11
Childhood infections
Infection used to be a major cause of mortality and morbidity in children. Improvements in nutrition and living conditions, together with the advent of routine immunisation programmes, have reduced the incidence and changed the pattern of infectious diseases dramatically. However, infection remains a cause for concern in at risk groups such as babies and children with certain underlying disease states. It warrants immediate and appropriate management. The ability to diagnose and appropriately treat childhood infections depends on an understanding of epidemiology and risk factors for infections, including underlying disease states. Today, the majority of childhood infections are viral in origin and many are selflimiting. However, it can be difficult to differentiate between bacterial and viral infections and, consequently, antibiotics are frequently prescribed inappropriately. Some children, such as those on immunosuppressive therapy, are more vulnerable to infections and antibiotics should be more readily prescribed for them. Children are also at risk of developing fungal or parasital infections. Some of the most common infections that children can develop will be discussed in this chapter. Immunisation is covered separately in Chapter 5, Section 2 (see page 63).
Objectives On completion of this chapter you will be able to:
•
describe the signs and symptoms of the most common childhood infections
•
discuss the best ways to manage such infections
•
outline the complications of certain treatments.
Childhood infections
1. Bacterial meningitis Bacterial meningitis is an inflammation of the membranes of the brain and spinal cord as a result of bacterial infection. Early recognition and treatment is crucial as it is a life threatening condition that still causes a number of deaths and permanent disability. The organism can cause both meningitis and septicaemia, but it is the septicaemia that kills rapidly. It also causes the characteristic non-blanching purpuric rash†. Meningitis usually develops in children following invasion of the bloodstream by organisms that have colonised mucosal surfaces. This is often preceded by an upper respiratory tract viral infection and subsequent penetration of vulnerable sites of the blood-brain barrier. Severe head trauma, neuro-surgical procedures, penetrating wounds and extension of infection from the middle ear to the meninges can all cause meningitis.
Likely pathogen The most common meningeal pathogens in infants and children are:
• • •
Streptococcus pneumoniae Neisseria meningitides Haemophilus influenzae type b in those under five years. Most cases of H. influenzae occur in children aged three months to three years. In the first few months of life, most infants are protected by their mother’s antibodies while natural immunity to H. influenzae has usually developed by age three. This pathogen is becoming increasingly rare in areas where routine vaccination programmes are in place.
Signs and symptoms Generally the younger the patient, the more atypical are the signs and symptoms. This makes diagnosis more difficult. The classic symptoms of meningitis are: fever, chills, vomiting, photophobia, severe headache and neck rigidity. Convulsions and other central nervous system (CNS) manifestations can occur such as drowsiness, delirium, lethargy and even coma. A non-blanching purpuric rash† can occur, usually indicative of meningococcaemia (i.e. presence of pathogen in bloodstream), rather than a pneumococcal or haemophilus infection. Meningeal inflammation (and the resultant neurological damage) is caused by activation of the host’s inflammatory pathways rather than being the direct result of the micro-organisms themselves.
Diagnosis If meningitis is suspected, a lumbar puncture should be carried out. This allows examination and culture of the cerebrospinal fluid (CSF). The CSF of a patient with acute bacterial meningitis will usually show an increase in the white cell count (predominantly polymorphonuclear leucocytes), together with a positive stained smear and culture for the causative pathogen. Antimicrobial treatment prior to lumbar puncture can modify the findings, although the results are usually still indicative of meningitis. When bacterial meningitis is suspected, antibiotics should not be withheld while awaiting the results of diagnostic tests.
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Management Antimicrobial therapy The 3rd generation cephalosporins, cefotaxime (50mg/kg four times a day) and ceftriaxone (80mg/kg once daily), are commonly used in infants and children. They offer:
• • •
good penetration into the CSF an excellent safety record very good activity against common meningeal pathogens. (There is increasing resistance to penicillins – estimated 20-45% of S. pneumoniae strains worldwide.) If resistance is suspected, the addition of vancomycin is recommended. If resistance is suspected, the addition of vancomycin to the initial empirical regimen is recommended. Once culture results and antibiotic sensitivities are available, the antibiotic regimen may need to be altered. Other agents that may be used include:
•
the carbapenem antibiotics, imipenem and meropenem, which have been shown to have good activity in vitro against S. pneumoniae
•
fluoroquinolones, such as trovafloxacin, gatifloxacin and moxifloxacin are potentially effective in the treatment of multiple resistant pneumococcal isolates due to their activity and CSF penetration
•
rifampicin, in combination with a beta-lactam antibiotic such as ceftriaxone, may offer additional benefits by reducing the release of pro-inflammatory markers, decreased secondary brain injury and a lower early mortality rate. The recommended duration of antibiotic treatment is as follows:
• • •
meningococcal meningitis: at least 5 days pneumococcal meningitis: 10-14 days haemophilus meningitis: at least 10 days.
