Common Pediatric Infections Christina Gillespie MD, MPH, FAAFP Georgetown University / Providence Hospital Family Medicine Residency Program Special Thanks to: Thomas C. Newton, MD Major, USAF, MC
Criteria for Initial Antibiotic Treatment vs Observation in children with AOM Observation option Antibacterial therapy if severe illness; observation option if non-severe illness 2 to 12 years Antibacterial therapy if severe illness; observation option if non-severe illness Antibacterial therapy 6 months to 2 years Antibacterial therapy Antibacterial therapy < 6 months Uncertain Diagnosis Certain Diagnosis AGE
Comparative AOM Outcomes for Observation versus Antibacterial Agent - 2% Skin Rash/Allergy - 16% Diarrhea/Vomiting 26% 21% Persistent MEE 3 mo. 48% 45% Persistent MEE 4-6 wks 0.17% 0.59% Mastoiditis/Complication 72% 82% Clinical Resolution 71% 79% Relief at 4-7 days 87% 91% Relief at 2-3 days 59% 60% Relief at 24 hours Observation Antibacteral Rx AOM Outcome
Visits for acute upper respiratory illnesses, fever, earache, and crying – present in 90% with AOM but also in 72% with viral URI Important to differentiate OME from AOM – OME may accompany viral URIs, prelude an AOM, or be a sequela or AOM – mistaken identification can lead to unnecessary antibiotic prescrtiptions Also need to avoid false-positive diagnosis with otalgia caused by eustachian tube dysfuntion or retraction of the TM
Topical agents – additional benefit over acetominophen but brief Limited effectiveness to home remedies such as distraction, external applications or heat or cold, or oil and no controlled studies that directly address pain witih homeopathic agents
Guidelines apply to otherwise healthy children without underlying conditions that may alter the natural course of AOM including anatomic abnormalities such as cleft palate, genetic conditions such as Down’s Syndrome, immune system disorders, and cochlear implants. Also excluded are children with a clinical recurrence of AOM within 30 days or AOM with underlying chronic OME. Observation is appropriate only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Non-severe illness is mild otalgia and fever <39C in the past 24 hours. Severe illness is moderate to severe otalgia or fever >39C.
Van Buchem and colleagues – only 2.7% of 4860 Dutch children older than 2 given symptomatic treatment and observation developed severe illness (persistent fever, pain, or discharge after 3-4 days) and only 2 developed mastoiditis (both responded promptly to treatment).
Gets additional coverage for beta lactamase positive M catarrhalis and H influenza
Maxillary - Unique as outflow tract sits high on medial sinus wall negating gravitational effects Ethmoid – multiple air cells with narrow ostia – predisposing to obstruction Ostiometeal complex – area between the middle and inferior turbinates that represents the confluence of the drainage areas of the frontal, ethmoid, and maxillary sinuses – cilia move in opposite directions – potential for infection even without physical obstruction
Malodorous breath – often reported in preschoolers, facial pain and headaches are rare, child does not appear ill and if fever present – is usually low grade Physical exam cannot distinguish between viral URIs and ABS
CT scans should not be used in patients who have simple upper respiratory tract symptoms because it does no distinguish between mucosal abnormalities due to viral infections vs ABS Complicated ABS – proptosis, impaired vision, limited extraoccular movements, severe facial pain, notable swelling of the forehead or face, deep-seated headaches, or toxic in appearance
Use of antibiotics for more that a few weeks is not supported by clinical studies, exposes patients to developing allergic hypersensitivity, and may increase the development of resistant organisms
Preseptal or periorbital cellulitis, subperiosteal abscess, orbital abscess, orbital cellulitis, optic neuritis, frontal osteomyelitis (Pott Puffy Tumor), maxillary osteomyelitis, epidural abscess, subdural empyema/abscess, cavernous or sagittal sinus thrombosis, meinigitis, or brain abscess Surgery focus on the ostiomeatal complex – use of the endoscope to enlarge the natural meatus of the maxillary outflow tract and perform an anterior ethmoidectomy