Categories
Infectious Diseases

Pertussis

In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore pertussis, also known as whooping cough – a disease that remains a public health challenge despite widespread vaccination efforts. We will review the clinical presentation, diagnostic strategies, management protocols, infection control practices, and vaccination updates. This episode also covers what healthcare providers need to know about post-exposure prophylaxis, respiratory precautions, and managing occupational exposures.

Learning Objectives

  1. Understand the clinical progression of pertussis through its three distinct stages and identify key symptoms, including age-specific presentations in infants and older children.
  2. Implement effective management strategies for pertussis, including supportive care, appropriate antibiotic regimens, and post-exposure prophylaxis for contacts and healthcare providers.
  3. Promote pertussis prevention by understanding vaccination schedules (DTaP vs. Tdap), addressing vaccine hesitancy, and adhering to infection control protocols in clinical settings.

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References

StatPearls
Lauria AM, Zabbo CP. Pertussis. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519008/

AAP Pediatrics in Review
Heather L. Daniels, Camille Sabella; Bordetella pertussis (Pertussis). Pediatr Rev May 2018; 39 (5): 247–257. https://doi.org/10.1542/pir.2017-0229

UpToDate

Yeh S et al. Pertussis infection in infants and children: Clinical features and diagnosis. UpToDate. Available at: https://www.uptodate.com. Accessed December 3, 2024.

MMWR

Seither R, Yusuf OB, Dramann D, et al. Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten — United States, 2023–24 School Year. MMWR Morb Mortal Wkly Rep 2024;73:925–932. DOI: http://dx.doi.org/10.15585/mmwr.mm7341a3

Transcript

Note: This transcript was partially completed with the use of the Descript AI

Welcome to PEM Currents, the pediatric emergency medicine podcast. As always, I’m your host, Brad Sobolewski, and today we’re talking about pertussis, a disease that is challenging clinicians and public health officials alike. Despite being vaccine preventable, Pertussis is on the rise, yet again, fueled by declining vaccination rates, waning immunity, and the fact that people can’t stop coughing on each other.

In this episode, we’ll go over clinical presentation, diagnosis management, infection control, and post exposure protocols. So pertussis, or whooping cough, is caused by Bordetella pertussis, a gram negative coccobacillus. It definitely spreads via respiratory droplets, and has no environmental or animal reservoirs, making humans the sole carriers.

The incubation period averages about 7 to 10 days, and the disease progresses through some distinct clinical stages, which I will go over in a moment. Pertussis has been recognized since the 16th century. I was not practicing medicine back then. Um, with the first documented epidemic occurring in Paris in 1578.

Bordetella pertussis was isolated in 1906 by Belgian researchers, Jules Bordet and Octave Gengou, I hopefully I pronounced them right, but they’re long gone, so they won’t be mad at me,, leading to the development of a whole cell pertussis vaccine in the 1940s. Introduction of the DTP, the diphtheria tetanus pertussis vaccine, dramatically reduced disease incidence overall.

In the 1990s, we got the acellular pertussis vaccine, the DTaP, which replaced the whole cell formulation due to concerns about some side effects. So pertussis remains endemic in many regions of the world despite vaccination efforts. During the 23 24 school year, DTaP coverage among kindergartners in the United States dropped to 92.

3%, which is below the 95 percent threshold needed for herd immunity. That is is why we’re seeing an outbreak now. This is a pretty troubling trend that began during the COVID 19 pandemic and has just gotten worse since. The exemption rate for vaccines rose to 3. 3 percent. This is the highest on record.

Non medical exemptions accounted for over 93 percent of these exemptions. And 14 states in the U. S. have reported exemption rates exceeding 5 percent. Idaho is leading at 14. 3 percent. So the implications of these declining vaccination coverage rates are significant and that’s why we’re seeing more and more outbreaks, especially putting our vulnerable populations at highest risk.

Alright, let’s get back to the clinical presentation. Wait, what’s that sound? Hold on. Coughing. Yeah, so that’s the whoop and the cough of pertussis. And I’d wager that many of you have not yet heard that clinically, so that’s why I included it on this episode. So here’s the stages of disease. First is the catarrhal stage, which lasts one to two weeks.

You have rhinorrhea, mild cough, and a low grade fever, if any. You are highly contagious during this phase, but it’s often unrecognized as pertussis. Then, in the next two to eight weeks, you have the paroxysmal stage. You have these severe paroxysms of coughing, the inspiratory whoop right beforehand, post tussive emesis.

Infants, especially under six months of age, may present atypically with just apnea, cyanosis, or bradycardia. for that. Following that, you have the convalescent stage, which lasts weeks to months. You have gradual resolution of symptoms, though residual cough may persist. That’s why they call it the 100 day cough.

