Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Greetings
from
IAP Executive Board 2007
:
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:
:
Dr Naveen Thacker
Dr R K Agarwal
Dr Nitin K Shah
Dr Ajay Ganbhir
Dr Deepak Ugra
Dr Rohit Agrawal
Dr Gadadhar Sarangi
Dr Panna Choudhury
Dr A Balachandran
Dr Kamlesh Srivastava
4
: Dr Naveen Thacker
: Dr Deepak Ugra
National Convener
Co Convener
: Dr Baldev Prajapati
Writing Committee
: Dr Tanu Singhal
Dr Suhas Prabhu
Dr Indu Khosla
10
Zonal coordinators
East : Dr Nupur Ganguly
North : Dr Shyam Kukreja
South : Dr S Balasubramanian
Central : Dr Rajeswar Dayal
West : Dr Digant Shastry &
Dr Kamlesh Srivastava
11
Contributors
Dr Rohit Agrawal
Dr Nupur Ganguly
Dr Tapan Kumar Ghosh
Dr Indu Khosla
Dr Ritabrata Kundu
Dr Baldev Prajapati
Dr Suhas Prabhu
Dr Tanu Singhal
Dr Vipin Vashishtha
Dr Vijay Yewale
12
13
Module 1
Febrile child with CNS manifestations
Case - 1
15
16
17
Provisional diagnosis
Pyogenic meningitis
Delay in LP
When should LP be delayed?
Hypotension, Shock
Severe respiratory distress
Signs of herniation such as unequal pupils
Papilloedema
Decerebration
What if LP is delayed?
Send blood cultures and start empirical Abx
CNS imaging if possible (Contrast CT is adequate)
21
Cytology
Sugar, Protein
Gram stain ( Sens 40-70%, Specificity 97%)
Latex agglutination for H flu, Meningococci,
Pneumococcus (Sens 70%)
CSF cultures (Sens 70-85% in antibiotic
nave)
22
23
Traumatic
40,000 RBC, 500 WBC, 60% polymorphs
RBC: WBC ratio is 80:1
CSF sugar 30 mg%, blood sugar 80 mg%
CSF protein 200 mg%
CSF Gram stain negative
Latex negative for H flu, S. pneumoniae, Meningococci
Culture awaited
26
CSF evaluation
Parameter (normal)
Pyogenic
Aseptic/
Viral
Partially
treated pyo
men
Early TBM
10010,000,
Polys
10-1000
Lymphos
5-10,000
Lymphos>
polys
10-500, polys
early and then
lymphos
N except
mumps
< 50%
100-500
mg%
50-200 mg%
Positive
Neg
Usually Neg
Neg
High
High
High
27
Interpretation of traumatic LP
Fairly common, especially in neonates
Interpretation is tricky
Usual ratio of RBC: WBC is > 500:1
Protein content increases by 1 mg% for 100 rbc
Sugar may be low
28
29
30
Management algorithm
Suspicion of pyogenic meningitis
Any contraindication to LP
No
Blood C/s, LP STAT
Abx + Steroids
Yes
Blood C/s, Empirical Abx,
CNS Imaging ( CT)
Case 2
32
Japanese encephalitis
Herpes simplex encephalitis
Mycoplasma
Enterovirus
Other viruses varicella, mumps, measles, rabies,
dengue, chandipura
Acute disseminated encephalomyelitis (ADEM)
Cerebral malaria
Encephalopathy (Reyes syndrome, metabolic
encephalopathy, epileptic encephalopathy)
Rarely pyogenic meningitis, TBM
33
34
35
Negative history
No pallor, icterus, organomegaly
No skin rash
No respiratory signs
Left sided hemiparesis
No abnormal movements, no meningeal
signs
36
37
CBC
PS for MP
Rapid malaria antigen tests?
SGPT, BS, creatinine, electrolytes
CXR
CSF unless contraindicated
cytology, sugar, protein, gram stain & C/S
ABC of resuscitation
Supportive care
Anticonvulsants
IV Acyclovir 10 mg/kg 8 hourly
IV azithromycin 10 mg/kg for mycoplasma
IV antimalarials not required
IV ceftriaxone ?
