Pediatric ID

Discharge from the ear, originating from the external auditory canal, middle ear, mastoid, inner ear, or intracranial cavity

Accute otitis media
*rapid onset* of signs and symptoms of inflammation in the middle ear with effusion (fluid in the middle ear)
Most common in children 6 months to 2 years, rare after 5 years old

AOM with only mild ear pain (doesn't interfere with eating/sleep) for less than 48 hours and a temperature below 39C

AOM with any of the following:
Moderate to severe pain
Pain that lasts more than 48 hours
Fever of over 39C

The eustachian tube becomes inflammed from a cold or something similar, which can lead to it becoming blocked and causing fluid buildup (effusion) of the middle ear. This can cause viruses or bacteria to get pulled into the middle ear and cause an infection. Narrower, shorter, and more horizontal eustachian tube in children, which is why AOM is more prevalent

Middle ear effusion plus:
1. Moderate to severe bulging of the tympanic membrane (TM) with otorrhea not due to otitis externa
2. Mild TM bulging with onset of pain within 48 hours or intense redness (erythema) of the TM

Analgesia with ibuprofen or acetaminophen for up to 72 hours

re-evaluate signs and symptoms in 48-72 hours or when symptoms get worse to determine if a new or different antibiotic is needed.

Severe AOM
Non-severe AOM with otorrhea
Non-severe AOM that effects both ears if the patient is under 24 months

Patients with non-severe AOM and no ottorhea that only effects 1 ear (or both ears if older than 24 months) may be given antibiotics but it is not required.

Does the patient also have conjunctivitis (pink eye)
Has the patient been given amoxicillin in the prior 30 days
Does the patient have a penicillin allergy, and if so can they tolerate 2/3rd gen cephalosporins

PO amox/clav 80-90mg/kg/day

PO amox/clav

PO cefpodoxime, cefdinir, or cefuroxime
IM ceftriaxone

PO clindamycin (gram positive only, only useful against S. pneumoniea) or levofloxacin
May consider tympanocentesis (puncturing TM to drain fluid) without antibiotic therapy

PO amoxicillin 80-90mg/kg/day

Amox/clav

3 day course of ceftriaxone IM

Refer patient for further evaluation

Cause of most cases of AOM
High susceptibility to amoxicillin
Resistance to amoxicillin that is present is not due to beta-lactamases, but due to decreased binding affinity, so calvulanate doesn't improve efficacy, increase dose/frequency for amoxicillin resistance
Significant resistance to macrolides

30-50% resistance to amoxicillin, which is due to betalactamase production, so amox clav should be given to amox resistant strains
~50% self resolving without antibiotic treatment

Treatment is not geared towards M. catarrhalis as 90% of cases resolve without the use of antibiotics

80-90mg/kg/day PO

80-90mg/kg/day PO

50mg/kg/day IM

<2 years old: 10 days
2-5 years old or >5 years old with severe symptoms: 7 days
>5 years old with non-severe symptoms: 5 days

Ceftriaxone IM: 3 days

Room temp but refigerate for taste, stable for 14 days

Refigerate and stable for 10 days

Room temp for 10 days

room temp for 10 days

Refrigerate for 14 days

DO NOT refrigerate for 14 days

3 or more instances of AOM within 6 months, or 4 or more instances of AOM within 12 months, with at least 1 instance within 6 months
Should be referred to ENT

Otitis media with effusion, inflammation and fluid buildup in the middle ear but no signs of acute infection

Children with hearing impairment, developmental delay, celft palate, or recurrent AOM should have drainage with tympanostomy tube placement

OME that has persisted for at least 3 months

Acute otitis externa, aka swimmers ear. Rapid onset with signs or symptoms of ear CANAL inflammation
Most common in children ages 7-14

Systemic antipyretic therapy for pain and inflammation
Topical (ear drop) antibiotic therapy (better concentration at the site of infection, less resistance)
Topical corticosteroids often added as well

For intact TM: Polymixin B, neomycin, ciprofloxacin, ofloxacin
For non-intact TM or patients with tympanostomy tubes: ciprofloxacin or ofloxacin