Aside from coughing forever, there’s some important complications you need to be aware of. And they can be severe, especially, as I noted earlier, in young infants. So respiratory complications include apnea, secondary bacterial pneumonia, and pulmonary hypertension. Children encephalopathy, often due to hypoxia.

And the mechanical complications can include rib fractures, subconjunctival hemorrhage, and even rectal prolapse due to intense coughing and valsalva. Greater than 50 percent of kids under 12 months of age with pertussis could require hospitalization. 50 percent of those kids will have apnea, 20 percent will have pneumonia, and up to 1 percent will die.

Encephalopathy occurs in about 20 percent of mortality cases, probably due to hypoxia, or maybe the toxin produced by the bacteria itself. So, making the diagnosis of pertussis starts with high index of clinical suspicion. Early diagnosis, as you’d suspect, is critical to limiting disease spread and initiating treatment.

So, PCR testing, which is widely available now, has high sensitivity in the first three to four weeks and is the preferred diagnostic test. Culture is the old gold standard, but it’s slower and less sensitive. It can take up to a week to grow. CBC might show significant lymphocytosis, um, most often in infants, but it ain’t going to make the diagnosis of pertussis for you.

And a chest x ray will just show you some non specific findings, such as peribronchial thickening in severe cases. And unless you’re worried about concomitant bacterial pneumonia, you probably don’t need a chest x ray to make the diagnosis of pertussis. You can get an isolated pertussis PCR, or Or it can come as part of a respiratory panel.

But remember those comprehensive viral respiratory panels cost 1, 600. So if you’re just worried about pertussis, don’t get the whole panel. So management starts with supportive care. Infants with apnea, cyanosis, or feeding difficulties should obviously be admitted to the hospital. They may need oxygen and or nutritional support.

And you definitely have to watch those kids very closely for the complications such as hypoxia and secondary infections. Remember, a tiny baby with pertussis can go apneic at a moment’s notice even without a persistent cough. Antibiotics reduce transmission. But do not significantly alter disease progression once the paroxysmal stage begins.

So again, you are treating with antibiotics to prevent more people from getting sick, more so than shortening the duration of illness. The main antibiotic that we use is azithromycin. For infants under 6 months of age, that’s 10mg per kg daily for 5 days. For children older than 6 months of age, 10mg per kg, max of 500mg on day 1, followed by 5mg per kg per day, max of 250mg on days 2 through 5.

That is the same dosing that you can give to a grown up. An alternative treatment, you would be trimethoprim sulfamethoxazole for patients who are allergic to macrolides. Post exposure prophylaxis is recommended for household contacts, so the people that the index patient lives with, any high risk individual, and infant, pregnant women, or immune compromised individuals that have been in any sort of contact with the person with pertussis, and and a health care worker exposed without appropriate PPE.

Again, pertussis spreads through respiratory droplets. So this necessitates strict infection control. So that starts in triage. So if you think that a patient has pertussis, then they need to be place on droplet precautions as soon as they are assessed. You wear a surgical mask and eye protection, so goggles or a face shield, and you want to maintain these precautions for five days after starting effective antibiotics or for 21 days if the patient is untreated.

As a clinician, Just ask yourself, did you wear appropriate PPE, mask and goggles? Don’t get lazy. Was the exposure prolonged or close? And rely on infection control in your institution to help decide whether or not you need post exposure prophylaxis. If you’re vaccinated and you wore PPE, you don’t need anything.

Unless you have symptoms. If you’re vaccinated and you did not wear PPE, then prophylaxis is recommended. If you’re unvaccinated and not up to date, well then what are you doing in healthcare? And immediate prophylaxis and vaccination update are required. And, okay, ’cause I just mentioned it. Let’s talk about vaccines.

So first I wanna talk about DTaP, dt, lowercase a uppercase p and t dap. Uppercase T D A P. So DTAP contain higher concentrations of diphtheria and pertussis antigens. It’s used for children under seven years of age. TDAP contains lower antigen concentrations and it’s designed for adolescents and adults to reduce reactogenicity.

There is no standalone pertussis vaccine. I’ve had patients say, well, I don’t want tetanus. Just give me the pertussis one. Well, tough Schenectes. We do not have a pertussis vaccine. alone. It’s only available in combination with diphtheria and tetanus toxoids, DTaP or Tdap. The combined vaccine boosts efficacy and ensures broader protection against all of the included infections.

Now the routine vaccination schedule, which if you are a pediatric resident, you know, like the back of your hand, the DTAP is administered at 2, 4, 6, and then between 15 and 18 months with a booster at 4 to 6 years. The Tdap is one dose at 11 to 12 years and then during every pregnancy to confer passive immunity to the newborns.

And again, depending on when you’re listening to this, you may be in the midst of a pertussis outbreak. And if you listen to this a few years later, after the original publication date in the fall of 2024, and you’re seeing another pertussis outbreak, well, dang it, we haven’t done our job. We need to strengthen school vaccination requirements.