No empirical steroids
39
Investigation results
Hb 11.0, TLC 7000, P 50 L 40 M5 E5, platelet
count 2,00,000
MP negative, Malaria antigen negative
SGPT 34, BS 76
CXR NAD
CSF: 70 WBC, 90% lymphos, 10 RBC, Sugar
64, Protein 100 mg% , Gram stain negative
40
Diagnosis
HSV encephalitis
Differential diagnosis
Paramet
er
Viral E
Mycopla
sma
ADEM
Cerebral
malaria
CBC
Normal
Normal
Blood
sugar
Normal
Normal
Markedly
low
SGPT
May be
elevated
May be
elevated
Normal Mild
elevation
Markedly
elevated
CXR
Normal
Infiltrates
Normal Usually
normal
Normal
Contrast
MRI
Normal/
Cerebral
edema/
infarcts
Reyes
syndrom
e
Cerebral
edema
43
MRI
JE
ADEM
44
Viral E
Mycoplas
ma
ADEM
CSF
Usually
abnormal
50%
normal
Usually
Usually normal Normal
abnormal
Cells
50-1000
Mononucle
ar
RBC in
HSV
Few
Mononucle
ar cells
No cells/
few cells
Usually less
than 10 cells,
rarely upto 50
No cells
Sugar as
compared
to BS
Normal
Normal
Mumps
may be low
Normal
Normal or low
Normal
50-100
May be
Normal
elevated ( upto
200 mg%)
10-100
Cerebral
malaria
Reyes
syndrome
45
No definitive diagnosis
Continue acyclovir, macrolide
Omit Abx if pyomen ruled out
Omit antimalarials
46
if repeat smears negative
Module 2
Child with Fever and Respiratory
Symptoms
Case
5 yr male
Fever and cough since 3 days
Difficulty in breathing for 1 day
48
Sneezing/ coryza
Nature of cough
Feeding and activity
History of immunization (Hib, Pneumococcal)
History of antibiotic use, day care and
hospitalization
History of pyoderma/ measles
Previous episodes of breathlessness
History of atopy and use of bronchodilators
Family history of atopy/asthma
49
Respiratory rate
Vitals, general appearance
SpO2 (If available)
In our patient..
What is tachypnoea ?
Age
< 2 months
Respiratory rate
(breaths/min)
60 or more
50 or more
40 or more
Bronchiolitis
WALRI
Asthma
Metabolic acidosis (DKA, CRF)
Congestive Heart Failure
54
55
Is a CXR required ?
All patients do not require a CXR to confirm
the diagnosis
Reliability in predicting the etiology is poor
However CXR is indicated when
Diagnosis is in doubt
No improvement/ worsening after 48-72 hours of
therapy
Complications suspected - empyema
56
Investigation results..
CBC: Hb 9.5, TLC 14,000, 70% polys
CXR
57
Lobar pneumonia
59
61
Age
Severity
Predisposing conditions if any
Local epidemiologic data on etiology and drug resistance
63
Gram Negative
Chlamydia trachomatis
Viruses
S. pyogenes
3 months- 5
years
Viruses (35%)
S. pneumoniae
H. influenzae
S. pyogenes
Mycoplasma pneumoniae
> 5 years
S. pneumoniae
Mycoplasma pneumoniae (24-30%)
Staphylococcus
Viruses
S. pyogenes
64
Pneumocystis
Neutropenia
Cystic fibrosis
Pseudomonas,
Staphylococcus
65
First Line
Second line
3 months- 5
years
Amoxicillin*
Coamoxiclav/
Chloramphenicol
> 5 years
Amoxicillin*
Macrolide**/
coamoxyclav/
chloramphenicol
First Line
Second line
< 3 months
3 months- 5
years
Coamoxyclav OR
Amp + Chloro
Coamoxyclav/
Ceftriaxone/
Cefotaxime
> 5 years
Ampicillin/
Chloramphenicol/
Coamoxyclav/
Macrolide (if mycoplasma
suspected)
Coamoxiclav/
Ceftriaxone/
Cefotaxime
AND
Macrolides
Suspected
staph
Cefuroxime
Or co amoxiclav
Or IV 3rd gen ceph.+ clox
Ceftriaxone/
Cefotaxime AND
Vancomycin/teico/li
68
nezolid
In this case..