Administer drops while laying down with ear towards the cieling, allow drops to sit for at least 3 minutes
If there is debris in the ear re-evaluation is needed by prescriber

Improvement and follow up within 2-3 days, if no improvement may need treatment escalation
7 days for full course of therapy, lowers risk of fungal infection
If not fully recovered after 7 days, follow up for potential change in therapy rather than just continuation of treatment

Acute bacterial sinusitis. It is defined as a URI (upper repiratory tract infection, cold etc), with any of the following:
1. Persistent illness: nasal discharge or daytime cough lasting >10 days without improvement
2. Worsening course: worsening or new nasal discharge, daytime cough, or fever after initial improvement
3. Severe disease: Fever >39C with purulent (thick) nasal discharge for at least 3 days

for patients with a worsening course or severe disease, persistent illness doesn't require antibiotic treatment but it may be used

amox clav when risk factors are present
otherwise plain amoxicillin

Age <2 years
attends day care
antibiotics within prior 28 days
Severe disease

(Unlike with AOM, ABS is more likely to be caused by H. influenzae than S. pneumoniae, so it is more likely ABS will be amoxicillin resisant and will benefit from the addition of clavulanate)

80-90mg/kg/day divided BID

<10% of local S. pneumoniae strains resistant to amoxicillin: 45mg/kg/day divided BID
>10% of local S. pneumoniae strains resistant to amoxicillin: 90mg/kg/day divided BID

10mg/kg/day
125mg/dose

14mg amox to 1mg clav, used for typical 80-90mg/kg/day divided BID or TID
Comes in a 600mg/5mL suspension

7mg amox to 1mg clav, used for 25-45mg/kg/day divided BID (lower dose of amoxicillin than standard, so ratio of clav is increased to maintain clav concentration)
Comes in 400 or 200mg/5mL suspensions, or a chewable tablet

XR 1000mg amox to 62.5mg clav (usually take 2 at once)
The 250, 500, 875mg etc immediate release tablets all have 125mg clavulanate, the maximum per dose
Very important for conversion from liquid to tablet formulations, typically much higher ratios of clavulanate per tablet than in the liquid formulations

7 days after clinical resolution, typically 10-14 days
If patient doesn't improve after 72 hours of treatment, escalate treatment

Same as AOM, amox->amox/clav->ceftriaxone IM->referral

Coughing, wheezing, runny nose, fever, caused most commonly by RSV or other viruses. Symptoms get worse over the first 3-5 days and most children are infected by age 2, most common cause of hospitalization in this age group.

Only with evidence of concomitant bacterial infection, broncholitis itself is not helped by antibiotics.

Mild can be treated with fluids and antipyretics at home
Moderate to severe requires oxygen and parenteral fluids/nutrition
Beta agonists and nebulized epinephrine not indicated due to lack of bronchiole narrowing
Ribavirin not indicated despite activity against RSV

Infants <6 months
Infants <12 months with premature birth (<29 weeks) or neuromuscular issues leading to issues clearing secretions
<2 years old with immunocompromised, cystic fibrosis with respiratory symptoms or failure to thrive, native american/alaskan, chronic lung diseases in the prior 6 months requiring medical support

Community aquired pneumonia, presents with difficulty breathing, tachypnea (rapid breathing), fever, and poor feeding
Most commonly caused by viruses (s. pneumoniae most common bacterial cause) and often requires hospitalization

Usually no treatment required
If bacterial infection is suspected, can use amoxicillin

Generally requires hospitalization, patients who recieved Hib vaccine can be given ampicillin IV. Non vaccinated patients need additional H. influenzae coverage

Requires intubation or associated with abscess/empyema
Rule out MRSA, can begin vancomycin if unable to rule out
Significant abscess/empyema, add anaerobic coverage with ampicillin/sulbactam or ceftriaxone and clindamycin

Mild: 3-5 days
Moderate: 5-7 days
Complicated: 7-10+ days

Conjunctivitis
Runny nose
Cough
Oral ulcers
Hoarseness
Sore throat
Possible fever

Group A Strep pharyngitis, it is the only type of pharyngitis which requires antibiotic treatment