We need to educate parents about vaccine safety and the risks of exemptions. And we need to broadly improve and ensure access to vaccinations through our community clinics. Thanks. Alright, so that’s it for this episode on Pertussis, which remains a significant public health challenge due to its severe complications in young patients and the ongoing decline in vaccination coverage.

Healthcare providers play a vital role in diagnosing and managing it, preventing its spread, and educating patients and families about the benefits of vaccination. Infection control practices and post exposure protocols are critical for protecting both clinicians and close contacts and other exposures.

Thank you so much for listening to this episode. I hope you found it educational and informative. If there’s other topics that you want to hear about, let me know. I’m on X, I’m on Blue Sky, I’m on Mastodon, I take emails, you can leave a comment on the blog, you can leave a review on your favorite podcast site, any feedback is good feedback, and encourage your colleagues to listen, and as the kids say, like and subscribe, I told my 12 year old I would say that at the end of the episode.

For PEMCurrents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski, see you next time.

Categories
Adolescent Infectious Diseases

Syphilis

Syphilis has gone by many nicknames over the years including “The Great Pretender” and “The Great Imitator.” Emily Labudde, MD, a Pediatric Emergency Medicine fellow at Children’s Healthcare of Atlanta and recent pediatric residency graduate from Cincinnati Children’s discusses the various manifestations of this sexually transmitted infection, and how we can’t miss this very treatable, but sneaky malady.

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References

Emily J. Labudde, Jane Lee; A Review of Syphilis Infection in Pediatric Patients. Pediatr Rev. July 2024; 45 (7): 373–380. https://doi.org/10.1542/pir.2023-006309

Centers for Disease Control and Prevention. “Sexually Transmitted Disease Surveillance 2021.” Centers for Disease Control and Prevention, 2021. Available from: https://www.cdc.gov/std/statistics/2021/default.htm.

Centers for Disease Control and Prevention. “Sexually Transmitted Infections Treatment Guidelines 2021.” Centers for Disease Control and Prevention, 2021. Available from: https://www.cdc.gov/std/treatment-guidelines/syphilis.htm.

Centers for Disease Control and Prevention. “Youth Risk Behavior Surveillance System.” Centers for Disease Control and Prevention, 2021. Available from: https://www.cdc.gov/healthyyouth/data/yrbs/index.htm.

Transcript

Note: This transcript was partially completed with the use of the Descript AI

Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast, as always, I’m your host Brad Sobolewski. Today’s episode is all about the great pretender, syphilis. And let’s face it, it’s not just a disease for Medieval royalty. It’s on the rise in the United States and abroad. So let’s talk about the manifestations and management.

And I’ve got a special guest host. This is Emily Labudde, originally from Detroit, at the time of recording this episode, a third year categorical pediatric resident at Cincinnati Children’s and a soon to be pediatric emergency medicine fellow in Atlanta. I’m going to pass the mic to you, Emily. My name is Emily Labudde, and I’m a third year pediatric resident at Cincinnati Children’s Hospital, and I’ll be starting fellowship in pediatric emergency medicine this summer at Emory University Children’s Healthcare of Atlanta.

Today’s podcast is going to cover acquired syphilis infection. Now, I know what you’re thinking. We don’t see a lot of syphilis in the pediatric ED. That’s what I thought, too, until I saw it, and with syphilis on the rise, it’s likely we’ll start to see more. I recently published a review article on syphilis in Pediatrics in Review, which you should check out.

It is far more detailed and also covers congenital syphilis, which is beyond the scope of this episode. At the end of this podcast, you should be able to appreciate the rising incidence of syphilis in the United States, especially amongst young people, recognize various signs and symptoms associated with different stages of syphilis infection, and identify the appropriate workup for possible syphilis infection, including co infections.

Syphilis is fondly referred to as the great imitator because of its various presentations. Headache? Could be syphilis. Rash? Could be syphilis. Weight loss? Could be syphilis. Epitrochlear lymphadenopathy? That’ll be on your boards. Definitely syphilis. I bet I could argue to have syphilis on every differential in some way, shape, or form.

But there are certain clues that can help guide you toward a more reasonable consideration of syphilis infection. Thank you, Jen. The U. S. is seeing a lot more cases of syphilis over the last decade or so. And, since we know from the CDC’s Youth Risk Behavior Survey that many American teens are having sex with less than optimal condom use and infrequent STI testing, pediatricians everywhere should be thinking more about acquired syphilis infection, not just congenital syphilis.

There are three stages of syphilis infection. Primary syphilis is often missed as it presents as a painless genital ulcer. Secondary syphilis causes systemic symptoms such as fever, anorexia, headache, malaise, lymphadenopathy, arthralgias, and rash, that classic rash on the palms and soles. It’s worth looking at a variety of pictures of this rash, some examples of which we have included in the show notes, as its appearance can vary, especially between different skin colors.