Etiology
Most likely Pneumococcal
Management
Hospitalization
IV Ampicillin (100- 200 mg/kg/day)
69
71
Investigation results
72
73
74
Module 3
Pneumococcal Disease Burden,
Antimicrobial Resistance
and
Prevention
Case
76
77
78
Diagnosis
Pneumococcal pneumonia with
empyema
81
Noninvasive
Meningitis
Bacteraemia
Pneumonia
X 10
X 100
Prevalence
Disease severity
Invasive
X 1000
Otitis media
82
% pneumococcus*
30%
15-44%
70- 90%
30-40%
83
84
Which route ?
Parenteral (IV) for severe infections
Sequential parenteral-oral after patient improves
What dose ?
Pen G 2,00,000 U/kg/day Q 6 hrly
Ampicillin 100-200 mg/kg/day Q 6 hrly
85
Why Penicillin?
Penicillin is a narrow spectrum and cheap drug
In India pneumococci show fair susceptibility to
penicillin
Rates of penicillin drug resistance
High (40-80%) in Taiwan, Korea, Thailand, Sri Lanka,
Vietnam
Less than 10% in India, Pakistan, Australia
India: IBIS (93-97) 1.3%, ANSORP (96-97) 3.8-12.8%
80%
10%
39%
4%
58%
41%
61%
9%
23%
65%
21%
87
91
In our case.
High resistance to penicillin
Changed to ceftriaxone ( 100 mg/kg/day q 12
hourly)
Patient afebrile after 4 days, drain removed
Discharged on high dose oral amoxicillin (80
mg/kg/day)
92
93
Question
Large
Yes
94
96
Pneumococcal Sero-epidemiology
90 serotypes; but 13 serotypes cause 75% of
IPD globally
Vary between countries, age, site of infection
Developed countries - 14, 6, 19, 18, 9, 23, 7, 4,
1, 15
India (IBIS) - 6, 1, 19, 14, 4, 5, 45, 12, 7, 23
Immunity is sero type specific
Therefore vaccines have to be polyvalent
incorporating several different antigens
97
Increasing Clinical
Severity
Hosp. pneumonias
Ambulatory
bacteremia;
Borderline
pneumonias
1 5 14 12
1 56
14 19
23 9 7
4 6 9 14
19 19 6
very high
Latin America
high
23 14
18
14
19 19 6
18
23
14 19 19 6
14
18
4 6 9 14
Non-bacteremic
pneumonias?
Mild fever but no
medical care sought
Poorer developing
countries?
W. Europe
low
Australia
U.S./Canada
(Pneumo serogroups)
???
98
The Invasive Pneumococcal Disease Iceberg, from W.Hausdorff
Pneumococcal vaccines
Parameter
Conjugate
Simple
Basis
Poly + protein T
cell dependent
T cell independent
Immunity
Can be given
below 2
Serotypes covered
23
Yes
No effect
Reported
?
99
Conjugate Vaccine
7 valent (4, 6B, 9V, 14, 18C, 19F, 23F)
Covers 85% serotypes in developed countries, including
most DRSP
US data shows
Vaccination Schedule
Conjugate vaccine
Routine vaccination
Catch up vaccination
7-11 months of age 2 primary doses at least 4 weeks apart and 1
booster
12-23 months of age 1 primary dose and 1 booster
24 months and older (only high risk) 1 dose
101
Pneumococcal Disease is
Common
Pneumococcal disease is the No. 1 cause of vaccinepreventable mortality
Serious
Mortality rates of upto 40%
Serious morbidity such as seizures, mental handicap,
hearing loss, motor deficits, restrictive lung disease due to
pleural thickening, etc.
Preventable
Existing vaccines can save lives starting now
103
Module 4
The child with fever
Case 1
105
106
No localizing signs
Feeding normally
Axillary temperature 37.5 C (99.5F)
Activity, NNR normal
No pallor, rash or jaundice
Otoscopy, fontanel normal
Abdomen soft, no organomegaly
108
Hospitalization
Sepsis evaluation
Antibiotics ?
109
Why hospitalize?