Abrupt sore throat and painful swallowing
Headache, nauseua, vomiting, abdominal pain
Redness and inflammation of the tonsils and pharynx (possible white patchy spots), red swollen uvula, petechiae (spotting) on the soft palate (roof of mouth)
Scarlatiniform (sandpaper like) rash
Enlarged, tender lymph nodes

Only those >3 years old with symptoms specific to GAS
If 3-18 years old, send negative rapid antigen detection test (RADT) out to lab to confirm GAS culture also negative

Acetaminophen or NSAID
Topical agents / gargles (no benzocaine for patients under 2 due to risk of methemoglobinemia)
Hard candy/lozenges if not choking risk (usually age 6)
Hydration
Antibiotics for GAS

Amoxicillin 50mg/kg/day once or twice daily for 10 days, max of 1000mg/day
Penicillin V used in adults, 500mg BID for 10 days

12mg/kg/day once daily for 5 days, max 500mg daily (about double typicaly azythromycin dosing)

12 hours after antibiotic therapy started as long as they are no longer febrile

Infection and inflammation of the meninges, the layers of tissue that surround the brain and spinal cord
Can be aseptic, not caused by bacteria, or bacterial meningitis

Infection and inflammation of the brain

Inflammation of the ventricles in the brain which circulate CSF

Puss filled areas within the brain, which can be the result of infection or trauma

Neonates: no clear/specific symptoms
Children and adults: fever, headache, nausea/vomiting, altered mental status, neck stiffness, seizures, rash

No clinical differentiation between viral and bacteria meningitis, but do not delay antibiotics for testing

fever, headache, or altered conciousness, with focal neuorological signs such as memory loss, seizures, or trouble speaking

ampicillin+aminoglycoside or ampicillin+ceftazidime (no ceftriaxone, associated with kernicterus in this age group)

vancomycin+3rd generation cephalosporin (ceftriaxone)

Vancomycin is to cover for MRSA, discontinue vancomycin if further testing shows no MRSA present

Vancomycin+ampicillin+3rd generation cephalosporin (ceftriaxone)

Vancomycin is to cover for MRSA, discontinue vancomycin if further testing shows no MRSA present

<5 (<30 for newborns)

1000-5000

50-1000

monocytes

neutrophils

lymphocytes

<50

elevated

slightly elevated

45-80 (2.5-4.4mmol/L)

low

normal

In patients with diabetes, cancer, patients taking immunosuppressive medications, <1 month old, or >50 years old, antibiotic coverage should include ampicillin

Neonates and infants <3 months old should recieve IV acyclovir until HSV can be ruled out

Vancomycin+cefepime or meropenem to cover possible MRSA and gram negative infections
May consider intraventricular administration if responding poorly to systemic therapy

Lab values more similar to aseptic meningitis than bacteria, should be suspected in areas of high lyme prevalence during lyme season

Ceftriaxone IV/IM
Doxycycline IV/IM/PO (ok for all children, as long as total therapy is <21 days)

Controversial, given in adults with S. pneumoniae or H. influenzae meningitis. If given to pediatrics, must be started before or up to 4 hours after initiation of antibiotic therapy, and should be discontinued if source of meningitis is found to no be due to S. pneumoniae or H. influenzae

H. influenzae type B (Hib) or N. meningitidis
No prophylaxis indicated for S. pneumoniae

When indicated, contacts of the patient should be given a 4 day course of rifampin

Houshold contacts should be treated if anyone in the house is <4 years old and not completely vaccinated, <12 months old and has not recieved the primary series, or if there is an immunocompromised child
Childcare/nursery school contacts should be treated if there are >2 cases in 60 days
All susceptible contacts if patient is not treated with ceftriaxone

When indicated, contacts of the patient should be given a 2 day course of rifampin (first line for pediatric contacts), or 1 day course of ceftriaxone (first line for pregnant or nursing contacts) or ciprofloxacin

Prophylaxis should be given to all household, nursery school/day care, social, or anyone else who shared a common eating/sleeping quarter with the patient within the last 7 days

At least 21 days