key: cord-0042161-l7iuk73z authors: Naga, Osama; Hakim, M. Nawar title: Infectious Diseases date: 2015-03-28 journal: Pediatric Board Study Guide DOI: 10.1007/978-3-319-10115-6_12 sha: f56d0958165a42ff852834f5481bd37a9d9bb995 doc_id: 42161 cord_uid: l7iuk73z Infectious diseases is one of the most common cause of the visits to pediatric office and emergency department as well. • Good hand washing; wash hands with soap and water, alcohol-based antiseptic is acceptable • Disinfecting environmental surfaces • Frequent facility cleaning • Appropriate food handling • Teach children and staff to sneeze or cough into elbow (not hands) • Use gloves when contacting body fluids Common organism in child-care centers: • Shigella infection -Transmitted from infected feces (person-to-person contact) -Do: stool bacterial cultures for any symptomatic contact -Know: if Shigella infections are confirmed should receive appropriate antibacterial treatment -Return to child-care center: ͦ If diarrhea has resolved and stool cultures are negative • Nontyphoidal Salmonella species -No antibiotic is required except: ͦ Infants younger than 3 months of age ͦ Immunocompromised host -Infected individuals should be excluded from child care until symptoms resolve • Salmonella serotype typhi -Treatment is indicated for infected individuals -Return to child-care center ͦ 5 years of age or younger: 48 h after antibiotic treatment ͦ Older than 5 years: 24 h after the diarrhea has resolved • Other risk of infection: e.g., giardia, rotavirus, cryptosporidiosis, respiratory syncytial virus (RSV), parainfluenza virus, adeno, rhino, and corona viruses hemophilus influenza, pneumococcal, hepatitis A and, cytomegalovirus infections • Standard precautions are indicated in the care of all patients including: • Hand hygiene before and after each patient contact • Protective equipment when needed Preventive methods • Alcohol-based products are preferred because of their superior activity and adherence • Soap and water are preferred when hands are visibly soiled or exposed to a spore-forming organism, e.g., ( Clostridium difficile is the most common) • Gloves, isolation gowns, masks, and goggles for any exposure to body fluids contaminated materials or sharps • Strict aseptic technique for all invasive procedures, and for catheter care • Separate well and sick children areas in the medical offices • Contact precautions, e.g., RSV, C. difficile, and Staphylococcus aureus -Gloves and gowns are required when there is direct patient contact • Droplet precautions, e.g., Influenza, Neisseria meningitidis, and Bordetella pertussis -Use of a surgical mask is required -A single room is preferred -Remember all office and hospital staff should receive an annual influenza immunization • Airborne precautions, e.g., Mycobacterium tuberculosis, measles, and varicella (with contact precautions) -Negative pressure airborne infection isolation room -Room needs 6-12 air changes per hour or recirculated through a high-efficiency particulate air (HEPA) filter -Tested N95 or similar sealing mask • Exclusive breastfeeding for the first 6 months is recommended by American Academy of Pediatrics (AAP) • Postpartum colostrum contains high concentrations of antibodies and other infection-protective elements (natural immunization). • The actual antibodies against specific microbial agents present in an individual woman's milk depends on her exposure and response to the particular agents. • Lactoferrin: Limits bacterial growth by iron chelation. • Lysozyme: Bacterial cell wall lysis. • Lactalbumin: Enhance the growth Bifidobacterium and affects immune modulation. • Casein: Limits adhesion of bacteria and facilitates the growth of Bifidobacterium. • Carbohydrates: Enhance the growth of probiotics. • Lipids: Lytic effect on many viruses and are active against Giardia as well. Absolute contraindication of breast feeding • Human immunodeficiency virus 1 (HIV-1) infection (if replacement feeding is acceptable, feasible, affordable, sustainable, and safe) • Human T-lymphotropic virus 1 and 2 infection (varies by country; in Japan, breastfeeding is initiated) • Tuberculosis (active, untreated pulmonary tuberculosis, until effective maternal treatment for the initial 2 weeks or the infant is receiving isoniazid) • Herpes simplex virus infection on a breast (until the lesions on the breast are cleared) • Evaluation for tuberculosis (TB) infection and purified protein derivative (PPD) testing • Written immunization record is accepted for the number of doses, interval, and appropriate age of immunization • Serologic testing to determine protective antibodies: Tetanus antibodies (the test of choice) other antibodies for diphtheria, polio, and hepatitis B can be measured • Pertussis titer do not reliably predict protection against infection • Measles vaccine should not be administered routinely to children younger than 1 year • Chemoprophylaxis before travelling to endemic areas, e.g., mefloquine for malaria should be given before travelling to endemic areas • Use mosquito netting during sleep in tropical areas • Use protective clothing and garments • Repellents, e.g., DEET (< 30 %) applied to children as young as 2 years of age and should be used in endemic area -DEET can be applied every 6-8 h all over the body areas -Insecticide should not applied to children's hands because of risk of ingestion • Use of occlusive cloth to prevent tick bite is paramount • Immunization against disease when travelling to endemic area 1-2 months before, e.g., dengue, typhus, cholera depending on the country of destination • Exposure to contaminated water can cause diarrhea, and other infections, e.g., swimmer's ear • Cryptosporidium is the most common cause of gastrointestinal diseases associated with recreational water • People with diarrhea should not participate in recreational water activities • Children with diarrhea should avoid swimming for 2 weeks after cessation of diarrhea • Avoid ingestion of water • Clean the child with soap and water before swimming • Diaper change in the bathrooms • Indication for monitoring aminoglycosides -If the drug to be used 5 days or more -If there is renal impairment -Trough level is used only but the peak level used in certain circumstances • Trough level: -Serum level of drug obtained just before the fourth or fifth dose -Trough concentration for gentamicin or tobramycin that are greater than 2 µg/mL associated with risk of toxicity -Prolonging the interval or decreasing the dose can be used to address elevated trough level • Peak level (not commonly used) -Should be measured 30 min after completion of fourth or fifth dose -If too low increase the dose by 25 % to reach the desired peak level (e.g., gentamicin peak level 8-10 µg/mL) • Drug use in serious infections (used in combination with other antibiotics), e.g., -Septicemia -Neutropenic fever -Nosocomial respiratory infections -Complicated intra-abdominal infections -Pyelonephritis • Penicillins • Cephalosporins • Carbapenems • Monobactams • Inhibit cell wall synthesis by binding and inhibiting cell wall proteins called penicillin-binding proteins (PBPs). Penicillins, e.g., crystalline penicillin • First generation cephalosporin, e.g., cefazolin and cephalexin -Bacterial coverage ͦ Many gram-positive cocci including methicillinsensitive S. aureus and most Streptococcus ͦ No reliable central nervous system (CNS) penetration, do not use for meningitis or arteriovenous (AV) shunts infections -Indications ͦ Skin and soft tissue infection • Second generation cephalosporins, e.g., cefaclor, cefoxitin, cefuroxime, and cefotetan -Bacterial coverage ͦ Maintains gram-positive activity but less than first generation ͦ Greater coverage for gram-negative bacteria than first generation, e.g., ( H. influenzae Enterobacter aerogenes, and some Neisseria) ͦ Extend the coverage to respiratory gram negative, e.g., ( H. influenzae and Moraxella) ͦ Has variable activity against gut anaerobes except cefuroxime ͦ Do not use for meningitis -Indications ͦ Abdominal surgeries ͦ Community acquired pneumonia ͦ Pelvic inflammatory disease (PID) • Third generation cephalosporins -Bacterial coverage ͦ Extended gram-negative activity, loss of gram-positive activity ͦ Penetrates the cerebrospinal fluid (CSF) well ͦ Has greater activity in deep tissue infections and less toxicity than aminoglycosides ͦ Only few drugs are active against P. aeruginosa, e.g., ceftazidime -Ceftriaxone ͦ Has the longest half-life and effective against most S. pneumoniae ͦ Crosses the blood brain barrier and indicated as the primary therapy for meningitis ͦ Ceftriaxone can be used as single agent for empiric treatment of meningitis while lab results are pending except neonates ampicillin need to be added to cover for Listeria -Cefotaxime ͦ Bacterial coverage is the same as ceftriaxone ͦ It is preferred in neonates or < 30 days old • Fourth generation