Chemoprophylaxis Rifampicin is widely used for secondary prophylaxis for all close contacts of suspected H. influenzae and meningococcal meningitis cases. The current dosage recommendations are available in the BNF. Alternatively, in cases of meningococcal meningitis exposure, a single intramuscular dose of ceftriaxone can be given if the oral rifampicin regimen is unsuitable. Chemoprophylaxis is not recommended in cases where exposure to pneumococcal and other types of bacterial meningitis has occurred.
Supportive treatment Dexamethasone therapy Steroids have anti-inflammatory effects and decrease the release of inflammatory mediators. Some studies have shown that dexamethasone reduces overall mortality, the development of hearing loss and long-term neurological problems, especially in children with haemophilus meningitis. Other studies have not found these benefits. Concern has also been raised about the decreased penetration of antibiotics when dexamethasone is used. However, it is felt in many circles that the advantages of dexamethasone treatment, when given with the first parenteral dose of antibiotic, outweighs the possible disadvantages. There is no general consensus on the dose to be used – recent evidence suggests 400 microgram/kg every 12 hours for two days.
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The management of children with bacterial meningitis may also require:
• • • •
adequate oxygenation prevention of hypoglycaemia and hyponatraemia anticonvulsant therapy the use of agents to reduce intracranial hypertension and fluctuations in cerebral blood flow.
Complications Complications can occur early in the course of the illness. Systemic circulatory problems, profound shock and intravascular coagulation can develop, most often associated with meningococcaemia. Neurological complications include hemiparesis†, quadriparesis†, facial palsy and visual field defects. Reversible or permanent deafness can occur if there is inflammation of the auditory nerve or cochlear aqueduct. Seizures are common in the initial stages of the disease but can also occur later. Problems in the joints can occur in the early stages of the disease when the pathogen invades the joint. This can also occur later as a result of an immune-mediated process.
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2. Upper respiratory tract infections Upper respiratory tract infections are common in children, resulting in discomfort for the child, and consequent worry for parents and carers. Most patients are cared for successfully in the community but, occasionally, hospital admission will be necessary in severe cases or following the development of complications.
2.1 Otitis media Otitis media is an infection of the middle ear cavity and most commonly occurs between the ages of six and 15 months. It results from bacteria entering the middle ear. This usually occurs when the normal patency of the Eustachian tube is blocked (e.g. by local infection, pharyngitis, or hypertrophied adenoids†). Air trapped in the middle ear is reabsorbed, creating a negative pressure and permitting the reflux of bacteria. Obstruction of the flow of secretions (from the middle ear to the pharynx), together with the bacterial reflux, results in a middle ear effusion. This, in turn, becomes infected by nasopharyngeal bacteria. Acute otitis media is the most common cause of ear pain with fever in children.
Likely pathogens Otitis media is most commonly caused by Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Mycoplasma pneumoniae. It may also occasionally be caused by gram negative bacteria. These bacteria are not always isolated from infected patients. Respiratory syncytial virus (RSV), cytomegalovirus (CMV) and rhinovirus have also been recovered as co-pathogens or on their own from 20-25% of patients.
Signs and symptoms Patients with otitis media commonly present between one and seven days after nasopharyngitis (rhinorrhoea/sinusitis). Common symptoms include:
• • •
fever irritability ear pulling. Children may also present with:
• • • • •
vomiting and diarrhoea bulging fontanelle† vertigo tinnitus draining ear. Perforation of the tympanic membrane† may occur with dramatic relief of pain, with or without emergence of fluid from the ear canal.
