PEDIA OSCE NOTES

IMMUNIZATION Hepatitis B Vaccine

 Route: Intramuscular (IM)
 1st dose: All newborns >2kg within 24 hours of life
 2nd dose: 1-2 months after the birth dose
 Final dose: Not earlier than 24 weeks of age
*Another dose – if last dose was given <24 weeks

Born to HBsAg (+) Born to mothers with Preterm Infants

mothers unknown HBsAg status

Administer HBV BW: ≥2 kg HBsAg (-) mothers and

and HBIG (O.5mL) HBV w/in 12 hrs of birth
within 12 hours and determine mothers
of life HBsAg, give HBIg if HBsAg
Or (+) not later tha 7 days of
Not later than 7 age
days BW: <2kg
Give HBIg in addition to
HBV within 12 hrs of life
medically stable  1st
dose at 30 days of
chronological age
regardless of weight
(Part of 3-dose series)
<2kg  1st dose at birth
not counted, needs
additional 3 HBV doses

Pentavalent Vaccine
1 vaccine against 5 diseases:
 Diphtheria
 Pertussis
 Tetanus
 Hepatitis B
 Hib
Bacille Calmette Guerin (BCG)
 Route: Intradermal Haemophilus influenzae type b (Hib) Conjugate Vaccine
 Dose:  Route: Intramuscular (IM)
0.05 mL: <12 months  3-dose primary series
0.1mL: ≥12 months  Minimum age of 6 weeks
 Given within 1st 2 months of life  Minimum interval of 4 weeks
 Indication of PPD prior to BCG vaccination:  Booster dose: 12-15 months with interval of 6 months from the 3rd
 Congenital TB dose
 History of close contact
 Clinical findings suggestive to TB or CXR suggestive of TB
Pneumococcal Conjugate Vaccine (PCV) Influenza Vaccine
 Route: Intramuscular (IM)  Trivalent  IM or Subcutaneous
 Minimum age of 6 weeks  Quadrivalent  IM
 3 primary doses (4 week interval) plus booster dose at 6 months  Minimum age of 6 months
after the 3rd dose  6 months old – 8 years old: 2 doses (4 weeks interval)
 Healthy children (2-5 yrs with no PCV vaccination may be given 1  9 – 18 years old  1 dose yearly
dose of PCV 13 or 2 doses of PCV 10 at least 6 weeks apart)
Measles Vaccine
Diptheria and Tetanus Toxoid and Pertussis Vaccine (DTP)  Route: Subcutaneous
 Route: Intramuscular (IM)  Minimum age of 9 months old
 Minimum age of 6 weeks  May be given as early as 6 months of age in cases of outbreaks
 Primary series: 3 doses (4 week interval)  If monovalent measles vaccine is not available, MMR may be given
 Booster series: 3 doses until adolescence
- 12 to 23 months (DTP) Japanese Encephalitis live attenuated recombinant vaccine
- 4-7 years (DTP)  Route: Subcutaneous (SC)
- 9-15 YEARS (Td/Tdap)  Given at 9 months of age
 9 months to 17 years old  should receive 1 primary dose followed
Oral Poliovirus Vaccine by a booster dose 12-24 months after the primary dose
 Route: Per Orem  18 years and above  single dose
 3 doses: given at minimum age of 6 weeks (4 week interval)
 If not available, give IPV together with Penta3 then catch OPV Measles-Mumps-Rubella (MMR) Vaccine
before 1 year old  Route: Subcutaneous
 12 months of age
Inactivated Poliovirus Vaccine  2 doses
 Route: Intramuscular (IM)  2nd dose  4-6 years of age but may be given at earlier age with a
 Usually in combination with DTaP and Hib with or without Hep B minimum of 4 weeks interval between doses
 3 doses: given at minimum age of 6 weeks (4 week interval)
 Booster dose: On or before 4th birthday Varicella Vaccine
 Present in Hexa  Route: Subcutaneous
 Minimum age: 12 months
Rotavirus Vaccine (RV)  2 doses are recommended
 Route: Per Orem (PO)  2nd dose: 4-6 years of age (may be given earlier at an interval of 3
 Monovalent human rotavirus vaccine (RV1) months from the first dose)
 2 dose series  13 years and above: minimum interval between doses is 4 weeks
 Pentavalent human bovine rotavirus vaccine (RV5)
 3 dose series Hepatitis A Vaccine
 Given at minimum age of 6 weeks (4 week interval), last dose: not  Route: Intramuscular (IM)
later than 32 weeks  Minimum age: 12 months
 2 doses are recommended
 2nd dose is given at least 6 months from the 1st dose
Human Papilloma Vaccine (HPV)
 Ages 9-14 years: 2 doses  given at 0 and 6 months of age
Bivalent: (2vHPV)
Quadrivalent (4vHPV)
Nonavalent (9vHPV)

Bivalent: Cervarix (Females only) HPV 16 and 18

Quadrivalent: HPV 6, 11 , 16 and 18 (both male and female)
Nonavalent: HPV 6, 11, 16, 18, 31, 33, 45, 52, 58