Tertiary syphilis is rare, and you’re almost guaranteed not to see it in a pediatric ED as it develops decades after initial infection. It’s characterized by gummas, which are granulomatous soft tissue tumors seen most often in the liver, but also in the bone, brain, heart, skin, testis, and eyes, and end organ damage, particularly of the central nervous system.

At any stage, patients can develop neurosyphilis, that can present with vision changes, neuropathies, seizures, or altered mental status. You may have heard this once or twice before, but your history and physical exam are so important, especially when looking for an infection like syphilis that can present in many different ways.

A thorough review of systems can help guide your differential and can point towards co infections with other STIs. Brush up on your sexual history taking skills because they’re critical here. This includes all the details like who has what parts and where they put them. Teens are awkward and they get super nervous when you kick out mom and dad and ask them what they’ve been doing on the weekends, but you won’t fully understand your patient’s risks without asking these questions.

It’s good preparation prior to the physical exam, which, you guessed it, should be thorough. We’re talking full body skin exam, neuro exam, genital exam, and all of the lymph nodes. Now, it would be really nice if our patients came in saying, Hey, my partner has syphilis, please test me for syphilis. And, like we talked about, syphilis can look like a lot of different things, so it’s important to keep your differential broad.

Syphilis testing can be divided into two types, treponemal and non treponemal. You’ll want to start with a non treponemal test, such as an RPR or VDRL. The RPR or Rapid Plasma Reagent, which has now largely replaced the earlier VDRL or Venereal Disease Research. Laboratory Test is a non-specific serological test for syphilis that uses CARDIOLIPIN as antigen.

These are highly sensitive tests. But watch out for false positives. The RPR is also useful for post treatment monitoring. Trepanemal tests, such as the FTA ABS, are used as confirmation in the setting of a positive non trepanemal test. Patients with neurologic complaints should undergo CSF testing as well.

And, of course, where there’s one, there’s probably more. Use the information from your very thorough sexual history to test your patient for any other STIs they are at risk for. Patients with primary or secondary syphilis can be treated with a single dose of benzathine penicillin G or a 14 day course of doxycycline if your patient has a penicillin allergy.

For any patient with tertiary or neurosyphilis or a pregnant patient with any stage of infection, 10 to 14 days of penicillin G is the only option, even in penicillin allergic patients. So, if a patient has a severe penicillin allergy, have rescue medications available. Watch out for that Gerrish Herxheimer reaction, I know you haven’t heard those words since medical school, which can cause fever, headache, myalgias, or nausea and vomiting in the first 24 hours after treatment.

Last, but not least, remember that in some cases you’re telling your patient about their disease and possibly some dishonesty from their partner. Be sure to counsel them on sharing their results with all of their sexual partners, as well as your responsibility to inform the local health department for disease tracking purposes and the option for third party partner notification.

A few brief points on congenital syphilis, which is covered more in depth in the review article. We most often see this in infants born to mothers with poor prenatal care, as our OB colleagues do a great job screening for syphilis multiple times during pregnancy. Most infants with congenital syphilis are asymptomatic at birth, with appearance of hepatomegaly, jaundice, copious rhinorrhea, lymphadenopathy, and a similar maculopapular rash on their hands and feet that develop later in infancy.

Think about congenital syphilis in your little ones presenting like biliary atresia, who have a normal gallbladder treon ultrasound. Late congenital syphilis in children older than two can present with more severe features that are frequently tested on boards. Things like gummas, facial dysmorphias like saddle nose deformity and frontal bossing, sabershins, Hutchinson teeth, developmental delay, and hearing and vision concerns.

You’ll want to check a non trepanemal test in these kids, as maternal trepanemal antibodies can persist for over 15 months. Patients with congenital syphilis also receive treatment with penicillin G, 50, 000 units per kilo, frequency determined by their age. Thanks so much for listening, now get out there and practice your sexual histories.

Emily, thank you very much. Hopefully you all found this information helpful and we’ll be able to pick syphilis out of the lineup the next time you encounter it in the emergency department. If you want to learn how to produce a podcast episode, reach out to me, just like Emily did, and we will go through the entire process.

If you’ve got ideas for topics, send them my way. Any feedback that you have is greatly appreciated. Send me an email, leave a comment on the blog, a review on your favorite podcast site, or even a message through social media. And as my 12 year old would remind me to say, subscribe and share. For Pam Currens, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski.

See you next time.

Categories
Infectious Diseases

Cellulitis

This episode will help you recognize cellulitis and even differentiate it from erysipelas which is totally a different thing. You’ll also learn about treatment, whether or not a blood culture is necessary, and a whole lot more!

