Bacteremia, Sepsis, and Meningitis in Children

1. Bacteremia, Sepsis, and Meningitis in Children Tintinalli Chapter 116

2. Serious Bacterial Infections • Pathophysiology • Birth to 3 years at increased risk • Immature reticuloendothelial system Bacteremia Septicemia Spontaneous resolution Focal serious bacterial infection (SBI)

3. Serious Bacterial Infections • Risk by age

4. Serious Bacterial Infections • Associated with bacteremia: • Meningitis • Pneumonia • Pyelonephritis • Bacterial enteritis • Facial cellulitis • Septic arthritis • Osteomyelitis

5. Serious Bacterial Infections • Clinical features • Fever >100.4 or < 98.0 • Overall ill appearance • Decreased feeding / activity • Poor head control in young • Lethargy • Irritability

6. Serious Bacterial Infections • Clinical features • Minor source does not exclude bacteremia or SBI

7. Serious Bacterial Infections • Low Risk • Full term • No prior infections / medical problems • Well appearing • No focus of infection • WBC 5000-15000 with <1500 bands • Urine <10WBC, negative esterase, nitrite • Stool smear <5WBC (if diarrhea) • Normal chest X-ray • Reliable parents / follow up

8. Serious Bacterial Infections • Diagnosis • Sepsis workup • CBC • Blood culture • Urine and culture (catheter) • CSF • Chest film

9. Serious Bacterial Infections • Diagnosis • Indications for blood culture • Unexplained ill appearance • Febrile neonate or young infant (30 – 90 days) • Febrile with immune deficiency • Sepsis • Meningitis • Pneumonia (requiring admission) • Pyelonephritis (age <6 mo or requiring admission) • Bacterial enteritis • Facial cellulitis • Septic arthritis • Osteomyelitis

10. Documented fever, age <90 days yes Age < 30 days no yes Full sepsis workup Antibiotics in ED Admit yes High risk (Low risk criteria not met) no Outpatient management Management febrile Infant 0 –90 days Option 1 Full sepsis workup Rocephin 50 mg/kg if negative LP Option 2 Selective LP No antibiotic if LP negative

11. Documented fever, age > 3 months yes Ill appearance no yes Full sepsis workup Antibiotics in ED Admit High risk (Low risk criteria not met) yes no Localizing signs or symptoms Individualize Management yes no Workup as indicated Antibiotics as indicated Admit as indicated Consider UA and Culture for all Females< 6 months Management febrile Infant and children 3 months and older Option 1 Blood culture Rocephin IM If WBC > 15K or No blood culture or antibiotics Outpatient management Follow up in 24 hours Age 3 – 6 months yes no No blood culture No antibiotics Outpatient management Follow up in 24 hours

12. Sepsis • Life threatening syndrome defined by • Bactremia • Clinical evidence of invasive, systemic infection that can lead to cardiovascular collapse

13. Sepsis • Clinical features • Altered mental status • Poor feeding • Irritability • Hyperpyrexia (rectal >106) not uncommon • Hypothermia • Tachypnea • Metabolic acidosis

14. Sepsis • Diagnosis • Clinical diagnosis • WBC >30,000 is supportive (no count is diagnostic) • WBC < 5,000 is grave prognostic marker • Routine septic labs • CBC, CMP, Urine and culture, Blood culture, Stool smear if diarrhea, CXR, ABG if indicated, Coagulations studies

15. Sepsis • Treatment • Stabilization, ABCs • Vascular access, 20mL/Kg NS • Foley to gauge UO (1-2 mL/Kg) • Fingerstick BGL and correct with D25 • Antibiotic therapy • Admission

16. Meningitis • Usually complication of bacteremia • Usual suspects: • Neonatal • Group B Strep • Older infant / children • S. pneumoniae • N. meningitidis • Infants who have not received Hib vaccine are at greater risk.

17. Meningitis • Clinical features • Overlap with SBI • Insidious progression of febrile illness • Altered mental status, irritability, lethargy • Fever not always present but common • In older children • Photophobia, headache, nausea and vomiting • Neck pain • Kernig sign • Seizures (25%)

18. Meningitis • Diagnosis • LP • WBC is not adequate test • CT should not delay LP if meningitis highly suspected

19. Meningitis • Treatment • Stabilization, ABCs • Be careful of airway during LP • Fluid resuscitation • Treat seizures with ativan 0.1 mg/Kg IV, phosphenytoin 15 mg/Kg if needed • Correct hypoglycemia • Empiric and early antibiotics

20. Meningitis • Treatment • Consider dexamethasone 0.15 mg/kg IV • Has been shown to decrease neurological complications when meningitis is due to Hib only. • Administer before or immediately after antibiotic in those over 1 month • Consider prophylaxis of contacts • Hib and N. meningitidis – consider rifampin • No prophylaxis for S. pneumoniae • Admission