cephalosporin, e.g., cefepime -Bacterial coverage ͦ Equal gram-positive as the first the generation cephalosporins ͦ Equal gram-negative as the third generation cephalosporins ͦ Excellent Pseudomonas coverage Carbapenems, e.g., imipenem/cilastatin and meropenem • Imipenem is a very-broad-spectrum carbapenem antibiotic. • It is very active against Bacteroides fragilis. • It kills most Enterobacteriaceae, pseudomonas, gram-positive bacteria, and is inhibitory for listeria, and Enterococcus faecalis. • Imipenem can lower the seizure threshold and should not be used in patients with seizures or renal insufficiency. • Meropenem is a similar carbapenem with a longer half-life, less likely than imipenem to cause seizures. Monobactam, e.g., aztreonam • Aztreonam is often used in patients who are penicillin allergic or who cannot tolerate aminoglycosides. • Aztreonam has strong activity against susceptible aerobic and facultative gram-negative bacteria, including P. aeruginosa, most Enterobacteriaceae. • Aztreonam is not active against gram-positive cocci or anaerobes. • Fluoroquinolones has no documented evidence of increased incidence of arthropathy in pediatric patient using fluoroquinolones Bacterial coverage • Tetracycline provides coverage against tick borne organisms, e.g., (Lyme disease, Rocky Mountain spotted fever) • Doxycycline and minocycline are used for acne ( Propionibacterium acnes) • Doxycycline may have MRSA coverage as well Adverse reaction • Tetracyclines causes staining of dental enamels. • Tetracycline is not recommended in children less than 8 years old. • Tetracyclines can be used in children younger than 8 years in life threatening situations, e.g., rocky mountain spotted fever (doxycyclines is the drug of choice). • Doxycycline does not cause staining of permanent teeth comparing to tetracyclines. Herpetic Whitlow (Fig. 1) • Due to autoinoculation of HSV-1 (more in children) or HSV-2 (more in adolescents) • Vesiculoulcerative lesions affect the pulp of the distal phalanx of the hand associated with deep-seated swelling, and erythema • Oral antiviral medications are optional and are used in extensive disease • HSV-1 is more likely to be the agent than HSV-2 • Herpes gladiatorum occurs in contact sports, e.g., wrestling and boxing • Most commonly affects exposed areas, e.g., face and upper extremities • Patients should avoid contact sports during outbreaks until the culture results are negative • Suppressive therapy is likely to be effective, but data about such therapy are insufficient • CMV is a double-stranded DNA virus and is a member of the Herpesviridae family. At least 60 % of the US population has been exposed to CMV. • CMV usually causes an asymptomatic infection; afterward, it remains latent throughout life and may reactivate. • AAP recommend annual vaccination of all children ages 6 months through 18 years before the start of influenza season. • Regardless of seasonal epidemiology, children 6 months through 8 years of age who previously have not been immunized against influenza require two doses of trivalent inactivated influenza vaccine (TIV) or live-attenuated influenza vaccine (LAIV) administered at least 1 month apart to produce a satisfactory antibody response. • TIV. • Quadrivalent influenza vaccine now available. • LAIV. • Egg allergy is not a contraindication to influenza vaccine anymore, except severe allergic reaction (e.g., anaphylaxis) • Children who have influenza and are at high risk for complications, regardless of the severity of their illness. • Healthy children who have moderate-to-severe illness. • Oseltamivir is a neuraminidase inhibitors approved for treatment and prophylaxis of both influenza A and B. • Oseltamivir is administered orally. • The most common adverse effects are nausea and vomiting, although neuropsychiatric events have been reported. Background • Reported cases were in south Asia, Iraq, Turkey, and Egypt • Highly pathogenic strain in birds and poultry • It is not a human strain • The most common cause of common cold (25-80 % of cases). • The common cold is an acute respiratory tract infection (ARTI) characterized by mild coryzal symptoms, rhinorrhea, nasal obstruction, and sneezing. • The most common virus triggers asthma. • About 200 antigenically distinct viruses from eight different genera can cause common cold as well (66-75 %). • HIV genotype to assess for baseline resistance, and mutations • Complete blood count with differential count • Serum chemistries with liver and renal function tests • Lipid profile and urinalysis • For children younger than 5 years of age, CD4 percentage is the preferred test for monitoring immune status • Screening for hepatitis B and C infection as well as for tuberculosis is recommended for all HIV-infected patients • Breastfeeding is contraindicated in HIV positive mothers. • All exposed infants should receive 6 weeks of ZDV • Condoms and abstinence are the best forms of preventing sexual transmission of AIDS • Cesarean delivery and treatment of HIV-positive mothers (specially with high viral load) decreases the risk of transmission of HIV to their infants • Immunization of infants and children -Immunization schedule for HIV-exposed children is the same as for their healthy peers, with only a few exceptions: ͦ Patients who have severely symptomatic illness. ͦ Patient with CD4 percentage of less than 15 % or CD4 counts of less than 200 cells/mm 3 should not receive measles-mumps-rubella (MMR), varicella vaccines or live vaccines. -Annual influenza immunization is recommended for all children older than age 6 months, but only the killed vaccine. • Mode of transmission: respiratory droplets (airborne). • The virus is infectious for 3-4 days before the onset of morbilliform rash and 4 days after the exanthem. • IgM level serology (most reliable test) • Antigen detection in respiratory epithelial cells • Tissue by immunofluorescent method or PCR • Rash is erythematous maculopapular rash spread from up-down and disappear the same way • Intramuscular (IM) immunoglobulin prophylaxis should be given to unimmunized child if exposed to measles infection • Infants (6-12 months) should be pre-vaccinated before travelling to high risk areas, e.g., India. • Children received measles vaccine before 1 year do not count and need to receive two doses of MMR after 12 months for full immunization. • Infected child with measles should be placed under airborne precaution transmission and isolated for 4 days after the rash and for all duration of illness if immunocompromised. • Otitis media is the most common • Pneumonia (common cause of death) • Encephalitis • Subacute sclerosing panencephalitis (SSPE) is rare and it may occur after 6-15 years • Mumps is an acute, self-limited, systemic viral illness characterized by the swelling of one or more of the salivary glands, typically the parotid glands. • The illness is caused by a specific RNA virus, known as Rubulavirus. Clinical presentation • Symptoms in the patient's history consist mostly of fever, headache, and malaise. • Within 24 h, patients may report ear pain localized near the lobe of the ear and aggravated by a chewing movement of the jaw. • Unilateral or bilateral parotid swelling at least for 2 days. Prophylaxis recommendation • All person bitten by, bats, carnivores, e.g., raccoon, foxes, and coyotes • Domestic animals that may be infected • Open wound or scratch contaminated with saliva of infected animals or human • Prompt local flushing and cleaning the wound with soap and water • The need for tetanus and antibiotic should be considered Passive and active immunization should be started as soon as possible • Human rabies immunoglobulin (passive). • Rabies vaccine (active). • Both should be given together. • Human rabies immunoglobulin as much as possible of the dose should be infiltrated directly to wound, the remainder of the dose should be given intramuscularly. • Rabies vaccine should be given IM, the first dose immediately after exposure then repeated at days 3, 7, and 14. • HAV is the most common cause of viral hepatitis worldwide • No known animal reservoir • Mode of transmission is fecal-oral route • Incubation period is 15-50 days • Highest period of communicability is 1 week before and after the onset of symptoms • CD8 + T cells are responsible for the destruction of infected liver cells • In children younger than 5 years may be asymptomatic or with just few symptoms • Older children and adult may develop symptoms of acute infection which may last 2 weeks to several months • Malaise, anorexia, fever, nausea, vomiting, and eventually jaundice • Most of the cases generally resolve without sequelae within a few weeks • Anti-HAV immune globulin M (IgM) in a single serum sample is a good test for current or recent infection. • HAV vaccine at 12 months and booster dose at least 6 months after the initial dose. • Prevention of HAV infection can be promoted by