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References

Chen AE, Carroll KC, Diener-West M, Ross T, Ordun J, Goldstein MA, Kulkarni G, Cantey JB, Siberry GK. Randomized controlled trial of cephalexin versus clindamycin for uncomplicated pediatric skin infections. Pediatrics. 2011 Mar;127(3):e573-80. doi: 10.1542/peds.2010-2053. Epub 2011 Feb 21. PMID: 21339275; PMCID: PMC3387913.

Daniel J. Pallin, William D. Binder, Matthew B. Allen, Molly Lederman, Siddharth Parmar, Michael R. Filbin, David C. Hooper, Carlos A. Camargo, Clinical Trial: Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial, Clinical Infectious Diseases, Volume 56, Issue 12, 15 June 2013, Pages 1754–1762, https://doi.org/10.1093/cid/cit122

Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.

Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e10.

Transcript

Note: This transcript was partially completed with the use of the Descript AI

 Welcome to another episode of PEM Currents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and today’s episode is all about cellulitis. What is it? Well when a break in the skin occurs, normal skin, flora, and bacteria can enter the subcutaneous tissue, where they do not belong, and they can also invade the lymphatic system.

And although this podcast episode is entitled cellulitis, I’m also going to talk about erysipelas. The two terms are not interchangeable. but both manifest as areas of skin, erythema, edema, and warmth. Cellulitis involves the deeper dermis and subcutaneous fat. Whereas erysipelas involves the upper dermis and there’s a more clear demarcation between the involved and uninvolved tissue.

There’s a fun fact, since the ear doesn’t have deep or dermal tissue, it’s always. ear-a-sipelas. I’ll pause for laughter. Anyway, a skin abscess, which is not the focus of this episode, is a collection of pus deep within the dermis or subcutaneous space. Impetigo, also not included in this episode, is a very superficial infection with that honey crusted drainage. There are also bullous versions. So cellulitis tends to develop in a bit more of an indolent fashion over a few to several days, whereas erys syphilis is more acute. You get systemic symptoms faster, such as fever. Chills, severe malaise, and headache. These can precede the onset of the local skin changes and start just in a matter of hours.

Clinically, for both, you’ll see areas of skin erythema. edema and warmth. You can also see petechiae and hemorrhage, as well as superficial bulla, vesicles, or even echemosis. Sometimes you also see regional lymphangitis or enlargement of the regional lymph nodes. If you’ve got a lot of edema surrounding the hair follicles, you can see some dimpling in the skin.

This creates an orange peel texture appearance, peau d’orange. I hope I pronounced that right. I took Spanish in high school. Anyway, the skin is warm to the touch, it’s uncomfortable, it hurts with movement, and some patients can describe an itchiness or a tight feeling in addition to the pain. You may see fever and other systemic symptoms, and cellulitis and erysipelas, especially in children, are nearly Always unilateral.

Bilateral red limbs? That’s probably something different. Complications that you should be aware of include bacteremia, endocarditis, septic arthritis, or osteomyelitis. Full blown sepsis and toxic shock syndrome. Fortunately, those are rare. So, in general, mild cellulitis has no systemic features in a patient with no significant comorbidities.

Moderate cellulitis has moderate swelling and tenderness with some systemic features like fever or tachycardia. Severe cellulitis has severe swelling and tenderness. really affecting function. It’s a larger body surface area, and you’ve got marked systemic features. So fever or hypothermia, extreme tachycardia, tachypnea, altered consciousness, a very unwell appearance, or even hypotension.

So what causes it? Well, bacteria, and the most common etiology. Staphylococcus aureus is actually an infrequent cause of cellulitis in children. But it can be seen more often in penetrating wounds. Methicillin resistant Staphylococcus aureus classically causes abscess formation. So you won’t really see that as the cause of isolated cellulitis or erysiplas in children.

So how do you make the diagnosis? Well, it’s clinical, right? Look for areas of skin that are erythematous, edematous, warm, and painful. Labs or imaging are not routinely necessary. If you think that there’s an abscess, you can diagnose it clinically by a localized area of induration or fluctuance or use an ultrasound.

Cellulitis can look like a cobblestone street on sonogram. And you should consider whether or not an abscess is present if you see significant induration, so thickening or hardening of the soft tissues, of greater than three centimeters or non uniform induration. The lesion’s been present greater than two to three days and changing or getting worse, and there’s a history of a previous incision and drainage in that patient.

And so do you need labs? Nah, not really. And the vast majority of patients of CBC or other labs will not aid in making the diagnosis of cellulitis. What about blood culture? Every febrile kid with cellulitis needs a blood culture, right? Not so fast, right? A blood culture can cost more than $200-300.

If you’re sending the kid home. Well, you definitely shouldn’t be sending a blood culture because if you’re worried about bacteremia and sepsis, that kid needs to stay in the hospital. And think about the risk of a false positive versus the risk of a true positive. So if the risk of a contaminant culture is greater than the risk of actually catching a bacteria, then don’t send it.

