toxic appearance with respiratory findings; <3/12 as part of septic screen; <5yrs with T >39°C, WCC >20 and no source; ambiguous clinical findings; ?complication; not responding to antibiotics; ?congenital lung malformation; follow up of round pneumonia; specific exam findings suggesting pneumoniaAdmission criteria: <6-12/12, toxic, altered LOC, complicated pneumonia, hypoxia, unrelieved respiratory distress; inability to feed; co-morbidities, dehydration, not tolerating PO antibiotics, social issues00Epidemiology: up to 40% are mixed; viral more common than bacterial; strep pneumoniae most common bacterial cause (especially <5yrs); mycoplasma up to 30%History: if neonate, ask about mother’s pre- and perinatal health including infections and fever, premature rupture of membranes, peripartum complications, meconium; wheeze in young infant = bronchiolitis, in child = mycoplasmaAtypical pneumonias (eg. Mycoplasma, C pneumoniae) non-specific appearanceStaph rapidly progressive symptoms high fever, toxic, abscesses, cavitations, pleural effusions C trachomatis staccato cough, diffuse rales, no fever, sore throatMycoplasma hacking dry cough, arthralgia, rash (in 10%), indolent course, Kawasaki syndrome, erythema multiforme, Guillian Barre syndromeB pertussis paroxysmal coughing, gasping, colour change, URTIPneumococcal round pneumonia (should have FU to ensure resolution)If severely unwell: ?staph aureus, grp B strepIf underlying lung disease: ?HibApnoeas: more common in RSV, chlamydia, B pertussisEffusions: strep pneumoniae most common cause; also mycoplasma, HibEmpyema, pneumatocoele, cavitation: staph aureusExamination: toxic appearance has better sensitivity than other parts of exam; SaO2 <90% on air ? risk of treatment failure with PO amoxicillin; fever + ? RR / ? BS / fine crackles predicts XR positive pneumonia with 93-96% sensitivity; fever + all 3 = 98% sensitivity; absence of ? RR, respiratory distress, rales and ? BS excludes pneumonia in 100%; SOB is best sign to rule outBloods: blood culture +ive in <5%; NPA helpful to identify virus in younger, mycoplasma in older; mycoplasma cold agglutinins 72-92% sensitivityCXR: cons: may be false –ive / +ive; may be poor quality image; cost; delay; exposure to radiation; can’t distinguish between bacterial and viral Indications for CXR: toxic appearance with respiratory findings; <3/12 as part of septic screen; <5yrs with T >39°C, WCC >20 and no source; ambiguous clinical findings; ?complication; not responding to antibiotics; ?congenital lung malformation; follow up of round pneumonia; specific exam findings suggesting pneumoniaAdmission criteria: <6-12/12, toxic, altered LOC, complicated pneumonia, hypoxia, unrelieved respiratory distress; inability to feed; co-morbidities, dehydration, not tolerating PO antibiotics, social issues3600452052320Antibiotic Choice in Paediatrics00Antibiotic Choice in Paediatrics162369520523200025958804980940 Gentamicin 7.5mg/kg OD (max 240-360mg) IVor Cefuroxime 25-30mg/kg/dose IV00 Gentamicin 7.5mg/kg OD (max 240-360mg) IVor Cefuroxime 25-30mg/kg/dose IV16294104980940>3/1200>3/1216268705483860Well Child00Well Child25958805482590If 6-24/12, give 1x IV/IM dose ceftriaxone 50mg/kg, then discharge on PO for 10/7 (<2yr) or 7/7 (older child) Augmentin 10mg/kg TDS PO Or Cotrimoxazole 4mg/kg BD PO Or Cephalexin 10mg/kg TDS PO00If 6-24/12, give 1x IV/IM dose ceftriaxone 50mg/kg, then discharge on PO for 10/7 (<2yr) or 7/7 (older child) Augmentin 10mg/kg TDS PO Or Cotrimoxazole 4mg/kg BD PO Or Cephalexin 10mg/kg TDS PO16306806268085Meningitis00Meningitis16300456622415<1/1200<1/1222453606622415 Amoxicillin 50mg/kg QID (TDS if <1/52) + Cefotaxime 50mg/kg QID (BD if <1/52)or Gentamicin 2.5mg/kg TDS (BD if <1/52)00 Amoxicillin 50mg/kg QID (TDS if <1/52) + Cefotaxime 50mg/kg QID (BD if <1/52)or Gentamicin 2.5mg/kg TDS (BD if <1/52)22453607287895 Amoxicillin 50mg/kg QID + Cefotaxime 100mg/kg loading dose 50mg/kg QID 00 Amoxicillin 50mg/kg QID + Cefotaxime 100mg/kg loading dose 50mg/kg QID 16306807287895<3/1200<3/1216294107748270>3/1200>3/1222472657748270 Cefotaxime 100mg/kg loading dose 50mg/kg QIDOr Ceftriaxone IM 100mg/kg loading dose 80-100mg/kg OD if no IV access 00 Cefotaxime 100mg/kg loading dose 50mg/kg QIDOr Ceftriaxone IM 100mg/kg loading dose 80-100mg/kg OD if no IV access 16306808213090Once sensitivities available: if Hib – amoxicillin; if pneumococcus / meningococcus – penicillin G, vancomycin00Once sensitivities available: if Hib – amoxicillin; if pneumococcus / meningococcus – penicillin G, vancomycin16306808740140Meningococcal Sepsis00Meningococcal Sepsis16306809106535<1/1200<1/1222472659106535 Amoxicillin 50mg/kg QID (TDS if <1/52) + Cefotaxime 50mg/kg QID (BD if <1/52)?+ Gentamicin 7.5mg/kg OD (5mg/kg if <1/52)00 Amoxicillin 50mg/kg QID (TDS if <1/52) + Cefotaxime 50mg/kg QID (BD if <1/52)?+ Gentamicin 7.5mg/kg OD (5mg/kg if <1/52)16313159772015<3/1200<3/1222472659772015 Amoxicillin 75mg/kg QID + Cefotaxime 100mg/kg loading dose 50mg/kg QID 00 Amoxicillin 75mg/kg QID + Cefotaxime 100mg/kg loading dose 50mg/kg QID 16351254457065<3/12CNS excluded00<3/12CNS excluded25996904457065 Amoxicillin 50mg/kg QID (TDS if <1/52) (use ceftriaxone 25mg/kg BD if penicillin allergy)+ Gentamicin 7.5mg/kg OD (max 240-360mg) IV (Not as good at CNS penetration as cef)00 Amoxicillin 50mg/kg QID (TDS if <1/52) (use ceftriaxone 25mg/kg BD if penicillin allergy)+ Gentamicin 7.5mg/kg OD (max 240-360mg) IV (Not as good at CNS penetration as cef)21780503088005Cefotaxime 100mg/kg loading dose 50mg/kg QID00Cefotaxime 100mg/kg loading dose 50mg/kg QID21780502422525 Amoxicillin 50mg/kg QID (TDS if <1/52) (or ampicillin 50mg/kg QID) (to cover Listeria + Gp B strep)+ Cefotaxime 100mg/kg loading dose 50mg/kg QID (BD if <1/52) (to cover G-ive)or Gentamicin 7mg/kg OD and consider aciclovir00 Amoxicillin 50mg/kg QID (TDS if <1/52) (or ampicillin 50mg/kg QID) (to cover Listeria + Gp B strep)+ Cefotaxime 100mg/kg loading dose 50mg/kg QID (BD if <1/52) (to cover G-ive)or Gentamicin 7mg/kg OD and consider aciclovir16236953088005>3/1200>3/1216281402422525<3/1200<3/1225996903796665 Amoxicillin 50mg/kg QID (TDS if <1/52) + Cefotaxime 100mg/kg loading dose 50mg/kg QID (BD if <1/52)00 Amoxicillin 50mg/kg QID (TDS if <1/52) + Cefotaxime 100mg/kg loading dose 50mg/kg QID (BD if <1/52)16281403797299<3/12CNS not excluded00<3/12CNS not excluded16338553434715Urinary Tract Infection00Urinary Tract Infection16338552059940Fever without Focus00Fever without Focus360045565785Management of the Febrile Child00Management of the Febrile Child1633855565784Fever reduction: Pros: ? metabolic demands; improved neurological assessment; symptomatic relief Cons: doesn’t ? febrile convulsions, fever ? WBC motility and Fe, fever beneficial to immune response, ? ability to assess children with SBIAdmit for antibiotics if: <1/12 (regardless of septic screen result); <3/12 with WCC >15 or any abnormal result on septic screenSepsis: 10-20ml/kg IV saline bolus until perfusion improves (stop if rales or hepatomegaly develops); if shock not reversed, begin inotrope (use dopamine if “cold shock”, noradrenaline if “warm shock”); give hydrocortisone if resistant to inotropes00Fever reduction: Pros: ? metabolic demands; improved neurological assessment; symptomatic relief Cons: doesn’t ? febrile convulsions, fever ? WBC motility and Fe, fever beneficial to immune response, ? ability to assess children with SBIAdmit for antibiotics if: <1/12 (regardless of septic screen result); <3/12 with WCC >15 or any abnormal result on septic screenSepsis: 10-20ml/kg IV saline bolus until perfusion improves (stop if rales or hepatomegaly develops); if shock not reversed, begin inotrope (use dopamine if “cold shock”, noradrenaline if “warm shock”); give hydrocortisone if resistant to inotropes6858007058025003581405408295Discharge Criteria00Discharge Criteria16357605408295In fever: Term baby; no co-morbidities; no antibiotics during illness; WCC 5-15; other investigations normal; responsible carer; high probability of follow upIn febrile convulsion: simple seizure, now normal neurological exam, source of fever determined, sensible parents with action plan, able to access help; consider seizure prophylaxis if prolonged recurrent seizures00In fever: Term baby; no co-morbidities; no antibiotics during illness; WCC 5-15; other investigations normal; responsible carer; high probability of follow upIn febrile convulsion: simple seizure, now normal neurological exam, source of fever determined, sensible parents with action plan, able to access help; consider seizure prophylaxis if prolonged recurrent seizures358140564515Antibiotic Choice in Paediatrics(cntd)00Antibiotic Choice in Paediatrics(cntd)16357605657850025888954883150 Flucloxacillin 50mg/kg QID IV (unwell, post-viral, abscesses)+/- Clindamycin 10mg/kg TDS-QID IV00 Flucloxacillin 50mg/kg QID IV (unwell, post-viral, abscesses)+/- Clindamycin 10mg/kg TDS-QID IV16357604883150Staph00Staph16357604386580Mycoplasma00Mycoplasma25895304386580 Erythromycin 12.5mg/kg QID PO for 7-10/7 (if not improving on amoxicillin)or Roxithromycin 4mg/kg BD PO00 Erythromycin 12.5mg/kg QID PO for 7-10/7 (if not improving on amoxicillin)or Roxithromycin 4mg/kg BD PO16357604049395If well00If well25895304049395 Amoxicillin 30mg/kg TDS PO for 5-7/7 00 Amoxicillin 30mg/kg TDS PO for 5-7/7 25806403558540 Flucloxacillin 50mg/kg QID IV (to cover staph)+ Cefotaxime 50mg/kg QID IV00 Flucloxacillin 50mg/kg QID IV (to cover staph)+ Cefotaxime 50mg/kg QID IV16357603558540>3/12, unwell ++00>3/12, unwell ++16357602905125>3/12, complicated00>3/12, complicated25806402905125 Augmentin 30mg/kg TDS-QID (ie. ?staph, lung abscess, pleural effusion) Or Cefuroxime 30mg/kg TDS+ Erythromycin / clarithromycin if severe (for atypicals, mycoplasma)00 Augmentin 30mg/kg TDS-QID (ie. ?staph, lung abscess, pleural effusion) Or Cefuroxime 30mg/kg TDS+ Erythromycin / clarithromycin if severe (for atypicals, mycoplasma)16357602082800<3/1200<3/1225888952082800 Amoxicillin 50mg/kg QID (TDS if <1/52) (or ampicillin 50mg/kg QID)+ Cefotaxime 100mg/kg loading dose 50mg/kg QID (BD if <1/52) (or gentamicin)00 Amoxicillin 50mg/kg QID (TDS if <1/52) (or ampicillin 50mg/kg QID)+ Cefotaxime 100mg/kg loading dose 50mg/kg QID (BD if <1/52) (or gentamicin)16357602567940>3/1200>3/1225888952567940 Amoxicillin 30-50mg/kg TDS00 Amoxicillin 30-50mg/kg TDS16357601722120Pneumonia00Pneumonia16357601184276Brain Abscess: fluclox 50mg/kg IV Q4hrly + cefotaxime 50mg/kg QID + metronidazole 7.5mg/kg TDSHSV encephalitis: aciclovir <3/12 = 20mg/kg TDS <12yrs = 500mg/m2 TDS >12yrs = 10mg/kg TDS00Brain Abscess: fluclox 50mg/kg IV Q4hrly + cefotaxime 50mg/kg QID + metronidazole 7.5mg/kg TDSHSV encephalitis: aciclovir <3/12 = 20mg/kg TDS <12yrs = 500mg/m2 TDS >12yrs = 10mg/kg TDS1635760564515>3/1200>3/122249805564516 Cefotaxime 100mg/kg loading dose 50mg/kg QIDOr Ceftriaxone 50mg/kg BDOr Ceftriaxone IM 100mg/kg loading dose 80-100mg/kg OD if no IV access 00 Cefotaxime 100mg/kg loading dose 50mg/kg QIDOr Ceftriaxone 50mg/kg BDOr Ceftriaxone IM 100mg/kg loading dose 80-100mg/kg OD if no IV access ................
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