enforcing good hygiene in child care centers, with conscientious hand washing after changing diapers and before handling food. • If travelling is imminent to endemic areas or the patient is immunocompromised, immunoglobulin (IG) can be administered simultaneously with vaccine. • Mainly supportive • Avoid acetaminophen, it can exacerbate damage to liver cells • The infection has an incubation period of 2-6 months • HBV is commonly transmitted via body fluids such as blood, semen, and vaginal secretions • HBV does not spread by breast feeding, kissing, hugging, sharing utensils • Acute self-limited hepatitis: -Increase in serum transaminases and resolution of the infection within 6 months -Nausea -Fever -Abdominal pain -Jaundice, fatigue -General malaise • Fulminant hepatitis: -Acute hepatitis associated with a change in mental status due hepatic encephalopathy • Chronic hepatitis: -Generally is asymptomatic in childhood, having minimal or no effect on growth and development -Serum transaminase values usually are normal -They can flare at any time • HBsAg is the first serologic marker to appear and found in infected persons, its rise correlates with the acute symptoms. • Anti-HBc is the single most valuable serologic marker of acute HBV infection, because it appears as early as HBsAg, and continue later in the course of the disease when HBsAg disappeared. • Anti-HBs marks serologic recovery and protection; marks vaccine immunity. • Both Anti HBs and Anti HBc are detected in person with resolved infection. • HBeAg is present in person with active acute or chronic infection and marks infectivity. • Anti-HBe marks improvement and is the goal of therapy in chronically infected patients. • Remember: Alanine transaminase (AST) and aspartate aminotransferase (ALT) can be derived from muscle, you should verify that serum creatine kinase and aldolase values are within the normal range before assuming that the elevated serum AST and ALT values are hepatic in origin. • HCV is a spherical, enveloped, single-stranded RNA virus belonging to the Flaviviridae family and Flavivirus genus • Egypt had the highest number of reported infections with 22 % prevalence of HCV antibodies in persons in Egypt. • Infants and children -The maternal-fetal route is the principal route of transmission • Adults -Injection during drug abuse is the most common mode of transmission • Chronic carrier • Chronic hepatitis • Hepatocellular carcinoma • HCV infection is investigated by measuring anti-HCV antibody and is confirmed by the detection of serum HCV RNA by PCR. • Screening of infants born to HCV-infected mothers is recommended by measuring serum anti-HCV antibody at 18 months of age. • Know that children with chronic hepatitis C infection should undergo periodic screening tests for hepatic complications and the treatment regimens are available. • Genotype 1 is the most aggressive and most resistant to antiviral therapy • Genome 2 and 3 has a better response • Remember: A high rate of spontaneous mutations in the viral genome is the reason for the lack of an effective vaccine. • Oncogenic strain 16 and 18 are responsible for two thirds of all cervical cancers • Nononcogenic HPV type 6 and 11 are responsible for > 90 % of anogenital wart • Bullous and crusted impetigo. • Soft tissue or lymph node infection. • If the organism seeds the bloodstream, dissemination to joints, bones, kidney, liver, muscles, lung, and heart valves may occur, causing substantial morbidity and potential mortality. • S. aureus is the most common cause of osteomyelitis, except sickle cell anemia patients is usually caused by salmonella. • Children with cyanotic congenital heart disease are at high risk of staphylococcal brain abscess. • Children who undergo neurosurgical procedures, specially shunt revisions at high risk for staphylococcal infection. • Catheters are usually associated with staphylococcal infection and must be removed if the patient develops symptoms or positive culture, and antibiotic must be started. • Folliculitis: superficial inflammation centered around a follicle. • Furuncles: bacterial folliculitis of a single follicle that involves a deeper portion of the follicle. • Carbuncle: bacterial folliculitis that involves the deeper portion of several contiguous follicles. • Bacterial folliculitis most often caused by S. aureus. • Hot tub folliculitis is usually caused by gram-negative bacteria (most often P. aeruginosa. It is self limited). • Usually the child looks healthy and does not appear ill. • Abscess (< 5 cm) drainage alone is curative and should be performed along with a request for culture. • Indication of antibiotics -The child has high fever or other systemic symptoms. -The abscess is larger than 5 cm. -Located in a critical location or in a difficult to drain area. -Signs and symptoms persist following incision and drainage. • Common anti-staphylococcal antibiotics: -TMP-SMX effective against MRSA -Cephalexin remains a good empiric choice for MSSA and GAS infections -Clindamycin -Doxycycline (in children older than 8 years of age) • Recurrent staphylococcal skin infections recommendations: -Enhanced hygiene and environmental cleaning -Treatment for anyone in the family who has active disease -Nasal mupirocin -Skin decolonization (chlorhexidine or bleach baths) -Treatment with antibiotic-based decolonization regimens (usually rifampin plus an additional agent) in selected cases • Production of toxic shock syndrome toxin-1 (TSST-1). • Can be caused by S. aureus or S. pyogenes. • Fever, malaise, and irritability. • Most of the patients do not appear severely ill. • Tenderness to palpation. • Dehydration may be present and can be significant. • Nikolsky sign (gentle stroking of the skin causes the skin to separate at the epidermis. • Bacteremia may or may not present. • Blood culture is usually negative in children (but positive in bullous impetigo) and is usually positive in adults. • A chest radiograph should be considered to rule out pneumonia as the original focus of infection. • A biopsy of the affected area will demonstrate separation of the epidermis at the granular layer. • Fluid rehydration is initiated with Lactated Ringer solution at 20 mL/kg initial bolus. • Repeat the initial bolus, as clinically indicated, and followed by maintenance therapy with consideration for fluid losses from exfoliation of skin being similar to a burn patient. • Prompt treatment with parenteral anti-staphylococcal antibiotics is essential. • Typically occurs within the first 24 h after birth but can occur up to 1 week of age. • Infants can present with a range of illness, from asymptomatic bacteremia to septic shock. • Respiratory symptoms, such as tachypnea, grunting, flaring, apnea, and cyanosis, are the initial clinical findings in more than 80 % of neonates. • Hypotension is present in 25 %. • Lethargy, poor feeding, temperature instability, abdominal distention, pallor, tachycardia, and jaundice. • Presents most commonly within the first 4-6 weeks after birth • Bacteremia without a defined focus remains the most common manifestation • Meningitis is more common in LOD than EOD • Pneumonia, cellulitis, and osteoarticular infections • Isolation of the organism from a normally sterile body site, such as blood or CSF • C-reactive protein level and white blood cell count, may be helpful • Initial treatment for EOD usually is ampicillin plus gentamicin, until the identity of the pathogen is determined. • If meningitis is suspected, the ampicillin dose should increase 150-200 mg/kg/day and the gentamicin dose is 7.5 mg/kg/day. • The drug of choice for treatment of proven GBS infections is penicillin. • The recommended dosage for treatment of bacteremia without meningitis is 200,000 units/kg/day and increases to 300,000-500,000 units/kg/day for meningitis. • Length of treatment depends on the site of infection. • Bacteremia without a focus requires 10 days of therapy. • Meningitis requires a minimum of 14 days. • The drug of choice for intrapartum prophylaxis remains intravenous penicillin, with ampicillin as an acceptable alternative. • Both agents are given every 4 h until delivery, with at least one dose administered 4 h before birth. • S. pneumoniae is a gram-positive, catalase-negative, alpha-hemolytic bacterium. • The bacteria are gram-positive diplococci (Fig. 8 ). • Introduction of PCV7 and PCV13 significantly reduced invasive pneumococcal disease in children. • The highest age-specific attack rates of IPD occur during the first 2 years after birth • Children who have sickle cell disease • Children who have asplenia • Congenital immune deficiencies • Immunosuppressive medications or bone marrow transplants also are at increased risk • CSF leaks, e.g., neurosurgical procedures or skull fractures • Cochlear implants • Common pneumococcal infections include: -AOM -Sinusitis -Pneumonia -Bacteremia (most common manifestation of invasive