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Management Analgesics and antipyretics should be used for symptomatic relief. It is not necessary to determine the specific pathogen before initiating treatment. Amoxicillin is the treatment of choice, for its effectiveness, safety, patient acceptability and low cost. Erythromycin is recommended for penicillin allergic patients. Symptoms of fever, ear pain and irritability should resolve within 72 hours. If these persist despite compliance (which suggests bacterial resistance) then treatment may be changed to co-amoxiclav, or to a cephalosporin, such as cefalexin. Decongestants and anti-histamines are not considered to be effective in the treatment of otitis media, either alone or in combination with an antibiotic.
Complications Temporary hearing loss at all sound frequencies is common. In the past, chronic otitis media has been attributed to inadequate treatment of acute infection, but this relationship is not clear. Acute mastoiditis is a complication of otitis media with inflammation and potential destruction of mastoid air spaces. Treatment includes systemic antibiotics and incision and drainage (if the disease has progressed to abscess formation).
2.2 Sore throat Sore throat in children is often associated with upper respiratory tract infection. It is a common paediatric complaint and the majority of cases are self limiting. In the absence of other symptoms, it may be treated with simple analgesia. If bacterial infection is suspected, antibiotics should be given.
Likely pathogens Most sore throats are caused by viral pathogens including adenovirus, influenza and Epstein-Barr virus (the pathogen responsible for glandular fever). The primary bacterial pathogen associated with sore throats is group A beta-haemolytic streptococcus. It is difficult to distinguish between viral and bacterial infection and swab results often do not correlate to symptoms.
Signs and symptoms The main symptom is sore throat. This is often associated with inflamed tonsils which may or may not be coated with pus. The presence or absence of pus does not relate to the type of infection present.
Management Most children require only symptomatic treatment with simple analgesia. It has been suggested that the use of antibiotics reduces complications including rheumatic fever and acute otitis media, among others. However, the incidence of these complications is low and there is no convincing evidence to support the routine use of antibiotics. If group A streptococcus is thought to be responsible, then a 10-day treatment course of penicillin V is required. A shorter course of a cephalosporin or macrolide may be used but the convenience of this should be balanced against the potential for the emergence of resistant strains of streptococcus.
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Activity 11.1 Mrs A brings her two year old daughter Lucy to your pharmacy asking for something to settle her. On questioning, she tells you that Lucy is very irritable, not feeding as normal and has a temperature. In addition a few days ago she had developed ‘cold’ symptoms. Lucy weighs 12kg. a:
What do you advise?
Following consultation with her GP, Mrs A is advised to take her daughter to hospital for full assessment of symptoms. Whilst awaiting test results a provisional diagnosis of bacterial meningitis is made. It is decided to commence the infant on intravenous ceftriaxone. b:
What is the rationale for using this antibiotic?
c:
What dose would you recommend the medical staff to prescribe? Are there any particular precautions regarding its administration?
workbook page 23
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3. Lower respiratory tract infections Lower respiratory tract infections (LRTIs) are a common cause of mortality among children in developing countries, and represent a major cause of morbidity among children worldwide. One in four children has a LRTI in the first year of life.
3.1 Bronchiolitis Bronchiolitis is the commonest type of LRTI in infants and infection can cause both acute and long-term problems. Inflammation of the small airways leads to obstruction with exudates. This causes an increase in airway resistance and makes breathing more difficult. The respiratory muscles become fatigued by the increased effort required to oxygenate the body.
Likely pathogens Around 75% of cases are caused by the respiratory syncytial virus (RSV). Other pathogens include adenovirus and rhinovirus. RSV is widespread in the community and almost all infants have been infected by the end of their second year. Of these, 30% will develop lower respiratory symptoms and between 0.5% and 1% will be admitted to hospital with RSV bronchiolitis. Infants at high risk of severe RSV bronchiolitis include those:
• • • • •
born prematurely with cardiovascular disease with chronic respiratory disease (including bronchopulmonary dysplasia†) with cystic fibrosis with immuno-suppression.
Signs and symptoms Characteristically, a short upper respiratory tract illness produces cold-like symptoms. A slightly raised temperature is followed by rapid breathing, moist cough, and difficulty feeding. Signs of more severe illness include apnoea, irritability, listlessness, cyanosis and a reduced level of consciousness. Parents and health care workers should be alert to the symptoms so that treatment can start as quickly as possible. Definitive diagnosis is by immunofluorescence of nasopharyngeal aspirate (NPA), carried out in a hospital.
