Peds/family

E. coli

Other causes include: klebsiella, proteus, enterobacter, enterococcusand Stapylococcus saprophyticus.

Patients that are older than 2 months and arenot toxic appearing can be treated as outpatients with antimicrobial therapyand followed up closely. UpToDate suggests using a third generationcephalosporin such as cefixime as first line empiric therapy. Patients withpenicillin or cephalosporin allergy can be treated with TMP/SMX orciprofloxacin (risk for tendinitis and Achilles tendon rupture). Therapy should be initiated within 3 days of symptoms to preventrenal damage. Febrile UTIs in children is treated with a longer course of about10 days and is preferred over the shorter course used in afebrile UTIs. Mostpatient’s fever and symptoms will improve in 24-48 hrs. If the patient fails torespond, you should do a repeat urine culture to do antibiotic susceptibility.

the most acute consequence would be urosepsis. More long term consequences include renal scarring, hypertension and impaired growth (in kids).

look at temperature (> 102.2 is associatedwith renal scarring), blood pressure (high blood pressure can be an indicationof recurrent or chronic UTI), growth/weight gain (poor development can indicaterecurrent or chronic UTI), suprapubic/costovertebral tenderness, abdominal examfor mass (bladder or kidney obstruction), and genital exam to look for thingsthat can predispose to UTI.

Renal and bladder ultrasonography playsa role in looking for anatomical abnormalities that can cause UTIs such asduplicated or dilated ureters, size and shape of the kidneys, obstructiveuropathies and abscesses. RBUS is usually reserved for patients that fail torespond to antibiotics or those that have recurrent UTIs.

VUR can cause retrograde transport ofurine into the kidneys and cause UTIs and the test of choice for this isvoiding cystourethrogram.

Vulvovaginitis, Irritant urethritis (can get this from bubble baths), bowel and bladder dysfunction, STIs, urinary calculi, appendicitis, and kawasaki disease (appendicitis and KD may present with fever, abdominal pain and WBCs in the urine)

no. only used in cystitis as it does not have adequate tissue and serum levels.

infants less than 2 months of age, those that appear toxic/dehydrated, and those that are unable to retain oral intake.

Amoxicillin and TMP/SMX. TMP/SMX has variable resistance rates and can be used as empiric treatment if the local resistance does not exceed 20%.

Nitrofurantoin is the preferred DOC.

It is treated in pregnancy and screening for asymptomatic bacteriuria should be done at the first prenatal visit.

asymptomatic bacteriuria is defined as two consecutive voided urin specimens with isolation of the same bacterial strain > 100,000 cfu/mL or a single catheterized urine specimen with one bacterial species isolated with > 100 cfu/mL

Complications of untreated bacteriuria include preterm birth and low birth weight.

beta lactams (avoid ceftriaxone), fosfomycin and nitrofurantoin.

If S. aureus produces penicillin-binding protein then it is MRSA. The mecA gene encodes the PBP and mecA gene is carried by the mobile genetic element SCCmec.

clindamycin, TMP/SMX, and the tetracycline class of antibiotics.

Pasteurella.

Afebrile patients that are stable can be treated with outpatient oral augmentin (amoxicillin/clavulanate).

Patients requiring hospitalization can get IV Unasyn (ampicillin/sulbactam).

Aeromonas spp

fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, and absence of cough.

GAS pharyngitis should not be treated empirically. Diagnosis requires confirmation by rapid testing or culture.

cough, nasal congestion, conjunctivitis, hoarseness, diarrhea and oropharyngeal lesions. These symptoms are more typical of a viral infection and no testing is needed.

Serotype B is most common in infants < 1 year and Serotype C is seen in patients between 15-24 yrs old.

B = babies

C = college students.

rash that begins as macules, papules or urticaria but progresses to petechiae within hours, fever, hypotension, meningeal symptoms and sometimes seizures.

meningococcemia has a fatality rate of up to 40%.

rifampin. Other drugs that can be used are ciprofloxacin and 3rd gen. cephalosporins such as ceftriaxone.

Three potential clinical presentations:

1) Persistent symptoms: Most common. The cardinal features are nasal symptoms, cough, or both that persist for more than 10 but less than 30 days and are not improving (this point is very important).

2) Severe symptoms: ABRS can manifest with severe symptoms at onset. In children this is a fever > 39 C with concurrent purulent nasal discharge for a least 3-4 consecutive days and ill-appearance. Persistent high fever distinguishes this from viral as with viral URIs it is a low grade fever that only lasts for 1-2 days.

3) Worsening symptoms: ABRS also can present with worsening symptoms. Starts similar to a viral URI but symptoms get worse around day 6 (exacerbation of nasal discharge or cough, new headache or fever or recurrence of fever.

S. pneumoniae (30%), H. influenzae, nontypeable (20-40%, up to 50% Blac +), Moraxella catarrhalis (10-20%, >90% Blac +), GAS (<5%), anaerobes (usually seen with a dental infection).

Of note: these are same organisms (and roughly the same percentages) that cause acute otitis media.

Outpatient: Augmentin (amoxicillin/clavulanate) 45 mg/kg/day PO BID for patients that are > 2 yrs, mild-moderate severity, had no antibiotics in last 4 weeks and no daycare attendance.

In patients that are < 2 yrs, moderate-severe illness, had antibiotics in last 4 weeks, goes to daycare, recent hospitalization, immunocompromised or lives in an area with high rates of S. pneumo PCN resistance, give Augmentin 90 mg/kg/day PO BID

Clavulanate is used to overcome the Blac + organisms (H. influenza and moraxella). Treatment usually lasts for 2 weeks in children.

Inpatient: Unasyn (ampicillin/sulbactum) 200-400 mg/kg/day IV q6 or a third gen cephalosporin

Foreign born where it has high prevalence, IV drug abuse, FHx of TB, contact with HIV + individuals, contact with jail or nursing homes, and healthcare workers.

viral. Up to 2/3 of pneumonia in children is due to viruses. This can be even higher in children under age 2.

amoxicillin 90 mg/kg/day PO div tid for bacterial pneumonia (most likely S. pneumoniae). High dose amoxicillin is divided three times a day in order to achieve appropriate concentration in the serum (short half-life in serum) in order to get a MIC high enough in the lungs to kill the pathogen. Of note: in otitis media, amoxicillin is given b.i.d because the half life is greater in the ear.

For atypical pneumonia, empiric treatment is Azithromycin 10 mg/kg PO on day 1, followed by 5 mg/kg/day PO d. for 2-5 days.

In hospitalized patients that are fully immunized, ampicillin or penicillin G is recommended. Patients that are not immunized for Hib and S. pneumonia should receive ceftriaxone. Vancomycin can be added if CA-MRSA is suspected.

If the child: has received amoxicillin in previous 30 days, has concurrent purulent conjunctivitis or has history of recurrent acute otitis media unresponsive to amoxicillin.