6/25/2010

Presenter Disclosures No relationships to disclose No financial disclosures Tracy M. Parker, RN, FNP-BC Family Nurse Practitioner LSUHSC/Baton Rouge Children's Health Project [email protected]

No conflicts of interest Discussion of specific medication with trade names

LSU Health Sciences Division Children’s Health Fund (“Blue Bus”)

OVERVIEW • • • •

Common antibiotic principles Common acute bacterial infections Epidemiology and clinical characteristics Evidence-based approaches in prevention, treatment and pharmacological management

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OBJECTIVES

Antibiotic Principles • Kill the CORRECT bug!

• Describe the epidemiology, clinical characteristics and pathogenesis of Sinusitis, UTI & MRSA among children and adolescents. adolescents • Discuss principles of antibiotic therapy

• Know the CORRECT dose and duration • The more often a patient is exposed to an antibiotic, the more likely to harbor resistant organisms

• Identify evidence based approaches in prevention and treatment

Antibiotic Resistance

Antimicrobial Resistance Causes

“Resistance to antibiotics prescribed in primary care may last up to 12 months.”

• Inappropriate choices

“Longer duration of antibiotic use and multiple courses prescribed were associated with higher rates of resistance.”

• Overuse of antibiotics • Incorrect duration • Suboptimal dosage

BMJ. Published online May 19, 2010.

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Acute Sinusitis

Epidemiology

• • • •

• On average, children develop 5-10 respiratory tract infections yearly. The distinction between viral infections and acute bacterial sinusitis is based on the persistence and severity of upper respiratory symptoms.

Epidemiology Pathogenesis Clinical characteristics (symptoms) Treatment

Pathogenesis

Common Bacterial Pathogens

• Sinusitis occurs most frequently after a viral upper respiratory tract infection or as a result of nasal allergy

• Streptococcus pneumoniae • Haemophilus influenzae • Moraxella catarrhalis

• Inflammation and edema lead to obstruction

• Streptococcus pyogens (group A Streptococcus) both acute and chronic disease

• Pressure changes in the sinus from blowing and sniffing allow bacteria to invade the normally sterile sinus cavity

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Differential Diagnosis

Continued

• Differentiating upper respiratory tract infections (URIs) or allergic rhinitis from acute sinusitis can be difficult in children

• Colds include a daytime cough

• Most uncomplicated URIs improve after 5 to 7 days • It is common for colds to start with a clear, watery nasal discharge progressing after a day or 2 to thick, white, yellow or green.

• If a fever is present, it is usually at the beginning of the cold and is generally low grade lasting for 1 or 2 days • Cold symptoms usually peak in severity at 3 to 5 days then improve and disappear over the next 7 to 10 days

Clinical Characteristics

Clinical Characteristics

• Symptoms persisting without improvement for more than 10 but fewer than 30 days suggest bacterial super infection and a diagnosis of acute sinusitis can be made

• Nasal discharge may be clear or purulent

• Cough and nasal discharge are most common clinical manifestations • Cough is frequently worse at night or when supine

• Fetid breath • Headache and facial pain are manifestations but uncommon in children • High fever and purulent discharge that COEXIST for 3 or more days suggest sinusitis

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Examination • Nasal mucosa is usually erythematous and swollen or pale and boggy • Mucopurulent material can sometimes be seen in the nose or draining into the nasopharynx

Acute bacterial sinusitis Bacterial infection of the sinuses lasting less than 30 days in which symptoms resolve completely.

Recurrent acute bacterial sinusitis

Chronic sinusitis

Episodes of bacterial infection of the sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic

Episodes of inflammation of the sinuses lasting more than 90 days. Patients have persistent residual respiratory symptoms such as cough, cough rhinorrhea, rhinorrhea or nasal obstruction

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Treatment

Medication • Amoxicillin (geographic areas where the prevalence of beta-lactamase-producing strains of H influenzae and M catarrhalis are low) • Broader coverage with amoxicillin plus clavulanate (Augmentin) • Cephalosporins-cefdinir, cefpodoxime, cefprozil • Macrolide should be considered for children who are allergic or fail to respond to amoxicillin or recently received amoxicillin

Treatment

• Clinical improvement expected within 48 hours • Usually a minimum of 10 days of antibiotics is prescribed

Urinary Tract Infections • • • • •

Epidemiology Pathogenesis Clinical characteristics (symptoms) Laboratory Treatment

• Decongestants, antihistamines and saline nose drops have been recommended, but no proof of the efficacy exists • Further research needed to define role of intranasal steroids. Some benefit may exist

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Epidemiology

Pathogenesis

• In school-aged children, symptomatic UTIs is 5 times more common in girls than boys

• The vast majority of bacteria entering the urinary tract are eliminated by the wash effect of urine flow

• Febrile UTIs (pyelonephritis) is more common in children younger than 12 months and cystitis is most common in older children

• Bladder dysfunction (detrusor instability) is know to be a significant risk factor for UTI • Constipation can cause incomplete bladder emptying leading to retention of residual urine

Common Bacterial Pathogens

Clinical Manifestations

• Escherichia coli (occurring naturally in the feces) is responsible for more than 75% cases of community acquired UTI

Dependent upon:

• Other pathogens: Enterococcus, Enterococcus Klebsiella, coagulase-negative Staphylococcus, Proteus • Neisseria gonorrhoeae and Chlamydia trachomatis should be considered in sexually active adolescents