Management The objectives in the management of RSV are the maintenance of hydration and oxygen status. The nasogastric or parenteral route should be considered if the child is unable to take feeds or fluids orally. Oxygen may be given via nasal prongs or a mask, whichever is best tolerated. Current evidence does not support the use of other therapies for the treatment of RSV. There is no evidence of reliable benefit from bronchodilators and inhaled corticosteroids. Antibiotics are not appropriate, except in the case of secondary bacterial infection. Ribavirin is the only antiviral agent available for the treatment of RSV. Again, trials suggest no reliable benefit, except possibly as adjunctive treatment in specific circumstances for pre-term infants in neonatal intensive care.
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Prevention One product is available for the prophylaxis of RSV: Palivizumab (Synagis) is a monoclonal RSV antibody prescribed during the winter months when RSV infection is most prevalent. It is administered by intramuscular injection every four weeks up to a maximum of five doses. In a randomised double-blind controlled multicentre trial, palivizumab was found to:
• • • •
reduce hospital admissions reduce admissions to intensive care reduce the length of hospital stay reduce the number of days when children required supplementary oxygen. The high cost of palivizumab means that use may be restricted to those children at highest risk of severe infection.
3.2 Community acquired pneumonia Community acquired pneumonia (CAP) is an acute infection of the lower respiratory tract, commonly associated with consolidation of the alveolar spaces. It is potentially fatal. Although most cases can be treated in the community, hospital admission and intravenous antibiotic therapy may be required for more severe cases.
Likely pathogens In many cases, the responsible pathogens are not identified. A significant number of cases are thought to involve a mixed infection (including bacterial-bacterial, bacterial-viral, and viralviral, with RSV the predominant viral pathogen). Streptococcus pneumoniae is assumed to be the most common bacterial cause of CAP. Other bacterial pathogens associated with the condition are Mycoplasma pneumoniae and Chlamydia pneumoniae. Generally, viral infections are more common in younger children, while S. pneumoniae is the most frequent pathogen in older children, followed by Chlamydia and Mycoplasma.
Signs and symptoms Initial symptoms of respiratory infection may include raised temperature, difficulty breathing, wheeze, and increased respiratory rate. Some children may have a cough with sputum but this is not present in all cases (namely with viral infection). Clinical manifestations vary with the type of infection and the infecting organism. Viral infections present more commonly in younger children and are characterised by wheeze, low grade fever (38.5°C and respiratory rate >50/min. For older children, a history of breathing difficulties is more helpful than clinical signs. Pneumonia caused by Mycoplasma pneumoniae (also known as atypical pneumonia) may manifest in a slightly different manner to other bacterial infections. It is most common in children of school age with the main symptom being wheeze, in addition to other signs of bacterial infection.
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Bacterial LRTI
Viral LRTI Infants and young children
Fever >38.5°C
Fever >38.5°C
Respiratory rate >50 breaths/min
Respiratory rate normal/slightly raised
Chest recession
Wheeze
Management Paracetamol and ibuprofen (not withstanding allergy or other contraindications) should be offered to control temperature. Oxygen may be used for children who have an increased respiratory rate and difficulty in breathing. Decisions on the use of antibiotics are dependent on the suspected pathogens. Bacterial infections merit antibiotic treatment while there is no benefit in giving them for viral infections. This is important as bacterial resistance is on the increase and overuse of antibiotics is a large contributory factor. Treatment should start with a broad spectrum penicillin where bacterial pneumonia is suspected. (Erythromycin is a common alternative for patients who are allergic to penicillin.) There is no requirement for microbiological investigation in these patients. In severe cases where intravenous therapy may be indicated, a broad spectrum agent such as ceftriaxone should be used while the results of blood cultures are awaited. Intravenous antibiotics should be converted to oral when there is evidence of improvement in the child’s condition. If a child remains unwell or pyrexial 48 hours after commencing treatment, consideration should be given to bacterial resistance, or the development of complications. A macrolide antibiotic (such as oral azithromycin) may be used as first line therapy in children aged over five and should be used in younger children if either mycoplasma or chlamydia pneumonia is suspected. (The absence in mycoplasma of a cell wall, and the intracellular nature of chlamydia negate the action of penicillins and cephalosporins, both of which exert their bactericidal effect by attacking the bacterial cell wall.)