The cost of false positive cultures, repeat visits, length of stay, could be in the thousands of dollars. And so a lot of the previous studies on getting blood cultures were done in the immediate post Haemophilus influenzae B and Prevnar vaccine era. And we do now live in an era where these invasive organisms are fortunately not as big of a concern.

Vaccinate your children, people. But we do deal with MRSA. But still, for mild and moderate cellulitis, MRSA’s not really the etiology. And so even if a kid has a fever, But they look better after a dose of acetaminophen or ibuprofen. You don’t routinely need a blood culture. Now you could even admit a kid for IV antibiotics, maybe they’re dehydrated or they can’t take PO for some reason, without sending a blood culture.

So, admission does not mandate a blood culture. As always, you want to check with your local recommendations and follow algorithms present at your institution. So, what about disposition? So, with prompt identification and treatment with a correct antibiotic, which I’ll get to in a few minutes, patients can see an improvement in their signs and symptoms within about 48 hours.

The treatment failure rate is low, less than 1 out of 7, but probably a bit lower than that, with initial appropriate antibiotic treatment. Overall Cellulitis has a really good treatment prognosis. So when do you want to think about admission to the hospital or short stay unit versus discharge? Right, so you should probably admit a patient to the hospital if they have significant systemic symptoms.

You’re concerned about SIRS or sepsis. Again, fever alone does not necessitate admission. Especially if the kid looks better after antipyretics. If you are concerned that the child may need subsequent or future I& D, like they’re forming a phlegmon, they have a deeper infection, like necrotizing fasciitis, or they need sub sexually consultation, these are probably reasons to admit the patient to the hospital.

Now, some facilities have a short stay unit, like in their emergency department. So, if you don’t meet inpatient admission criteria, you’re likely to improve within 28 hours. Maybe the kid failed initial outpatient treatment with 48 hours of appropriate antibiotics, and they need just a day of IV. They’ve got a rapidly expanding lesion, but it’s probably IND.

The kid has a lot of pain. They can’t tolerate oral antibiotics, or they’re less than six months of age. You know, maybe that’s a patient you observe for just 24 hours in a short stay. And fortunately, cellulitis in children under the age of 2 months of age is rare, but those kids should probably be admitted for IV antibiotics as well, and you should get a blood culture in those situations. One example would be neonatal mastitis, a skin infection of the breast tissue.

Alright, so let’s talk about antibiotics. And generally, your best choice for the majority of children is cephalexin. You’d think because MRSA is everywhere. You want to avoid first generation cephalosporins, but it’s still mostly beta hemolytic strep.

And studies, including Chen et al., showed no difference between cephalexin and clindamycin. And what about length of treatment? Well, for mild cases, five days is probably just as good as ten days. But if you have moderate or severe symptoms, a week and a half is a good idea. You’ll see a lot of places start cephalexin plus clinda, or cephalexin plus trimethoprim sulfamethoxazole.

It’s still often done out in the community. A representative randomized control trial from Palin from 2013 showed that the addition of TrimSulfa did not improve outcomes in a very large cohort that contained lots of children. So the bottom line is, even in patients where you think they might have MRSA nasal carriage?

Monotherapy with cephalexin is fine. So, if you’re doing outpatient treatment or you’re transitioning patient to oral treatment after IV, the first line therapy is oral cephalexin. The dose is 50 mg per kg per day, divided every 8 hours or 3 times a day with a max of 500 mg per dose. If the patient has a true allergy to cephalosporins, you do oral clindamycin, 10 mg per kg per dose, every 8 hours, or 3 times a day, with a max of 1, 800 mg per day, or 600 mg per dose.

If you see treatment failure, that’s another reason to do clinda. So if the kid’s not getting better in 48 to 72 hours on cephalexin, you can do the same dosing of clinda that I just mentioned a moment ago. For inpatient treatment, first line therapy is intravenous cefazolin. So 20mg per kg per dose every 8 hours with a max of 1g per dose.

Cephalosporin allergy, you would use clindamycin. And yes, PO and IV clindamycin are bioavailable. But if you’re admitting somebody, there’s probably a reason that they may not be able to take PO. So if it’s IV, it’s 10mg per kg per dose every 8 hours with a max of 900mg. So it’s higher than the max for PO.

And so again, I will reiterate that 5 days for very mild cellulitis is totally okay. But you could do 10 if that’s what you do locally. Moderate and severe, you need 10 days. Some specific scenarios that you might want to deviate from cephalexin, so if there’s a mammalian bite, some don’t need prophylactic antibiotics, and I’ll admit, There’s no randomized controlled trials of dog bites.

