Acute Care Exam #3

• Urinary tract infection occurring with an indwelling urinary catheter
• Can occur within 48 hours of catheter removal

• Increased morbidity
• Increased mortality
• Increased length of stay
• Increased healthcare costs

• Fever
• Hypothermia
• Apnea and bradycardia (infants)
• Nausea and vomiting
• Flank pain
• Tenderness
• Hematuria
• Dysuria
• Pelvic pain
• Discomfort
• Frequent voiding
• Lethargy without another cause
• Positive urine culture

• Escherichia coli
• Pseudomonas aeruginosa
• Enterococcus faecalis

• Remove urinary catheters as soon as possible
• Reduce unnecessary catheter use

• Use aseptic insertion technique
• Replace the catheter and collection system if the catheter disconnects or leaks
• Teach and model proper catheter insertion technique

• Proper catheter securement
• Drainage bag below the bladder
• No dependent loops in tubing
• Daily assessment that the catheter remains indicated

• Microorganisms form antimicrobial-resistant biofilms on the catheter
• Biofilms cannot be eradicated without catheter removal

• Base therapy on local uropathogen resistance patterns
• In young febrile children, choose an antimicrobial with low resistance rates due to the higher risk of renal involvement

• Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality
• Pathogens are often multidrug resistant

• At least one of the following:
• New onset or worsening cough, dyspnea, tachypnea, expectorated sputum, or need for mechanical ventilation
• Hypoxemia
• Need for supplemental oxygen
• New onset of suctioned respiratory secretions

• Older children
• Longer PICU stay
• Aspiration risk
• Blood product administration within the past 7 days
• Frequent suctioning

• Staphylococcus aureus (most common)
• Pseudomonas aeruginosa
• Stenotrophomonas maltophilia

• Suspected based on clinical presentation and chest X-ray
• May be confirmed with positive blood culture matching respiratory pathogen
• Bronchoscopic sampling with quantitative Gram stain and culture can confirm diagnosis
• Bronchoscopy is not routinely performed in children

• Poor specificity for diagnosing VABP

• Frequent suctioning
• Head of bed elevated
• Gastric acid suppression
• Oral hygiene
• Sedation holidays
• Extubation readiness trials
• DVT prophylaxis

• Significantly reduces the incidence of VABP when used whenever possible

• Review prior respiratory culture results
• Cover pathogens isolated during current or recent admissions
• Consider local bacterial prevalence and resistance patterns

• Determined by clinical findings
• Procalcitonin can help guide duration of therapy

• Presence of viable bacteria in the blood
• Suspect in a febrile child without a specific source
• Increased suspicion in children with prematurity, chronic illness, recent gastroenteritis (Salmonella bacteremia), or acute fever without another source

• Rochester criteria
• Boston criteria
• Philadelphia criteria

• Birth–3 months: Group B Streptococcus (most common)
• 3 months–3 years: Streptococcus pneumoniae (most common)

• Significant fever (>40°C)
• Elevated white blood cell (WBC) count

• Absolute neutrophil count (ANC)
• C-reactive protein (CRP)
• Procalcitonin (PCT)

• Complete blood count (CBC)
• C-reactive protein (CRP)
• Procalcitonin (PCT)
• Blood culture
• Urinalysis (UA)
• Urine culture
• Consider lumbar puncture in infants <3 months

• Admit children with significant fever and no source
• Start IV third-generation cephalosporins while awaiting culture results

• Treat with antibiotics
• Ill-appearing, febrile, <3 months, or immunocompromised: Full sepsis evaluation and parenteral antibiotics
• Immunocompetent, afebrile children 3–36 months: Oral antibiotics may be appropriate

• Sepsis
• Pneumonia
• Septic arthritis
• Brain abscess
• Osteomyelitis
• Cellulitis
• Meningitis

• Well-appearing
• No evident source of infection
• Temperature ≥38.0°C

• Urinalysis
• Blood culture
• Lumbar puncture (LP)
• May obtain inflammatory markers (IMs)

• Send HSV studies
• Initiate parenteral antimicrobials, including acyclovir
• Observe in the hospital

• Initiate parenteral antimicrobials
• Observe in the hospital

• Treat the identified infection

• Discontinue antimicrobials
• Discharge hospitalized infant if culture results are negative at 24–36 hours
• HSV PCR must be negative if obtained
• Manage based on duration of illness

• Usually caused by a bacterial infection
• Historically most commonly caused by Haemophilus influenzae type b (Hib) before widespread vaccination

• Significant morbidity and mortality
• Can rapidly progress to upper airway obstruction, respiratory arrest, and death