Activity 11.2 a:
What agent is most commonly used for prophylaxis against respiratory syncytial virus (RSV) infection?
b:
Chemoprophylaxis is indicated for all close contacts of which meningeal pathogens?
workbook page 23
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4. Skin and soft tissue infections Skin problems occur in 20-30% of children who attend general paediatric clinics. Bacterial skin infection is the single most common diagnosis, accounting for 17% of clinic visits. Skin and soft tissue infections in an otherwise healthy child are usually curable with appropriate treatment. However, some infections have the potential to cause serious complications such as septicaemia or arthritis if treatment is delayed or sub-optimal. Persistent or severe infections, or those with unusual symptoms, indicate the possibility of other underlying disease states.
4.1 Impetigo The most common childhood bacterial skin infection is impetigo and accounts for approximately 10% of skin problems. This is a highly contagious infection common in pre-school and school age children. Predisposing factors include overcrowding, poor hygiene, skin abrasions, pre-existing viral or fungal infections or pruritic conditions, accompanied by scratching.
Likely pathogens The most frequent pathogens are Staphylococcus aureus and Streptococcus pyogenes.
Signs and symptoms Impetigo presents as either a non-bullous or bullous form. The non-bullous form is the most common (70% of cases). It presents as small vesicles usually on the face and limbs which rupture and develop a yellow-brown crusting. Bullous impetigo usually presents in the moist areas between the fingers and toes. In non-bullous impetigo the lesions extend slowly and remain smaller than in bullous impetigo. In the latter, blisters increase rapidly in size and number and rupture to form a peripheral brown crust. In most cases the lesions are asymptomatic but can be mildly itchy.
Management Spontaneous cure may occur within two to three weeks but often topical or systemic antibiotics are needed. Mupiricin is an ointment that is bactericidal. It is effective if applied three times daily for seven to ten days. Rare instances of bacterial resistance have been reported. Topical therapy will not eradicate bacteria on clinically uninvolved skin and, therefore, oral antibiotics are the gold standard therapy. Suitable antibiotics include flucloxacillin or erythromycin in cases of penicillin allergy.
Complications Potential complications of impetigo include cellulitis, septicaemia, staphylococcal scalded skin syndrome and acute post-streptococcal glomerulonephritis.
4.2 Cellulitis Cellulitis is characterised by infection and inflammation of loose connective tissue, with limited involvement of the dermis. It does not usually affect the epidermis. A break in the skin due to previous trauma, surgery, or an underlying skin lesion predisposes a patient to cellulitis.
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Likely pathogens Streptococcus pyogenes and Staphylococcus aureus are the most common organisms involved. Haemophilus influenzae is also sometimes seen.
Signs and symptoms The clinical symptoms include oedema, warmth, erythema and tenderness. Systemic manifestations, such as fever, chills, headache and myalgia are often present. Due to the association with previous trauma, cellulitis usually presents on the extremities but may also present in or around the eye (orbital/peri-orbital cellulitis). Erysipelas is a superficial cellulitis characterised by painful, demarcated, red, raised indurated lesions usually occurring on the face but also on the arms and legs.
Management Treatment is based on the history of the illness, the site of the infection, the age and immune status of the child. Blood cultures should be taken if sepsis is suspected. Antibiotic therapy is necessary to cure the infection. Early treatment is important to prevent systemic symptoms and spread to deeper tissues. The red, inflamed area should be marked to monitor if the infection is spreading. Cellulitis should be treated with oral phenoxymethylpenicillin and flucloxacillin where S. pyogenes or S. aureus are isolated or suspected. In severe cases, intravenous benzylpenicillin and flucloxacillin should be used. If H. influenzae is suspected, cefuroxime is the antibiotic of choice and, in penicillin-allergic patients, a macrolide such as erythromycin should be used. Anaerobic bacteria can be implicated in orbital cellulitis (post-septal), and metronidazole should be added accordingly. Ophthalmological opinion is essential where cellulitis is in or around the eye area. Usually a 10 day course of antibiotics is sufficient to treat the infection. However, if symptoms worsen after 24-48 hours, parenteral therapy should be initiated and/or the choice of antibiotics reviewed. Immobilisation and elevation of the affected limb can help to reduce the pain and swelling.