I don’t think the IRB would approve that, but if you are concerned about infection, amoxicillin clavulonate, 22. 5 milligram per kilogram with a max of 875 milligram per dose, oral twice daily. If the kid looks well, And the degree of redness or symptoms is very mild, you could do five days, that’s totally okay.

If the child got an infection in a seawater or freshwater environment, there’s some different organisms like Aeromonas and Vibrio and other things that you want to consider. So you would still start with Cephalexin, but you would add Ciprofloxacin, 10 mg per kg, max 500 mg per dose, twice a day. Or Trimethoprim sulfamethoxazole twice a day with an overall treatment length of 5 to 10 days.

And if you definitely think that it’s methicillin resistant staphylococcus aureus that you’re treating, mild cellulitis, you could do trimethoprim sulfamethoxazole or clindamycin. If you’re sure it is moderate MRSA cellulitis, you could do a trial of oral antibiotics with close follow up or vancomycin IV.

And if they have severe cellulitis, Vancomycin IV, and if you have Staphylococcal Scalded Skin Syndrome, consider adding clindamycin. Switch to oral antibiotics as soon as the patient looks better. And there are some cases of cellulitis where you might need a specific subspecialist. So a general surgeon should be consulted if you have cellulitis of the breast, perianal tissues, perineal tissues, a complex of recurrent pilonidal abscess, Though you could drain these and have them follow up as an outpatient.

Or the cellulitis is just large and complex, or you think it’s going to need drainage in a day or two. ENT should see invasive neck cellulitis, especially with significant symptoms, or you’re concerned that it might be a deeper infection. ophthalmology and or ENT for orbital or periorbital cellulitis, orthopedics for septic arthritis, tenosynovitis or osteomyelitis, and dental or oral maxillofacial surgery for facial cellulitis due to dental infection where the kid might need to be admitted.

All right, so that’s all for this episode on cellulitis. Remember, most cases are mild or moderate, and the child will do incredibly well with oral antibiotic therapy, which should generally be cephalexin. You do not need labs, and especially a blood culture, for the vast majority of children with infections like cellulitis or erysipelas.

A fever does not mean you have to get a blood culture or admit the kid. If they haven’t started antibiotic therapy yet, and they look better after they defer vest with antipyretics, Start oral antibiotic therapy and develop a close follow up plan. Well, I hope this episode is useful. Ultimately, my goal is to deliver succinct evidence based information to help you on your next shift in the ED.

If there’s other topics that you want to hear about, send them my way. I’ll take an email. I’ll take a comment on the blog. I’ll take a direct message on Twitter or X or whatever it’s called. Leave a review on your favorite podcast site. That helps other people find it. And if more people can learn, I’m going to be happy about it.

Encourage your colleagues to listen and subscribe to the podcast. And thank you so much for your time and attention. I know you’re all busy out there. For PEM Currents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

Categories
Choosing Wisely Infectious Diseases

Respiratory viral panels

Just because you can test for dozens of viruses with a single swab should you? Is this actually measuring a current infection, or a recent virus from which the child has since recovered. And what about the cost? Are these tests expensive (spoiler alert: They are!). Learn about the situations when we should get these panels, and how we can avoid overusing them when we shouldn’t in this tremendous discussion with Dr. Olivia Ostrow and Dr. Kelly Levasseur.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not obtain comprehensive viral panel testing for patients who have suspected respiratory viral illnesses

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


Bonus Resource: The Dialogue Around Respiratory Illness Treatment (DART) program which is designed to support antibiotic stewardship


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References

  1. Gill, PJ, Richardson, SE, Ostrow O. Testing for respiratory viruses in children: to swab or not to swab. JAMA Pediatr. 2017;171(8):798-804
  1. Noël KC, Fontela PS, Winters N, et al. The clinical utility of respiratory viral testing in hospitalized children: a meta-analysis. Hosp Pediatr. 2019;9(7):483-494
  1. Parikh K, Hall M, Mittal V, et al. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014;134(3):555-562
  1. Innis K, Hasson D, Bodilly L, et al. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5
Categories
Infectious Diseases

Epiglottitis

The epiglottis is the toilet seat of the airway. That’s a useful function. But what if becomes so swollen and inflamed that it leads to airway obstruction and respiratory failure. That’s bad. That’s also what epiglottitis is. You can also call it supraglottitis. Either way you need to recognize this potentially life threatening malady and secure a definitive airway in the sickest patients ASAP.

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References

Rafei K, Lichenstein R. Airway infectious disease emergencies. Pediatr Clin North Am 2006; 53:215.

Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am 2008; 41:551.

Richards AM. Pediatric Respiratory Emergencies. Emerg Med Clin North Am. 2016 Feb;34(1):77-96. PMID: 26614243.

Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg Care. 2006 Jun;22(6):443-4. PMID: 16801849

Categories
Infectious Diseases

Norovirus

Norovirus is the leading cause of viral gastroenteritis worldwide and is also a major cause of food borne illness. It spreads rapidly and causes vomiting and diarrhea that lead to many ED visits. Hopefully this brief episode will enrich the discussions that you have with patients and their families when making the diagnosis of viral gastroenteritis.

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References

O’Ryan ML, Peña A, Vergara R, Díaz J, Mamani N, Cortés H, Lucero Y, Vidal R, Osorio G, Santolaya ME, Hermosilla G, Prado VJ. Prospective characterization of norovirus compared with rotavirus acute diarrhea episodes in chilean children. Pediatr Infect Dis J. 2010 Sep;29(9):855-9. doi: 10.1097/INF.0b013e3181e8b346. PMID: 20581736.

King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003; 52:1.

Wilhelmi I, Roman E, Sánchez-Fauquier A. Viruses causing gastroenteritis. Clin Microbiol Infect 2003; 9:247.

Categories
Infectious Diseases

Periorbital Cellulitis

Perioribital cellulitis (AKA Preseptal cellulitis)is a soft tissue infection of the eyelids and skin anterior to the orbit. It must be differentiated from the more invasive and dangerous orbital cellulitis. Treatment varies depending on the original source (sinusitis, local trauma, stye etc,.). Learn all about periorbital cellulitis in this brief episode of PEM Currents: The Pediatric Emergency Medicine Podcast.

The companion blog post is right here!

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References

Fox S. Periorbital cellultiis. Pediatric EM Morsels. March 29, 2013. https://pedemmorsels.com/periorbital-cellulitis/. Accessed October 20, 2022.

Andrea Hauser, Simone Fogarasi; Periorbital and Orbital Cellulitis. Pediatr Rev June 2010; 31 (6): 242–249. https://doi.org/10.1542/pir.31-6-242

Murphy, D.C., Meghji, S., Alfiky, M. and Bath, A.P. (2021), Paediatric periorbital cellulitis: A 10-year retrospective case series review. J Paediatr Child Health, 57: 227-233. https://doi.org/10.1111/jpc.15179

Categories
Infectious Diseases Surgery

Neutropenic enterocolitis

Bad things happen when you don’t have enough neutrophils. After getting cytotoxic chemotherapy you tend to have even fewer neutrophils. This can put you at risk for neutropenic enterocolitis which should be suspected in an immunocompromised child with fever and abdominal symptoms. Treatment is broad spectrum antibiotics and the imaging test of choice is CT with contrast. Learn all about this potentially catastrophic condition in this brief podcast episode. 

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References

Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JA, Wingard JR. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2011 Feb 15;52(4):e56-93. doi: 10.1093/cid/cir073. PubMed PMID: 21258094.

McQueen A, et al. Oncologic Emergencies. In: Shaw KN, et al. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 8th ed. 2021:901-935.

Moran H, Yaniv I, Ashkenazi S, Schwartz M, Fisher S, Levy I. Risk factors for typhlitis in pediatric patients with cancer. J Pediatr Hematol Oncol. 2009 Sep;31(9):630-4. doi: 10.1097/MPH.0b013e3181b1ee28. PMID: 19644402.

Kirkpatrick ID, Greenberg HM. Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT. Radiology. 2003 Mar;226(3):668-74. doi: 10.1148/radiol.2263011932. Epub 2003 Jan 24. PMID: 12601214.

Categories
Infectious Diseases

Chicken Pox

Dewdrops on a rose petal. You’ve all heard the description, right? But how many of you have actually seen chicken pox in the wild. And what about monkey pox – does it look the same? How can I tell them apart? I wish there was a brief podcast episode focused on varicella that would help answer some of these questions…

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References

CDC for Healthcare Professionals: Chicken Pox (Varicella). https://www.cdc.gov/chickenpox/hcp/index.html. Accessed 8/11/2022.

Freer G, Pistello M. Varicella-zoster virus infection: natural history, clinical manifestations, immunity and current and future vaccination strategies. New Microbiol. 2018 Apr;41(2):95-105. PMID: 29498740.

Sauerbrei A. Diagnosis, antiviral therapy, and prophylaxis of varicella-zoster virus infections. Eur J Clin Microbiol Infect Dis. 2016 May;35(5):723-34. PMID: 26873382.

Categories
Infectious Diseases

Hand, Foot, & Mouth Disease

Hand, Foot, and Mouth (and Butt) disease is incredibly popular in the summer/warm weather months in the Northern Hemisphere (August through October). It is so popular that I guarantee you will see it many times. This brief episode will teach you how to make the diagnosis and review strategies for management – which are largely supportive.

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References

Guerra AM, Orille E, Waseem M. Hand Foot And Mouth Disease. [Updated 2022 May 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431082/

Woodland DL. Hand, Foot, and Mouth Disease. Viral Immunol. 2019 May;32(4):159.