High risk of serious bacterial infection (1015% SBI, 5% bacteremia) in infants less than
3 mths with fever
Risk greatest in those less than 1 mth
May look well and still have SBI
Serious outcome if missed
110
Test*
Sens
Spec
TLC< 5000
30
90
75
50
90
75
I:T >0.2
95
50
80
85
TLC <5000,
I:T> 0.2,
CRP> 1
Any 2/3
positive
100
83
111
Cons
Over use of antibiotics
113
114
116
Further progress
Repeat screen
TLC of 4000
I:T ratio 0.3
CRP 2.4 mg/dl
117
118
119
120
Management algorithm
Fever > 38C in less than 90 days, no focus
Well looking
< 1 month
Hospitalize
Screens
Normal
WBC 5000-15,000
No bandemia, CRP -ve
Urine normal
Sick looking
> 1 month
OPD
Screen
Hospitalize
CBC, CRP, Urine,
LP, Cultures
IV antibiotics
Abnormal
Repeat screen if needed
121
Observe till afebrile
Hospitalize
Investigations
Treatment
TLC > 15,000
Blood C/S,
Abx
Well looking
Observe, antipyretics
Explain danger signs
FU at 48 hrs
Fever persists
No focus
Case 2
123
124
126
What investigations ?
CBC with platelet count
Peripheral smear for MP
Urine R/M
128
SGPT
CXR PA view not required
Rapid Malaria antigen tests
Blood cultures
WIDAL
129
Investigation results
Hb 11.6
TLC 3400
P56L42E0M2
Platelet count 146000
One MP negative
Urine routine normal
Blood Culture awaited
133
134
Interpretation of CBC
Paramete Enteric
r
Malaria
Dengue
Other
viral
Hb/Hct
Low
N/High
TLC
N/ Low
N/Low
Low
N/ Low
DLC
Polys
eosinop
enia
Platelets
N/ Low
Low
Low
N/Low
135
Fever
Hematocrit
200,000
150,000
100,000
50,000
Platelet count
5,000
4,000
3,000
WBC count
120 mm
110 mm
100 mm
90 mm
80 mm
BP
0
10
12
137
138
Low resistance to NA
Ciprofloxacin/ Ofloxacin (Not approved by DCGI)
Case Progress
Day 7 of illness
No fever
Vomiting, abdominal pain, epistaxis
Tachycardia 110/mt, BP 106/90
Tender hepatomegaly
Hb 14 gm%, TLC 3000, platelet count 1,00,000
Blood cultures sterile
140
Admit
Fluid resuscitation
Careful monitoring
Stop antibiotics
141
Oxygen
Large bore IV lines
RL 20 ml/kg
Repeat upto three times
0.9% DNS 15 ml/kg/hr
Monitor clinically
Hct, platelet count
Improved
Taper fluids
over 24-48 hrs
Worsened
Fluid rate
10-15 ml/kg/hr
Worsening
No improvement
CVP, inotropes,
careful fluid management
142
Module 5
Rational antimicrobial
therapy
Case 1
3 Year old
Fever, cold, cough
Difficulty in swallowing since 2 days
History of similar illness in younger sib
Febrile, Vitals WNL
Congested, enlarged tonsils
Few cervical nodes +, non-tender
Oral cefixime started
144
Case progress..
Returned one day later with continuous high
fever
Throat swab culture sent
146
147
Case progress.
2 days later child is better
Throat swab cul.
Beta hemolytic strept.
resistant to penicillin
Antibiotics changed to Coamoxiclav
148
149
Case 2
8 mon. female, wt 8 kg
Loose stools for 2 days, no blood
Fever and vomiting present
Severe dehydration
Admitted, IV fluid, IV amikacin
Stool exam. WBC 5-6 / HPF, Few RBC / HPF
On discharge, Norflox + Metro combination
150
151
152
153
Furazolidone
I and II gen cephalosporins
aminoglycosides, colistin, amoxycillin, chloramphenicol
sulfonamides, nitrofurantoin
154
Case 3
Day 0, Neonate
36 weeks, 2.0 kg
C section, no asphyxia
No PROM/no maternal fever/ foul smelling liquor
Kept in nursery for observation
Started on IV cefotaxime and amikacin
156
Prophylactic antibiotics
The benefit of prophylactic antibiotics is limited
Extensive, broad spectrum antimicrobial use may
enhance emergence of resistance
Definite Prerequisites
Specific organism against which prophylaxis is planned
Increased susceptibility of the host against that particular
infection
158
159
160
Thank You!