Complications These include subcutaneous abscess, osteomyelitis, septic arthritis and thrombophlebitis. Lymphangitis and glomerulonephritis can also follow S. pyogenes infection.
Activity 11.3 What of the following statements about impetigo are true? a:
Not a very contagious infection.
b:
Spontaneous cure can occur in 2-3 weeks.
c:
Oral antibiotics are the treatment of choice.
workbook page 24
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4.3 Otitis externa This is an acute infection of the external auditory canal. It can be caused by excessive wetness (hence the common name ‘swimmers ear’), dryness, and/or the presence of skin pathology (such as previous infection, eczema, or dermatitis). These can all predispose the external ear to infection.
Likely pathogens It is most commonly caused by S. aureus and S. pyogenes but other bacteria including streptococci, klebsiella and fungi may also be isolated.
Signs and symptoms The predominant symptoms include severe unilateral ear pain (worsening on manipulation of the pinna), itching and inflammation. Conductive hearing loss may occur due to oedema of the skin and tympanic membrane. There may be increased waxy discharge from the affected ear.
Management Topical preparations containing antibiotics and corticosteroids are effective in treating most forms. Oral therapy with a seven-day course of flucloxacillin (or erythromycin in penicillin allergic patients) may be necessary in more severe cases. When the pain is severe, oral analgesics (paracetamol and ibuprofen) may be necessary. During an acute episode, patients should not swim and the ears should be protected from water during bathing.
Complications Abscess formation is a rare complication and requires incision and drainage. Severe cellulitis can develop which requires more prolonged antibiotic treatment.
Activity 11.4 What oral antibiotic therapy is advised in severe cases of otitis externa? workbook page 24
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5. Urinary tract infections In August 2007, NICE published clinical guideline CG54 Urinary Tract infection in children. You will find a copy on the NICE website www.nice.org.uk A urinary tract infection (UTI) occurs when bacteria invade the urethra and become established in the urinary tract. They are among the most common bacterial infections in children and require prompt treatment with antibiotic therapy to avoid the development of long term complications. UTIs are more common in girls than boys, probably due to the relatively short urethra.
Likely pathogens The most common infecting pathogen is Escherichia coli which accounts for up to 80% of cases. Other pathogens include gram negative organisms such as Pseudomonas aeruginosa and Enterobacter (Klebsiella, Proteus) and very occasionally gram positive pathogens such as staphylococcus and streptococcus. Rarely, fungal infection with Candida albicans may occur.
Signs and symptoms In young children, non-specific symptoms such as fever, malaise, irritability and vomiting may be present. In older children typical UTI symptoms are more likely. This includes pain and burning on passing urine, urinary frequency and incontinence. The presence of lower back pain, chills and fatigue may indicate that infection has spread to the kidneys (pyelonephritis) (see Table 1)
Diagnosis The child should be assessed for signs and symptoms of UTI. Infants < 3 months need referral to paediatric specialists care. Urine samples for culture and microscopy are required for all children under 3 years. Children three years and over should have urine dipsticks to measure for Leukocytes and nitrites, the result will determine whether urine cultures and microscopy are necessary. Clean Catch Urine Sample (CCUS) samples are preferable, but if not possible urine collecting pads/suprapubic aspiration may be necessary.
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Table 1 Signs and symptoms of UTIs Age group
Infants younger than 3 months
Infants & children 3 months or over
Preverbal
Symptoms and signs Most common
Least common
Fever
Poor feeding
Abdominal pain
Vomiting
Failure to thrive
Jaundice
Lethargy
Haematuria
Irritability
Offensive urine
Fever
Abdominal pain
Lethargy
Loin Tenderness
Irritability
Vomiting
Haematuria
Poor feeding
Offensive urine Failure to thrive
Verbal
Frequency Dysuria
Dysfunctional voiding Changes to continence Abdominal pain Loin tenderness
Fever Malaise Vomiting Haematuria Offensive urine Cloudy urine
(taken from NICE Guidance CG54 Urinary tract infection in children)
Management Children over 3 months with acute pyelonephritis / upper tract infection are normally treated with locally agreed oral antibiotics (cefalosporins or co-amoxiclav) for 7-10 days. If oral antibiotics can not be used IV (cefotaxime or ceftriaxone) is used for 2 to 4 days followed by oral treatment for a total of 10 days. Consider referral to a specialist. Children over 3 months presenting with cystitis / lower tract infection are usually treated with 3 days of oral antibiotics, children unwell after 24-48 hours should be reassessed. Trimethoprim, nitrofurantoin, cefalosporin or amoxicillin may be suitable.