• Age of child • Virulence of underlying pathogen • Inflammatory response of the host • Most common: dysuria, frequency, urgency and lower back pain • UTI should always be considered as a possible cause of unexplained fever

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Laboratory • Urinalysis and Urine culture • Urinalysis showing leukocytouria can support the diagnosis of UTI, but is not sufficient by itself to diagnose UTI because leukocytes may be present in urine (pyuria) for several reasons besides UTI

Treatment •

• • • • • • • • • • • •

U/A Dipstick

Color Odor Glucose Bilirubin Ketone Specific gravity (1.005-1.030) Blood PH 5.0-8.5 Protein Urobilinogen Nitrate Leukocytes

Treatment

1st

line therapy TMP-SMX (Bactrim) or amoxicillin (If resistance rate to TMP-SMX >20% in your locale, don’t empirically treat with TMP SMX) TMP-SMX)

Nitrofurantoin: • Concentrates well in urine and is renally eliminated (low serum concentration)

• Amoxicillin-clavulanate

• Treat for 5-7 days (increased failure rates on 3

• First generation cephalosporins (Cephalexin) • Usually 5 days of treatment

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Prevention

Continued

• Drink the equivalent of eight glasses of water a day • Don’t resist the urge to urinate, void at frequent intervals (every 3 to 4 hours) • Treat any underlying constipation • Urinate after sexual intercourse • Change tampons and sanitary napkins frequently and Do Not douche. • Wipe front to back, or from urethra/vagina toward the anus • STD prevention (abstinence, condom use)

• The role of circumcision in prevention of UTI has been debated. The possible benefits of circumcison can be explained partly by better penile hygiene when p to uncircumcised boys y compared

MRSA

Methicillin-Resistant Staphylococcus Aureus • • • • •

Epidemiology p gy Pathogenesis Clinical characteristics (symptoms) Treatment Prevention

• Cranberry may be of benefit, but further research needed to support use

Epidemiology • About ¼ of people are asymptomatic nasal carriers of S. aureus • Spread by direct contact • S. aureus tends to cause more localized skin infections than streptococci

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Epidemiology

Epidemiology

• MRSA in community settings is increasing

• According to CDC’s Active Bacterial Core Surveillance (ABCs) system, there are approximately 94,000 new cases of invasive methicillin-resistant Staphylococcus p y aureus ((MRSA)) infection reported annually in the United States, resulting in over 19,000 deaths

• These strains are associated with recurrent and severe skin and soft tissue infections including necrotizing fascitis

-Antimicrobial Resistance Interagency Task Force 2007 Annual Report (Released June 2008)

Boil

Impetigo

• A boil is a skin infection that starts in a hair follicle or gland

• Tiny flaccid vesicles or pustules which enlarge and rupture quickly and are followed by honey-colored crusted plaque

• Most common places: face, neck, axilla, shoulders, and buttocks

• Most often overlying an insect bite, abrasion or other skin rash

• Most are caused by staphylococcal bacteria and specifically MRSA

• Most common bacteria- S. aureus • Consider MRSA impetigo if not improving on standard antibiotics

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Clinical characteristics

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Treatment

Prevention

• Incision and drainage alone for cutaneous abscess (usually no antibiotic is prescribed following)

• Frequent hand washing/alcohol based hand sanitizers

• Uncomplicated skin infections -TMP-SMX (Trimethoprimsulfamethoxazole) -Clindamycin -Doxycycline or Minocycline • Antibacterial soap • Cool compresses

• Keep any lesions covered • Do not share towels, wash clothes, razors or other personal items with others • Frequently clean surfaces that child touches

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CASE #1

CASE #1 continued

• 6 year old elementary school female is brought in by teacher with green nasal discharge/congestion and cough all week • NKDA, no meds • No asthma or other chronic illnesses • Has NOT been on antibiotics or any meds all year • Afebrile at time of exam, parent has not taken a temperature • Lungs CTA • ENT-pale, boggy nasal turbinates, cobblestone throat

• One week later-same student brought back in by teacher with same symptoms

CASE #1 Continued

CASE #2

2 months later……..

• • • • • •

• Student back in office with 2 week history of same symptoms as previously • Parent stopped medication early because student’s symptoms had improved

• Parent never filled prescriptions from previous week

16 year old high school male Athlete No symptoms or complaints Routine sports PE Reports not being sexually active U/A Dipstick performed (small leukocytes, ph 6.0, blood moderate, all other values normal or negative)

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REFERENCES

AMERICAN ACADEMY OF PEDIATRICS Subcommittee on Management of Sinusitis and Committee on Quality Improvement Clinical Practice Guideline: Management of Sinusitis *”Just like any guideline, it is designed to assist pediatricians by providing an analytic framework for evaluation and treatment. It is not intended to replace clinical judgment or establish a protocol for all patients with this condition.”

REFERENCES

REFERENCES http://www.cdc.gov/Drugresistance/actionplan/2007_report/exec_ summ.html

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REFERENCES

Important Things our Kids Teach Us QUESTIONS AND DISCUSSION

• It’s more fun to color outside the lines • If you’re gonna draw on the wall, do it behind the couch • Ask why until you understand • Save S a place l in i line li for f your friends f i d • If you want a kitten, start out by asking for a horse

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• Making your bed is a waste of time • If your dog doesn’t like somebody, you probably shouldn’t either • Toads aren’t ugly-they’re just toads • Just keep banging until someone opens the door • Don’t pop someone else’s bubble • You shouldn’t ask to start over just because you’re losing the game • Chasing the cat is more fun than catching it

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