pneumococcal disease) -Meningitis (leading cause of meningitis) • Pneumonia -S. pneumoniae is the most common bacterial cause of community-acquired pneumonia in both children and adults -High fever and ill appearing -Cough and tachypnea -Respiratory distress -Crackles -Diminished breath sounds -Lobar consolidation may be noted on chest radiography in older children -Know that Infants and young children may have bronchopneumonia with a scattered distribution of parenchymal consolidation -Pleural fluid may be evident in some patients • Pneumococcal infection is diagnosed with certainty by isolation of the organism from blood or normally sterile body fluids such as CSF, pleural, synovial, or middle-ear fluid. • Antigen detection. • Susceptibility test. • Outpatient Pneumonia: Amoxicillin or amoxicillin-clavulanate in dosages recommended for AOM should be administered to children whose pneumonia is managed as outpatients. -Cefuroxime axetil and cefdinir also are effective empiric agents • Inpatient pneumonia Parenteral penicillin, ampicillin, cefuroxime, cefotaxime, and ceftriaxone are acceptable treatments for hospitalized children who have pneumonia. • Pneumococcal meningitis due to concerns about antibiotic resistance, the treatment of proven or suspected cases mandates empiric therapy with cefotaxime or ceftriaxone plus vancomycin. • Group A Streptococcus (GAS) is a gram-positive bacterium that grows in chains (Fig. 9 ). • GAS is a gram-positive bacterium that grows in chains • The most common GAS infection • Most often in school-age children • Transmission results from contact with infected respiratory tract secretions • Close contact in schools and child care centers • The incubation period for GAS pharyngitis is 2-4 days • Sore throat, fever, headache, and abdominal pain is the most classic presentation • Nausea, vomiting may occur • Pharyngeal erythema and palatal petechiae (Fig. 10) • Inflammation of the uvula • Anterior cervical lymphadenopathy • Tonsillar exudates may or may not present • Rapid antigen detection test is highly recommended to decrease overuse of antibiotics. • Testing of asymptomatic household contacts not recommended except when contacts are at increased risk of developing sequelae of GAS infection, e.g., rheumatic fever, poststreptococcal glomerulonephritis, or toxic shock syndrome. • If rapid antigen detection test (RADT) positive treat (specificity of 95 %). • If RADT is negative do throat culture (sensitivity of 65-90 %). • Treatment of GAS sore throat as long as 9 days after the onset of symptoms still effectively prevents rheumatic fever, initiation of antibiotics is seldom of urgent importance. • Reduces complications. • Decrease the duration of infection. • Reduces transmission to others. • Oral penicillin V K (250-500 mg twice to three times a day for 10 days) is the antibiotic treatment of choice for GAS pharyngitis. • Amoxicillin (50 mg/kg, maximum 1 g, once daily for 10 days) often is used instead of oral penicillin because of its more palatable liquid formulation. • Cephalosporins or macrolides may be used as first-line therapy in patients allergic to beta-lactam antibiotics but otherwise are not recommended as first-line therapy. • Intramuscular penicillin G benzathine 600 000 U for children who weigh < 27 kg and 1.2 million U for heavier children as single dose (if the adherence is a problem but is painful) • Know that treatment is indicated if a GAS carrier develops an acute illness consistent with GAS pharyngitis. • History of acute rheumatic fever • Close contact who has a history of rheumatic fever • Families experiencing repeated episodes of GAS pharyngitis • Eradication regimens include clindamycin, cephalosporins, amoxicillin-clavulanate Indications for tonsillectomy include • More than seven documented GAS infections in 1 year or • More than five episodes in each of the preceding 2 consecutive years • Know that incidence of pharyngitis decreases with age • Scarlet fever (scarlatina) is a syndrome characterized by exudative pharyngitis, fever, and scarlatiniform rash. • It is caused by toxin-producing GABHS found in secretions and discharge from the nose, ears, throat, and skin. • Fever may be present. • Patient usually appears moderately ill. • On day 1 or 2, the tongue is heavily coated with a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). • By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). • Red, edematous, exudative tonsillitis. • Diffuse, erythematous, blanching, fine papular rash that resembles sandpaper on palpation (Fig. 11 ) • The rash is prominent especially in the flexor skin creases of the antecubital fossa ( Pastia lines which pathognomonic for scarlet fever). • Circumoral pallor. • Desquamation after the rash starts to fade (usually the rash last about 1 week). • Throat culture or rapid streptococcal test • Anti-deoxyribonuclease B and antistreptolysin-O titers (antibodies to streptococcal extracellular products) • Penicillin remains the drug of choice (documented cases of penicillin-resistant group A streptococcal infections still do not exist). • First-generation cephalosporin may be an effective alternative. • Occur in children younger than 3 years Young infants may not present with classic pharyngitis • Low-grade fever • Thick purulent nasal discharge • Poor feeding • Anterior cervical lymphadenopathy • Some patient may be toxic with high fever, malaise, headache, and severe pain upon swallowing Impetigo Background • GAS impetigo is a superficial bacterial skin infection (small percentage) • In North America the etiologic agent is primarily S. aureus Clinical presentation: Fig. 12a and b • Common (i.e., crusted or nonbullous) impetigo: Initial lesion is a superficial papulovesicular lesions that rupture easily. • The lesion becomes purulent and covered with an ambercolored crust. • Bullous impetigo: superficial fragile bullae containing serous fluid or pus forms and then ruptured to form a round, very erythematous erosions. • The lesions usually located in exposed area specially the face and extremities. • Lesions usually often spread due to autoinoculation. • Topical mupirocin or retapamulin for localized lesions. Clinical presentation • Perianal rash, itching, and rectal pain; blood-streaked stools may also be seen in one third of patients. • Bright red, sharply demarcated rash around the anal area (Fig. 13 ). • A rapid streptococcal test of suspicious areas can confirm the diagnosis. • Routine skin culture is an alternative diagnostic aid. • Treatment with oral amoxicillin or penicillin is effective. • Topical mupirocin three times per day for 10 days. • Follow-up is necessary, because recurrences are common. • Hematuria resolve within 3-6 months. • Proteinuria may persist for up to 3 years. • GAS TSS is a form of invasive GAS disease associated with the acute onset of shock and organ failure. • Injuries resulting in bruising or muscle strain. • Surgical procedures. • Varicella infection. • NSAIDs use. • Streptococcal exotoxins that act as superantigens, causes release of cytokines leading to capillary leak, leading to hypotension and organ damage. • Fever. • Abrupt onset of severe pain, often associated with a preceding soft-tissue infection, e.g., cellulitis or osteomyelitis • Know that patient may be normotensive initially, but hypotension develops quickly. • Erythroderma, a generalized erythematous macular rash may develop. • Leukocytosis with immature neutrophils • Elevated serum creatinine values • Hypoalbuminemia • Hypocalcemia • Elevated creatine kinase concentration • Myoglobinuria, hemoglobinuria • Positive blood cultures • Diagnosis of GAS TSS requires isolation of GAS e.g., blood or CSF • Aggressive fluid replacement is essential to maintain adequate perfusion to prevent end-organ damage. • Vasopressors also may be required. • Immediate surgical exploration and debridement is necessary, and repeated resections may be required. • Empiric therapy with broad-spectrum IV antibiotics to cover both streptococcal and staphylococcal infections e.g.,: -Clindamycin IV plus penicillin G IV • Immune globulin intravenous (IGIV) also may be used as adjunctive therapy. • PANDAS describes a group of neuropsychiatric disorders, in particular obsessive compulsive disorder (OCD), tic disorders, and Tourette syndrome, that are exacerbated by GAS infection. • Diagnostic criteria for PANDAS include: -Tourette syndrome; abrupt onset in childhood -Relationship between GAS infection and episodic symptoms confirmed by RADT, throat culture, or skin culture or serologic testing -Evaluation for GAS infection should be considered in children who present with the abrupt onset of OCD or tic disorder • Treatment of the GAS infection and neuropsychiatric therapy • Behavioral therapy and pharmacological therapies, including: • Selective serotonin reuptake inhibitors (SSRIs) for OCD • Clonidine for tics Background • GAS necrotizing