CommonIDAbx - Case#1 An 8-year-old boy is seen in February...

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Case #1 An 8-year-old boy is seen in February because of fever, headache, sore throat, and malaise. He’s had no rhinorrhea, cough, or hoarseness. Physical examination reveals a temperature of 103.5, exudative pharyngitis, and tender cervical adenopathy. How will you treat him?
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Is penicillin still the drug of choice for treatment of  streptococcal pharygitis? AAP recommends oral penicillin V 2- 3 times daily for 10 days, a single dose of benzathine penicillin, or amoxicillin 250 mg/kg tid for 10 days Larger doses of penicillin once daily result in more relapses* *Breese, 1965, Gerber, 1989
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Once daily dosing? Recommended by the FDA: azithromycin (Zithromax) cefixime (Suprax) cefdinir (Omnicef) cefadroxil (Ultracef, Duracef) ceftibutin (Cedax) Amoxicillin (750 mg once daily)* *Feder, Pediatrics, 1999
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Shorter courses? Approved by the FDA for 5-day regimen: cefpodoxime (Vantin) cefdinir (Omnicef) azithromycin (Zithromax)
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What about the penicillin-allergic child? Erythromycin estolate (20-40 mg/kg/d divided bid) or ethylsuccinate (40 mg/kg/d divided bid) Azithromycin (12 mg/kg/d x 5 d), clarithromycin (15 mg/kg/d div q 12 hrs), clindamycin (20 mg/kg/d div q 6-8 hrs)
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Why penicillin might “fail” Non-adherance to prescribed therapy failure to recognize carriers ? beta-lactamase production by other pharyngeal flora new streptococcal infection
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Case #2 A 13-year-old boy has had fever and sore throat for two days. He now presents with a cough. On examination he has a temperature of 104, RR 22, O 2 saturation of 98%, retractions, and crackles over the posterior left lower lung. Chest x-ray confirms a left lower lobe pneumonia. What do you think is causing his pneumonia? How will you treat him?
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Common Causes of Community-Acquired Pneumonia in Otherwise  Healthy Children Viruses Respiratory syncytial virus Influenza A and B Parainfluenza 1, 2, and 3 Adenovirus Rhinoviruses Measles virus Mycoplasma Mycoplasma pneumoniae Chlamydia Chlamydia pneumoniae Chlamydia trachomatis Bacteria Streptococcus pneumoniae Mycobacterium tuberculosis Staphylococcus aureus Haemophilus influenzae type b non-typable H. influenzae McIntosh,K: NEJM 2002;346:429
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Likelihood that the pneumonia is bacterial  is greater if: Fever is > 39 degrees C The patient “looks sick” There are alveolar infiltrates on chest x-ray WBC is > 15,000 NB:  Blood culture is positive in about 10% of infants  and children with bacterial pneumonia and more likely in  those > 2 yrs
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Bacterial pneumonia according to age: < 28 days :  Group B streptococcus, Gram negative  enterics, CMV, listeria 3 wks - 3 months : C trachomatis, RSV, parainfluenza, S.  pneumoniae, B. pertussis, Staph aureus  4 months-4 years
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CommonIDAbx - Case#1 An 8-year-old boy is seen in February...

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