• Drooling
The child will present with drooling as secretions are thick and copious and it hurts to swallow
• Dysphagia
It is painful to swallow due to inflamed epiglottis
• Respiratory distress
Swelling of the upper airway results in turbulent airflow during inspiration or stridor
Signs of severe upper airway obstruction such as intercostal or suprasternal retractions, tachypnea, and cyanosis are concerning for impending respiratory failure and should signal the provider to act quickly

• Fever
• Drooling (>80% of children)
• Anxiety
• Restlessness
• Agitation

• Child may assume the sniffing position to maintain a patent airway

• Secure the airway before examination, IV placement, blood work, or imaging

• Intubation by a pediatric anesthesiologist, otolaryngologist, or pediatric surgeon
• Transfer to the PICU after airway stabilization

• Consider cricothyrotomy or tracheotomy

• Examine the epiglottis
• Obtain cultures
• Nasotracheal tube may replace the initial orotracheal tube
• Establish IV access
• Obtain laboratory studies and imaging as needed

• Not required for diagnosis
• Obtained at the provider's discretion

• Ceftriaxone
• Cefotaxime
• Cefuroxime

• Use remains controversial

• Bacterial infection of the trachea
• Usually follows a viral upper respiratory infection
• May also result from sinusitis, streptococcal pharyngitis, or postoperative tonsillectomy infection

• Relatively rare
• Critical illness requiring PICU monitoring
• Most common between infancy and 6 years of age

• Staphylococcus aureus (most common)
• Methicillin-resistant Staphylococcus aureus (MRSA)

• Often preceded by viral URI symptoms
• Fever
• Cough
• Stridor
• Dyspnea
• Respiratory distress
• Drooling is uncommon

• Clinical presentation
• Clinical history
• Radiographic evidence of tracheal distortion

• Evaluate airway
• Determine need for intubation
• Supplemental oxygen
• Racemic epinephrine for stridor
• Albuterol for wheezing
• IV fluids, including bolus if dehydrated

• Vancomycin or linezolid
• Plus a third-generation cephalosporin or ampicillin-sulbactam
• Follow regional guidelines

• Consider if intubation is not required
• Obtain secretions for culture
• Continue MRSA coverage until culture results return

• Used in intubated children to promote airway clearance

• Most children require intubation
• Usually improve within 2–3 days after appropriate antibiotics and supportive care
• Continue monitoring for acute respiratory distress and sepsis

• Parapneumonic pleural effusion (PPE)
• Pleural empyema (PE)

• Streptococcus pneumoniae
• Streptococcus pyogenes
• Staphylococcus aureus

• Child has received 2–3 days of antimicrobial therapy without clinical improvement

• Fever
• Respiratory distress
• Chest pain
• Leukocytosis
• Left shift
• Elevated protein
• Elevated procalcitonin
• Elevated D-dimer
• Hyponatremia

• Chest X-ray confirms pleural fluid and rules out pneumothorax or necrotizing pneumonia
• Thoracic ultrasound is the gold standard
• CT or MRI reserved for refractory cases

• Aminopenicillineta-lactamase inhibitor combinations
• Followed by second-generation cephalosporins
• Consider regional organism patterns and local antibiograms

• Generally not recommended

• Obtain pleural fluid for culture
• Drain large empyemas to allow lung re-expansion

• Large or loculated pleural effusions
• Reduces the need for repeated thoracentesis
• Allows administration of fibrinolytics

• Urokinase
• Streptokinase
• Alteplase
• Administered through the chest tube into the pleural space
• Promotes debridement
• Shortens disease course
• Reduces need for surgical intervention

• Reserved for refractory PPE/PE after unsuccessful drainage and fibrinolytic therapy

• Dengue fever
• Malaria
• Typhoid fever
• Viral hemorrhagic fever
• Rickettsiosis
• Leptospirosis
• Schistosomiasis

• Most often caused by a treatable respiratory or gastrointestinal illness
• May indicate a serious travel-related infection

• Malaria

• Children traveling abroad to visit family

• Time is available to evaluate and rule out treatable infections

• Begin empiric treatment immediately

• COVID-19: 2–14 days
• Influenza: 1–3 days
• Arbovirus encephalitis: 3–14 days
• Chikungunya: 2–4 days
• Zika virus: 3–14 days
• Dengue fever: 4–8 days
• Acute HIV: 7–21 days
• Typhoid/paratyphoid fever: 7–18 days
• Leptospirosis: 7–12 days
• Plasmodium falciparum malaria: 6–30 days
• Plasmodium vivax malaria: 8 days–12 months
• Spotted fever rickettsiosis: 3 days–3 weeks

• Amebic liver abscess: Weeks–months
• Hepatitis A: 28–30 days
• Hepatitis E: 26–42 days
• Acute schistosomiasis (Katayama fever): 28–60 days
• Hepatitis B: 60–160 days
• Visceral leishmaniasis: 2–10 months
• Tuberculosis: Weeks for primary infection