fasciitis is a form of invasive GAS disease. This infection is characterized by extensive local necrosis of subcutaneous soft tissues • GAS pyrogenic exotoxins that act as superantigens, which activate the immune system • Fever, hypotension, malaise, and myalgias • Rapidly increasing pain; and erythematous skin that progresses to blisters, bullae, and crepitus with subcutaneous gas. • Leukocytosis with a predominance of neutrophils • Elevated creatine kinase, lactate, and creatinine values • Positive blood cultures • Diagnosis is clinical and requires a high degree of suspicion because of the rapid progression of infection. • Early and aggressive surgical exploration and debridement • Antibiotic therapy with penicillin G IV plus clindamycin IV, and aminoglycoside as well is recommended • Hemodynamic support if GAS TSS is present as well • Repeat surgery is necessary until all necrotic tissue has been removed • Antibiotic therapy should continue for several days after completion of surgical debridement -Dirty wound, immunization is unknown or less than three tetanus shots: Give TIG + tetanus vaccine -Dirty wound, immunized > 5 years and < 10 years: Immunize, no TIG -Dirty wound, immunized < 5 years: No treatment -Clean wound, immunized < 10 years: No treatment -Clean wound, immunized > 10 years: Immunize, no TIG • Gram-positive anaerobes • Colonization -Around 50 % of infants younger than 1 year are colonized -Carriage decrease by 1-5 % by 2 years of age • Risk factor: -Having infected roommate or having symptomatic patient in the same ward -Antibiotics, e.g., beta-lactams drugs, clindamycin, and macrolides -Underlying bowel disease or surgeries • Symptomatic disease is due to toxins A and B produced by the organism • Asymptomatic colonization is common in infants and young children • Actinomycosis is a subacute-to-chronic bacterial infection caused by filamentous, gram-positive, non acid-fast, anaerobic-to-microaerophilic bacteria. • It is characterized by contagious spread, suppurative and granulomatous inflammation, and formation of multiple abscesses and sinus tracts that may discharge sulfur granules. • The most common clinical forms of actinomycosis are cervicofacial (i.e., lumpy jaw) usually caused by dental infection. • In women, pelvic actinomycosis is possible when IUD in place. • Initial therapy should include IV penicillin or ampicillin for 4-6 weeks followed by high dose of oral penicillin, clindamycin or doxycycline. • C. psittaci is obligate intracellular bacterial pathogen. • Birds are major reservoir of C. psittaci, e.g., parakeets, and parrots, also animal such as goats and cows may become infected. • • This disease is a chronic keratoconjunctivitis caused by the obligate intracellular bacterium C. trachomatis. • Disease transmission occurs primarily between children and the women who care for them. • Trachoma is the most common infectious cause of blindness worldwide. • Chronic follicular keratoconjunctivitis with corneal neovascularization resulting from untreated or chronic infection. • Blindness occurs in up to 15 % of those infected. • Trachoma rarely occurs in the USA. • It is a clinical diagnosis and nucleic acid amplification tests (NAATs) can confirm the causative agent. • The cicatricial phase has unique clinical features, which lead to definitive diagnosis in most cases. • N. gonorrhoeae is a gram-negative diplococcus. • Gonococcal infection is the second most common bacterial disease in the USA that is classified as a reportable and notifiable infection. • It is the highest in youth, especially females between 15 and 19 years of age. • The incubation period is 2-7 days. • A child abuse evaluation must be performed in any prepubertal case of gonococcal infection. • Conjunctivitis due to mucosal transmission during vaginal delivery. • Topical antibiotics (erythromycin, silver nitrate, or tetracycline) to the eyes of a newborn within 1 h of birth can prevent the infection. • Treatment is ceftriaxone 125 mg IM × 1. • Aerobic gram-negative diplococcus N. meningitidis. • Natural commensal organism living in the nasopharynx of humans. • Children younger than 2 years of age have a nearly fivefold greater risk of contracting meningococcal disease than the general adult population. • Risk of transmission; crowded living conditions, e.g., college dormitories, military barracks. • Rash -Any rash appearing in the context of a sudden febrile illness should raise concern -Meningococcal rash is typically present within 24 h of any symptomatology -Petechiae may be intraoral or conjunctival or be hidden in skinfolds -Early rash may not be petechial • True rigors -Shaking chill that cannot be stopped voluntarily -Prolonged (10-20 min) • Neck pain -Severe pain in the neck, back, or extremities -May manifest in younger children as refusal to walk -Meningismus: In patients older than 3 years, the classic signs of Kernig and Brudzinski may be elicited • Vomiting -May be associated with headache or abdominal pain without diarrhea • Cushing triads: -Bradycardia -Hypertension -Respiratory depression • Purpura fulminans (meningococcemia) -Aggressive spread of purpura to large areas with ischemic necrosis -Sudden drops in blood pressure -Acute adrenal hemorrhage (Waterhouse-Friderichsen syndrome) • Culture of the organism from a normally sterile site is the gold standard for bacteriologic diagnosis. • Cerebrospinal fluid study: -CSF WBC counts are elevated in most patients who have meningitis. -CSF WBC counts are low or even normal if the disease is severe and rapidly progressive. -Markedly low glucose and elevated protein values are associated with the diagnosis of meningitis. • All patients with meningococcal disease or meningitis must be tested for CH50 or CH100 assay (20 % of children with meningococcal disease will end having a complement deficiency). • Know that antibiotics or fluids should not be delayed for the sake of cultures or other testing. • Penicillin is effective treatment for both severe meningococcal septicemia (SMS) and meningococcal meningitis if the diagnosis is certain. • Broad-spectrum antibiotics effective against N. meningitidis and other potential pathogens are indicated (e.g., ceftriaxone, cefotaxime, vancomycin). • Emergency care evaluation and preferably transported via emergency medical services to allow for prompt delivery of intravenous fluids and airway management if the condition is suspected. • Large isotonic fluid boluses (20 mL/kg) over the first 5 min. • Inotropic/vasoactive agent such as dopamine or dobutamine. • Hydrocortisone may be beneficial in children who have SMS and respond poorly to vasopressors. • MCV4 is routinely recommended at 11-12 years of age. • Unvaccinated adolescents through 18 years of age should receive a dose at the earliest opportunity. • Military recruits and all college freshmen who will be living in campus dormitories. • Persons who have terminal complement component deficiencies. • Anatomic or functional asplenia. • Note: 30 % of infections are due to serogroup B which is not covered by the vaccine. • Antibiotic prophylaxis, e.g., Rifampin, ciprofloxacin, azithromycin, or ceftriaxone should be used for contacts: -Child care contact -Direct exposure to oral secretions of individual with meningococcal disease (such as personnel providing mouth-to-mouth resuscitation) Background • Pleomorphic gram-negative coccobacillus. • Used to be the most common cause of meningitis and serious bacteremia in children. • Introduction of the H. influenzae vaccine quickly reduced the incidence of encapsulated H. influenza type b. • Nontypeable strains are still responsible for a large number of mucosal infections, including conjunctivitis, otitis media, sinusitis, and bronchitis. • Peak age is less than 1 year. • Mortality rate around 5 %. • Common complications include: subdural empyema, brain infarct, cerebritis, ventriculitis, brain abscess, and hydrocephalus. • Long-term sequelae occur in 15-30 % of survivors with sensorineural hearing loss, others include language disorders, intellectual disability (ID), and developmental delay. • Dexamethasone before or with antibiotics such as ceftriaxone or cefotaxime to prevent hearing loss and neurologic sequelae. • H. influenzae type b (Hib) was the predominant organism (> 90 %) in pediatric epiglottitis cases (other bacteria can cause epiglottitis as well, e.g., S. pneumoniae, group A beta-hemolytic streptococci, S. aureus, and Moraxella catarrhalis. • Occurs primarily in children (ages 2-7 years). • The clinical triad of drooling, dysphagia, and distress is the classic presentation. • Fever with associated respiratory distress or air hunger occurs in most patients. • Treatment in patients with epiglottitis is directed toward relieving the airway obstruction and eradicating the infectious agent. • Optimally, initial treatment is provided by a pediatric anesthesiologist and either a pediatric surgeon