Supportive treatment Prevention of dehydration is important and the use of intravenous fluids may be appropriate. Good perianal hygiene should be encouraged.
Prevention Prophylaxis is not routinely recommended after first-time UTI but should be considered after recurrence. Encourage children to drink adequate amounts. Address dysfunctional elimination syndromes and constipation. Emphasise the importance of not delaying voiding.
Imaging Various imaging tests may need to be performed depending upon the age of presentation / whether there was reoccurrence or an atypical UTI, see NICE guidance for details.
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Referral Infants and children who have recurrent UTI or abnormal imaging should be assessed by a paediatric specialist.
Complications Generalised bacteraemia or sepsis can develop from an UTI. This is most likely in infants. If left untreated, UTIs or cystitis can progress to renal scarring which has the potential to cause irreversible kidney damage. Pyelonephritis can also occur.
Activity 11.5 a:
What is the most common pathogen that causes urinary tract infections (UTIs) in children?
b:
How long should a child be treated for a UTI that is not making them systemically unwell?
workbook page 24
Activity 11.6 Mr C has come to your pharmacy with his six year old son Tom. Tom has had coryzal symptoms for the last 4-5 days and now has a temperature of 38 degrees. Today he is “breathing quicker” and seems miserable. Occasional coughing fits are not productive of any sputum. a:
What are your initial thoughts and concerns?
b:
What advice do you offer Mr C?
c:
Tom is diagnosed as having a chest infection. What are the likely pathogens, taking into account Tom’s age, signs and symptoms?
d:
What antibiotic would you recommend as first line treatment and why?
workbook page 25
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6. Fungal infection Fungal infections are common in children and occur particularly in babies and young and immuno-compromised children, such as those taking steroids for other chronic diseases. Candidiasis is readily treatable and rarely serious. It can result from antibiotic treatment which alters the normal flora of the gut.
Likely pathogens There are almost 200 candida species. Candida albicans is the most common and most competent pathogen. It is found in many sites in the body particularly in the mouth, rectum, vagina or skin.
Signs and symptoms Oral thrush is identified by characteristic grey-white plaques on the gingival mucosa and gums. When these are removed, a red raw base is revealed. (This distinguishes the condition from deposition of milk curds, which may be scraped away to reveal a normal surface underneath.) Candidal nappy rash may be confused with nappy dermatitis. Although the two lesions may coexist, the sharply demarcated edges of candidal infection and association with oral thrush should suggest the diagnosis. (Many fungal infections originate in the child’s own gastro-intestinal (GI) tract, so it is common for oral and nappy candidal infections to occur simultaneously.) Infection may occur in any area that is moist and occluded such as the groin area and between fingers and toes. They may present as intensely red lesions.
Management Non pharmacological measures play a large part in the first line management of candidal infection. In the case of nappy candidiasis, parents and carers should be reassured that the infection is common and treatable, and advised to avoid the use of plastic or tight-fitting pants. The nappy area should be exposed to the air as much as possible. In oral candidiasis, nystatin oral suspension may be given (and continued for two days after the infection has resolved). Infection usually occurs at both ends of the GI tract and topical agents should also be applied to the nappy area (this is usually continued for seven days following symptom resolution). Nystatin is available as a topical formulation and can be used. Other antifungal creams such as Canestan (clotrimazole) and Daktarin (miconazole) are both available as OTC products. Ointments tend to be used for dry scaly conditions and creams in already moist lesions. Creams are easier to apply than ointments. Sources of possible re-infection should also be addressed. These can include mothers with mastitis who are breast feeding as well as poorly sterilised teats. Resistance is rarely a problem with superficial candidal infections.
Complications Infection of deeper tissues and organs rarely occurs in otherwise healthy children but, if left unchecked, the infection can manifest itself in several forms. Oral infection may progress to oesophageal or intestinal infection. In rare cases, pulmonary or disseminated infections may necessitate systemic therapy. Recurrent infection in an otherwise healthy older child should be investigated.
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