• Geographic region visited
• Freshwater exposure
• Camping or living with locals
• Food preparation methods
• Unpasteurized dairy consumption

• Schistosomiasis
• Leptospirosis

• Malaria
• Meningococcal disease
• Typhus

• Undercooked food: Nontyphoidal salmonellosis, trichinosis, typhoid fever
• Untreated water: Amebiasis, hepatitis A/E, cholera, nontyphoidal salmonellosis, typhoid fever, Cryptosporidium, Cyclospora, Giardia
• Freshwater: Schistosomiasis, leptospirosis, free-living amebiasis
• Unpasteurized dairy: Brucellosis
• Sexual contact: Chancroid, gonorrhea, hepatitis B, syphilis, HIV
• Animal exposure: Brucellosis, plague, Q fever, rabies, tularemia, avian influenza
• Ill contacts: Meningococcal disease, TB, viral hemorrhagic fevers, MERS-CoV, COVID-19
• Cave exposure: Histoplasmosis, rabies
• Mosquitoes: Dengue, malaria, yellow fever, chikungunya, Zika, JE virus, West Nile virus
• Ticks: Rickettsial disease, tularemia, Lyme disease, babesiosis
• Fleas: Murine typhus, plague

• Common in Latin America, Asia, the Caribbean, and Africa
• Transmitted by mosquitoes
• Caused by five Plasmodium species

• Symptoms develop as early as 7 days after a mosquito bite
• May present up to 2 months later

• Fever
• Abdominal pain
• Cough
• Vomiting
• Diarrhea

• Younger children are at greatest risk
• Severe anemia
• Cerebral malaria

• Thick and thin blood smears
• Repeat blood smears to avoid false-negative results
• Rapid tests available but have low sensitivity
• PCR available, but turnaround time varies

• Report to the local health department

• IV artesunate

• Follow CDC recommendations and local availability

• Contaminated food and water
• Person-to-person spread

• Fever
• Headache
• Abdominal pain
• Malaise
• Chills
• Myalgias

• Hepatomegaly
• Splenomegaly
• Rose spots

• Encephalopathy
• Intestinal hemorrhage or perforation
• Peritonitis

• Blood culture is most sensitive
• Stool and urine cultures are less sensitive

• Ceftriaxone is appropriate empiric therapy

• Mosquito-borne illness
• May progress to hemorrhagic fever and shock
• Leukopenia and thrombocytopenia are common
• Treatment is supportive
• No effective antiviral medications

• Contaminated water
• Recreational freshwater exposure (swimming, rafting)

• 5–14 days

• Usually a self-limited febrile illness

• Jaundice
• Renal failure
• Myocarditis
• Pulmonary hemorrhage
• Conjunctival suffusion leading to uveitis

• Usually retrospective by serology

• IV penicillin
• IV ceftriaxone
• Doxycycline
• Cefotaxime
• Severe disease requires supportive care

• Most commonly associated with travel to Africa
• Acquired by swimming or bathing in freshwater
• May begin with swimmer's itch

• Presents 2–9 weeks after freshwater exposure
• Fever
• Cough
• Urticaria
• Skin rash
• Eosinophilia
• Abdominal pain

• Praziquantel 40 mg/kg
• Repeat treatment in 6–8 weeks

• Tick-borne illness
• Incubation period 5–14 days
• Fever
• Malaise
• Myalgias
• Rash commonly involves the extremities

• Serology detects antigens

• Doxycycline

• May occur up to 8 days after leaving the foreign country
• Usually acquired from contaminated food or water
• Children <2 years are at greatest risk
• Diarrhea may last up to 17 days in children <3 years

• E. coli is most common in developing countries
• Viral causes are more common in industrialized countries
• Also consider rotavirus, norovirus, and Giardia

• Assess hydration status
• Replace fluid and electrolyte losses
• Azithromycin is recommended when the etiology is unknown

• Contraindicated with fever or bloody diarrhea
• Contraindicated in children <2 years

• Trimethoprim-sulfamethoxazole (TMP-SMX)
• Ciprofloxacin
• Rifaximin
• Nitrofurantoin

• Do not administer antibiotics
• Risk of hemolytic uremic syndrome (HUS) with EHEC/STEC infection

• Lower respiratory infection
• Consider with chronic cough, night sweats, weight loss, and lymphadenopathy
• Consider if bacterial pneumonia does not resolve

• Children <4 years are at risk for disseminated disease
• May present as miliary tuberculosis or TB meningitis

• Uncommon in children
• Sexual contact is the primary source of infection in adolescents

• Rash
• Fever
• Chills
• Sweats
• Lymphadenopathy
• Sore throat
• Myalgias