or a pediatric otolaryngologist. • Once the airway is controlled, a pediatric intensivist is required for inpatient management. • Buccal cellulitis previously was always caused by H. influenzae infection before the vaccine. • Always associated with bacteremia if present. • Present with palpable cellulitis on both checks, purplish in color and child looks very toxic. • Previously H. influenzae was the a common cause, now pneumococcus bacteria is the most common etiology • Minor trauma or insect bite of the eye lid usually associated with preseptal cellulitis due to S. aureus or a Group A Streptococcus Pyogenic arthritis • H. influenzae was the most common cause of septic arthritis before Hib vaccine in children less than 2 years of age • Occult bacteremia with H. influenzae will result in in 30-50 % developing meningitis or other deep, or focal infection from occult bacteremia. • All occult bacteremia from H. influenzae has to be treated immediately. • Pneumonia from H. influenzae used to cause about one third of bacterial pneumonia before Hib vaccine and usually associated with pleural effusion, positive blood culture in most of the cases. • Remember: the organism produces beta lactamase which makes amoxicillin is ineffective. • Cefotaxime or ceftriaxone is the antimicrobial of choice. • Meropenem or chloramphenicol is another option. • Amoxicillin is the drug of choice for noninvasive diseases such as otitis media or sinusitis, if amoxicillin fails, uses antibiotics against beta-lactamase-producing strains, e.g., nontypeable H. influenzae including amoxicillin/clavulanic, TMP-SMX, azithromycin, cefuroxime axetil, cefixime, and cefpodoxime. • All household who did not receive immunization • Less than 4 years with incomplete immunization • Younger than 12 months who did not complete primary HIB immunization • Immunocompromised child • Nursery school and child care center if two or more cases within 60 days • Small gram-negative coccobacilli, it is a normal flora in number of animals, e.g., dog and cats. • Dog or cat bite is a common risk. • Erythema, tenderness, and edema usually develop rapidly within 24 h. • Infection occurs few days after the bite is usually caused by S. aureus. • Clean the wound with soap and water. • Treatment should cover potential pathogens, e.g., P. multocida, S. aureus, and anaerobes. • Administration of antibiotic within 8-12 h of injury may decrease the risk of infection. • Amoxicillin-Clavulanate is the drug of choice • Ampicillin-sulbactam IV in severe cases • Clindamycin and TMP-SMX is appropriate for children allergic to penicillin. • Pertussis is a small gram-negative coccobacillus that infects only humans. • Pertussis is spread by aerosol droplets expelled while coughing or sneezing in proximity to others. • Incubation period of 7-14 days. • Catarrhal phase -Lasts from 1 to 2 weeks -Mild fever -Cough -The cough worsens as the patient progresses to the paroxysmal phase • Paroxysmal phase -Lasts from 2 to 6 weeks -Rapid fire or staccato cough -Five to ten uninterrupted coughs occur in succession, followed by a "whoop" as the patient rapidly draws in a breath -May occur several times per hour -Can be associated with cyanosis, salivation, lacrimation, and posttussive emesis -Despite the severe spells, patients often appear relatively well between episodes -Whoop is usually absent in infants less than 6 months of age -Gasping, gagging, and apnea can occur • Convalescent phase -Decreasing frequency and severity of the coughing episodes -Lasts from weeks to months • B. henselae is gram negative rod or bacilli with a polar flagellum. • Kittens or cats less than 1 year old are most common source (no human to human). • Transmission can occur by petting alone with subsequent self-inoculation via a mucous membrane, skin break, or conjunctiva. • Clue for the diagnosis; contact with cats and lymphadenopathy. Clinical presentation • Regional lymphadenopathy (cervical and axillary are common locations; Fig. 14) -Usually large and may be tender, warm and erythematous • Cat-scratch disease is self limited. • Use of antibiotics is controversial and not indicated for typical CSD in immunocompetent patients. • Azithromycin, doxycycline, or rifampin may reduce the time for lymph node swelling to resolve. • Antipyretics and analgesics. • Remember: Incision and drainage is not recommended (risk of sinus tract and persistent drainage). • Aspiration will be diagnostic and therapeutic; repeated aspirations may be performed if pus re-accumulates and pain recurs. • Cause brain abscess in neonates • Order CT or MRI if CSF grow citrobacter otherwise is very rare disease • It is a rare cause of pneumonia and meningitis. • It also can cause UTIs but is less common than E. Coli. • Most klebsiella are resistant to ampicillin. • Stool culture is diagnostic • Stool study with large number of neutrophil is suggestive but not specific • Peripheral WBCs are usually elevated; bandemia is very common • Antimicrobial therapy is recommended for all patient with shigellosis. • Antimicrobial therapy for 5 days will shorten the duration and eradicate the organism from stool. • Oral ampicillin or TMP-SMX but the resistance makes them useless of Shigella infection. • Ceftriaxone, ciprofloxacin or azithromycin are usually effective. • Ciprofloxacin is not recommended if less than 18 years, if there is an alternative. • Once Shigella is identified in a daycare or household, all other symptomatic individuals in these environments should be cultured for Shigella as well. • Anyone found to have Shigella cannot return to daycare until the diarrhea has stopped and stool culture test is negative. Background • E. coli is a gram-negative, lactose fermenting, motile rod, belonging to the Enterobacteriaceae. • E. coli is one of the most frequent causes of many common bacterial infections, including cholecystitis, bacteremia, cholangitis, urinary tract infection (UTI), and traveler's diarrhea, and other clinical infections such as neonatal meningitis and pneumonia. • The vast majority of neonatal meningitis cases are caused by E. coli and group B streptococcal infections. • Pregnant women are at a higher risk of colonization with the K1 capsular antigen strain of E. coli, which commonly observed in neonatal sepsis. • Low-birth weight and a positive CSF culture result portend a poor outcome. • Most survivors have subsequent neurologic or developmental abnormalities. • E. coli respiratory tract infections are uncommon and are almost always associated with E. coli UTI. • E. coli intra-abdominal infections often result from a perforated viscus (e.g., appendix, diverticulum) or may be associated with intra-abdominal abscess, cholecystitis, and ascending cholangitis. • They can be observed in the postoperative period after anastomotic disruption. Abscesses are often polymicrobial. • E. coli is one of the more common gram-negative bacilli observed together with anaerobes. • Gram-negative rods. • It occurs in all ages. • Transmitted via ingestion of contaminated food, e.g., (ground beef) or infected feces. • The disease linked to eating undercooked beef, and unpasteurized milk or apple juice. • Produces shiga toxins; the most virulent strain. • The incidence of E. coli O157:H7 > Shigella. • Usually begin as nonbloody diarrhea then become bloody • Severe abdominal pain is common • Fever in one third of the cases • May progress to hemorrhagic colitis in severe cases • Hemolytic uremic syndrome (HUS) may occur • No antibiotic is proven to be effective and no prove that antibiotic increase the risk HUS. • No antibiotics are indicated. • Do not use antimotility agents. • Erythema migrans is pathognomonic and is an early lesion and antibodies not developed yet. -No need to test the patient in order to treat in the first few weeks. • Serologic testing is to confirm the diagnosis in stage two or three or in atypical cases. • Initial test is sensitive enzyme immunoassay assay (EIA); high false positive rate. • Swimming with dog or contact with fresh water contaminated with the urine of an animal that is a chronic carrier, e.g., rats. • Fever • Headache • Elevated liver enzyme • Early blood culture, later in the disease urine culture may show the organism • Penicillin or doxycycline • M. tuberculosis, a tubercle bacillus, is the causative agent of TB. • Mycobacteria, such as M. tuberculosis, are aerobic, non spore-forming, non motile, facultative, curved intracellular rods measuring 0.2-0.5 μm by 2-4 μm. • It retains many stains after decolorization with acidalcohol, which is the basis of the acid-fast stains used for pathologic identification. • TB is transmitted most commonly via airborne spread. • Kissing, shaking hand, and sharing food do not spread the infection. • TB is unlikely to spread from child to another child < 4 years of age. • TB is likely to spread from infected adult to children (usually household or daycare). • Foreign-born individuals in the USA have TB rates 9.5 times higher than those in the US-born persons • Immigrants from Mexico, Philippines, Vietnam, China, and India • Only 5-10 % of children older than 3 years of age who have untreated LTBI progress to disease. • Most LTBI progress to disease within 1-2 years of initial infection. • The most common site of infection is the lung, which accounts for up to 80 % of all cases of disease. • Pulmonary Disease -Infants and adolescents are more likely to be symptomatic than 5-10-year-old children -Cough (usually last 3 weeks or longer) -Hemoptysis -Low-grade fever -Weight loss (rare) -Night sweat -Loss of appetite -Hilar or mediastinal adenopathy may be seen -Cavity lesions • Superficial lymphadenopathy: -The most common extrapulmonary form of TB. -Children who have TB lymphadenopathy tend to be older than those who have nontuberculous mycobacterial lymphadenopathy. -Common locations: anterior cervical, followed by posterior triangle, submandibular, and supraclavicular. -LNs usually measure 2-4 cm and lack the classic inflammatory findings of pyogenic nodes. -There may be overlying violaceous skin discoloration. -Surgical node excision is not curative but may be necessary to establish the diagnosis. -Most children respond well to a 6-month course of multidrug therapy, but occasionally therapy must be extended to 9 months, based on clinical response. compromised, INH should be continued for 9 months. • Infant whose mother has TB -The TST is helpful only if the result is positive, which is very rare. -If the mother has a positive TST result and negative chest radiograph (LTBI), the child needs no evaluation. -If the mother has radiographic features consistent with TB, the neonate requires evaluation for congenital TB. -If the infant does not have congenital TB, he or she should be separated from the mother until the infant is receiving INH and pyridoxine (if the mother is breastfeeding) and the mother is receiving appropriate multidrug therapy. -Once the infant is receiving INH, separation is unnecessary and breastfeeding should be encouraged unless INH resistance is suspected. • Health-care workers (HCWs) -If positive TST results they should receive chest radiographs. -If the chest radiograph is negative, the HCW may be offered therapy for LTBI after weighing the risks and benefits of INH in adults. -If the chest radiograph is positive, the HCW needs to be evaluated further. • Children who have TB disease should be seen monthly while receiving therapy to document medication tolerance and adherence, weight gain, and achievement of appropriate milestones. • Mycobacterium avium-intracellulare complex is the most common cause of nontuberculous disease in children • Candida albicans is the most commonly isolated species, and cause infections (Candidiasis or thrush). • Systemic infections of blood stream and major organs (invasive candidiasis or candidemia, particularly in immunocompromised patients. • Candida appears as budding yeast cells and pseudohyphae (Fig. 15 ). • Common is the first 6 postnatal months • Possibly due to infants' immunologic immaturity • Contaminated bottle nipples, pacifier, or dropper, e.g., vitamin dropper. • Infected mother's nipples (although the incidence is high in formula fed infants). • Maternal vaginal colonization with Candida. • Recurrent or persistent oral thrush beyond 6-12 months raises the concern of immunodeficiency, especially if associated with failure to thrive or hepatosplenomegaly. • Use of inhaled steroid without adequate rinsing afterward or oral antibiotics can cause oral thrush. • Poorly controlled diabetes in adult can cause candida infection however is not associated with gestational diabetes. Clinical presentation • Infant may have trouble feeding in severe cases. • Tiny focal white area that enlarge to white patches on oral mucosa (Fig. 16 ). • If scraped with a tongue blade, lesions are difficult to remove and leave behind an inflamed base that may be painful and may bleed. • Examine the patient with diaper dermatitis for oral lesions. • Oral nystatin. • Once-daily oral fluconazole is superior to oral nystatin for resistant thrush and effective candidal diaper dermatitis. Clinical presentation • Lesions consist of beefy-red plaques, often with scalloped borders. • Satellite papules and pustules may be observed surrounding the plaques (Fig. 17 ). • Maceration is often present, especially in intertriginous areas. • Once-daily oral fluconazole is superior to oral nystatin for resistant thrush and effective candidal diaper dermatitis. • Topical clotrimazole if resistant to topical nystatin. Fig. 16 Thrush: Tiny focal white areas that enlarge to white patches on oral mucosa, it was difficult to remove the white spots with the tongue blade • It is due to infection of large intestine with Trichuris trichiura. • More common in the Southern USA. • Transmitted to human by ingesting eggs. • Usually asymptomatic if only few worms. • Can cause fever, abdominal pain, weight loss, blood in stool and rectal prolapse. • Presence of eggs in stool is diagnostic. • Treatment is mebendazole. • Trichinella spiralis is usually found in pork. • Symptoms depend on the worm location. • After ingestion the eggs hatch, larvae invade the duodenum, and causes abdominal symptoms. • Larvae penetrate, reach bloodstream, end in muscular tissue and causes muscle pain. • If the larvae reach the heart can cause myocarditis. • Ocular involvement; presence of chemosis, periorbital edema, and eosinophilia usually suggest the diagnosis. • Diagnosis is confirmed by rising titers. • S. stercoralis is common in certain areas of the USA. • In the USA this infection is common in Kentucky and Tennessee. • It is the only helminthic organism replicates in the body with autoinfection, and the infection may persist for decades. • Can cause pulmonary symptoms with eosinophilia and GI symptoms as well. • It is potentially fetal in immunosuppressed patients. • Diagnosis of serial stool studies for larvae not the eggs. • Treatment is ivermectin or thiabendazole. • Toxocara canis and Toxocara catis can cause visceral larva migrans. • It is transmitted to human by ingesting soil contaminated with dog or cat excreta. • In human larva do not develop into adult worms but rather migrate through the host tissue; causing eosinophilia. • Treatment is albendazole or mebendazole. • Platyhelminthes include cestodes (tapeworms) and trematodes (flukes). • Cestodes are flatworms (tapeworms).The pork tapeworm. Taenia solium, present in two different ways. • If the cysticerci are ingested, taeniasis develops and tape worm grows in the intestine. • If contaminated food with eggs is ingested, the patient will develop cysticercosis. • Cysticerci go in CNS and the eyes and do nothing until they die. • Diagnosis of neurocysticercosis must be considered in the patients with new onset seizures and history of travelling to or immigration from Mexico, Central or South America or who is a household from these areas. • Trematodes or flukes. • Clonorchis sinensis is the Chinese liver fluke. • Schistosoma haematobium infects the bladder and cause urinary symptoms. • Schistosoma mansoni is a fluke found in Africa, the Middle East, and South America. • Schistosoma japonicum is found in Asia. • • Large majority of the children with fever without localizing signs in 1-3 months age group likely viral syndrome. • Most viral diseases has distinct seasonal pattern unlike bacteria, e.g., respiratory syncytial virus, and influenza more common during winter and enterovirus infection more common during summer and fall. • Ill appearing (toxic) febrile infants ≤ 3 months: -Require prompt hospitalization, immediate parenteral antibiotics after blood and CSF cultures are obtained. • Well appearing infants 1-3 months who is previously healthy with no evidence of focus of infection: -WBCs count of 5000-15,000 cells/µL, an absolute band count of ≤ 1500 cells/µL, and normal urinalysis, and negative culture (blood and urine) results are unlikely to have a serious bacterial infection. • The decision to obtain CSF studies in the well appearing 1-3 months old infant depends on the decision to administer empirical antibiotics. • If close observation without antibiotics planned, a lumbar puncture may be deferred. • FUO was defined as: -More than 3 weeks' duration of illness. Temperature greater than 38.3 °C (101 °F) on several occasions. -Failure to reach a diagnosis despite 1 week of inpatient investigation. • Patients with undiagnosed FUO (5-15 % of cases) generally have a benign long-term course, especially when the fever is not accompanied by substantial weight loss or other signs of a serious underlying disease. • FUO last more 6 months in uncommon in children and suggests granulomatous or autoimmune disease (Table 4) . • Age of the patient is helpful: -Children > 6 years of age often have respiratory or genitourinary tract infection, localized infection (abscess, osteomyelitis), JIA, or rarely leukemia. -Adolescent patients more likely to have TB, inflammatory bowel disease, autoimmune process or lymphoma in addition to the causes of FUO in younger children. • Exposure to wild or domestic animals, and zoonotic infection. • History of pica should be elicited; ingestion of dirt is a particularly important due to infection with Toxocara canis or Toxoplasma gondii. • Physical examination is essential to find any physical clues to underlying diagnosis, e.g., lymphadenopathy, rash, joint swelling, etc. • Laboratory it is determined on case-by-case bases. • ESR > 30 mm/h indicates inflammation and need further evaluation. • ESR > 100 mm/h suggests tuberculosis, Kawasaki disease, malignancy or autoimmune disease. • Low ESR does not eliminate the possibility of infection. • CRP is another acute phase reactant that is elevated and returns to normal more rapidly than ESR. • Cultures, serologic studies, imaging studies and biopsies depending on each case. • The ultimate treatment of FUO is tailored to the underlying diagnosis. -Fever (either acutely or in the 1-4 week interval before the onset of symptoms) -Meningeal irritation -Any child presenting with uncharacteristic behavior that is persistent and disproportionate to environmental and situational factors Initial evaluation of the patient include: • Seasonal presentation. • History of immunosuppression. • Travel history. • Recent local epidemiological information. • Presence of focal neurologic symptoms or deficits. • Complete blood count. • Complete metabolic panel. • Urinalysis. • MRI or CT scan for intracranial pressure. • EEG. • Enteroviral infections can produce a sepsis-like syndrome with more remarkable hematologic abnormalities. • GBS remains the predominant neonatal meningitis pathogen. • Early-onset disease, infants typically manifest with signs suggestive of sepsis, often with pneumonia, but less commonly with meningitis. • Late-onset disease; the typical infant who has late-onset disease is 3-4 weeks of age and presents with meningitis or bacteremia. • Gram-negative bacillary meningitis is rare and E. coli being the most commonly isolated pathogen. • Other gram-negative neonatal meningitis pathogens such as Citrobacter koseri, Enterobacter sakazakii, and Serratia marcescens. • HSV in the newborn can present as isolated skin or mucous membrane lesions, encephalitis, or a disseminated process. • HSV infection occurs most commonly in infants born to mothers who have active primary infection. • Frequently no maternal history or clinical evidence is available to alert the practitioner to this diagnosis. • The incubation period is 2 days to 2 weeks, and most infants who develop HSV CNS infection are 2-3 weeks of age. Neonatal Listeria meningitis • Common sources: -Unpasteurized milk -Soft cheeses -Prepared ready-to-eat meats -Undercooked poultry -Unwashed raw vegetables • Can precipitate abortion and preterm delivery. • Septic appearance in the neonate is typical in cases of early onset. • Papular truncal rash has been identified. • Pneumococcus is the leading pathogen causing bacterial meningitis in infants and young children in developed countries. • Meningococcal disease generally occurs in otherwise healthy individuals and often has a fulminant presentation with high fatality rates. • Enteroviruses virus infection is the most common. • B. burgdorferi in mid-Atlantic states. (Table 5 ). -Glucose concentration usually is less than one half of the measured serum value. -Protein value often is greater than 1.0 g/dL (10 g/L). -WBC often greater than 1.0 × 10 3 /mcL (1.0 × 10 9 /L), with a predominance of polymorphonuclear leukocytes. -Gram stain is extremely helpful if positive. -CSF culture remains the gold standard for diagnosing bacterial meningitis. • CSF finding viral meningitis -WBC count of 0.05-0.5 × 103/mcL (0.05-0.5 × 109/L). -Neutrophil predominance is common early in the course of infection, shifting to lymphocytic predominance quickly during the illness. -Glucose and protein concentrations frequently are normal, although the protein value can be slightly elevated. Gram stain is universally negative. -In cases of enteroviral meningitis, enteroviral PCR can confirm the diagnosis. • Tuberculous meningitis, epidemiologic clue, high protein and lymphocytosis. • SIADH and hyponatremia commonly occur in bacterial meningitis. • Leukopenia, thrombocytopenia, and coagulopathy may be present in meningococcal and rickettsial infection. • Therapy should not be delayed if CNS infection is suspected. • Appropriate antimicrobials are required in bacterial meningitis, HSV encephalitis, Lyme meningitis, tuberculous meningitis, and rickettsial infection, and in all cases, timely diagnosis and correct antimicrobial choice are critical. • If the practitioner cannot perform a lumbar puncture or there are contraindications to CSF examination, a blood culture should be obtained and antibiotics administered promptly. • For infants -Ampicillin (300 mg/kg/day divided every 6 h) and cefotaxime (200-300 mg/kg/day divided every 6 h) is appropriate. -Acyclovir (60 mg/kg/day divided every 8 h) should be added if HSV infection is a concern. -Vancomycin (60 mg/kg/day given every 6 h) should be added, if the Gram stain suggests pneumococcus. • Adjunctive treatment has reduced rates of mortality, severe hearing loss, and neurologic sequelae significantly in adults who have community-acquired bacterial meningitis. • For children beyond the neonatal age groups, available data suggest that the use of adjunctive corticosteroids may be beneficial for Hib meningitis and could be considered in cases of pneumococcal meningitis. • The dose of dexamethasone for bacterial meningitis is 0.6 mg/kg/day divided into four doses and administered IV for 4 days. The first dose should be given before or concurrently with antibiotics. Care of the child exposed to meningitis • Meningococcal and Hib disease create an increased risk for secondary infection in contacts. • Rifampin generally is the drug of choice for chemoprophylaxis in children. • Intellectual deficits (intelligence quotient < 70), hydrocephalus, spasticity, blindness, and severe hearing loss are the most common sequelae. • Hearing loss occurs in approximately 30 % of patients, can be unilateral or bilateral, and is more common in pneumococcal than meningococcal meningitis. Causes of brain abscess • Chronic otitis media • Paranasal sinus infection • Mastoiditis • Little in the laboratory investigation of patients who have brain abscesses is specific to the diagnosis except for culture of the purulent material and antibiotic sensitivity of the responsible organism. • CT scan of the brain: -Ill-defined -Low-density change within the parenchyma -Enhancement occurs following administration of contrast material -Classic ring-enhancing lesion with surrounding edema -Calcification is common in abscesses in neonates • Magnetic resonance imaging (MRI) Antimicrobial therapy • For abscesses arising as a result of sinusitis in which streptococci are the most likely organisms, penicillin or cefotaxime and metronidazole. • Chronic otitis media or mastoiditis often is associated with P. aeruginosa and Enterobacteriaceae, antibiotics to treat abscesses secondary to these infections should include penicillin, metronidazole, and a third-generation cephalosporin. National Resource Center for Health and Safety in Child Care and Early Education. Caring for our children: national health and safety performance standards: guidelines for out-of-home child care programs Ophthalmologic findings in children with congenital cytomegalovirus infection Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management Cytomegalovirus infection: Varicella-zoster infections Committee on Pediatric AIDS. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics Report of the Committee on Infectious Diseases Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis Cat-scratch disease Red Book: 2006 report of the committee on infectious diseases Red Book: 2006 report of the committee on infectious diseases Red Book: 2009 report of the committee on infectious diseases controlled trial of antibiotics in the management of communityacquired skin abscesses in the pediatric patient Elk Grove Village: American Academy of Pediatrics Perianal cellulitis associated with group A streptococci • Metastatic abscesses require a regimen based on the likely site of primary infection. • S. aureus commonly is isolated in abscess following trauma. • Provide a specimen of purulent material for bacteriologic analysis and antibiotic sensitivity testing. • Remove purulent material, thereby lowering intracranial pressure and decreasing the mass effect of the abscess. • Decompress and irrigate the ventricular system and debride the abscess in the event of its rupture into the ventricular system.