Tetanus and Diptheria Toxoid (Td)/ Tetanus and Diptheria Toxoid and
Acellular Vaccine (Tdap)
 Route: Intramuscular
 Fully immunized children: Td booster doses should be given every
10 years

ACUTE GASTROENTERITIS

Diarrhea
• passage of unusually loose or watery stools
• at least three times in a 24hr period
• Consistency of stools more important than number of
episodes
• Excessive loss of fluid and electrolyte in the stool

Acute Diarrhea/Gastroenteritis
• Sudden onset of excessively loose stools
• Infants: >10 mL/kg/day in infants
• Older children: >200 g/24 hr
• Less than 14 days

Persistent/Chronic Diarrhea
• Diarrheal episodes lasting > 14 days
Clinical Manifestations
• Related to the infecting pathogen or the dose/inoculum
• Non-specific
• Preformed Toxins
• Rapid onset nausea and vomiting within 6 hrs: S.
aureus
• Diarrhea and abdominal cramps 8-16 hrs: C.
perfringens, B. cereus
• Enterotoxins:
• Watery diarrhea 16-48 hrs after: norovirus,
cryptosporidium, cyclospora
• Bacterial dysentery (fever, tenesmus, bloody diarrhea,
abdominal cramps) Shigella, Salmonella

4.2 Treatment Plan A: home therapy to prevent

dehydration and malnutrition

Rule 1: Give the child more fluids than usual, to prevent

dehydration

What fluids to give

Most fluids that a child normally takes can be used. It is helpful to divide
suitable fluids into two groups: Fluids that normally contain salt, such as:
ORS solution
salted drinks (e.g. salted rice water or a salted yoghurt drink)
vegetable or chicken soup with salt.
 Rule 2: Give supplemental zinc (10 - 20 mg) to the child,
every day for 10 to 14 days
• Zinc sulfate
• Reduced duration and severity of diarrhea in
developing countries
• Give for 10-14 days
• <6mos: 10mg/day elemental zinc
• >6mos: 20mg/day elemental zinc

Rule 3: Continue to feed the child, to prevent malnutrition 4.4 Treatment Plan C: for patients with severe
dehydration
Rule 4: Take the child to a health worker if there are signs
of dehydration or other problems

4.3 Treatment Plan B: oral rehydration therapy for

children with some dehydration.
5.3 Antimicrobial therapy PEDIATRIC COMMUNITY ACQUIRED
PNEUMONIA

Etiology

Recurrent pneumonia
is defined as 2 or more episodes in a single year or 3 or more
episodes ever, with radiographic clearing between occurrences. An
underlying disorder should be considered if a child experiences recurrent
pneumonia

WHO SHALL BE CONSIDERED AS HAVING COMMUNITY-ACQUIRED

PNEUMONIA?

1. A patient presenting initially with cough and/or respiratory

difficulty may be evaluated for possible presence of pneumonia.
Pneumonia may be considered if any of the following positive
predictors of radiographic pneumonia is present.
• Oxygen saturation less than or equal to 94% at room air in a
patient aged 3 months to 5 years and above 5 years old in the
absence of any comorbid neurologic, musculoskeletal or cardiac
conditions that may potentially affect oxygenation
 • Tachypnea in a patient aged 3 months to 5 years and above 5 years
old
• Chest wall retractions in a patient aged 3 months to 5 years and
above 5 years old
• Fever grunting, wheezing, decreased breath sounds, nasal flaring,
cyanosis, crackles or localized chest findings at any age
• Consolidation as visualized in lung ultrasound
2. Pneumonia may not be considered if any of the following negative
predictors of radiographic pneumonia is present.
• Oxygen saturation greater than 94% at room air in a patient aged 3
months to 5 years and above 5 years old
• Absence of fever, nasal flaring and chest wall retractions in a patient
aged 3 months to 5 years and above 5 years old At the Out-Patient
Clinic as the site-of-care.
3. Chest x-ray may be requested to determine the presence of pneumonia
in any of the following situations:
• Dehydration in a patient aged 3 months to 5 years
• High index of clinical suspicion.
WHO WILL REQUIRE ADMISSION?
2. A patient initially classifed as pCAP A or B but is not responding to
current treatment after 48 hours may be admitted
3. A patient classified as pCAP C may be
• admitted to the regular ward
• managed initially on an outpatient basis if all of the following are
not present at initial site-of-care
• Age less than 2 years old.
• Convulsion.
• Chest x-ray with effusion, lung abscess, air leak or
multilobar consolidation.
• Oxygen saturation < 95% at room air.
4. A patient classified as pCAP D may be admitted to a critical care unit
WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT
CLASSIFIED AS EITHER pCAP A or pCAP B BEING MANAGED IN AN
AMBULATORY SETTING?
WHAT DIAGNOSTIC AIDS ARE INITIALLY REQUESTED FOR A PATIENT
CLASSIFIED AS EITHER pCAP C or pCAP D BEING MANAGED IN A HOSPITAL
SETTING?
 WHAT TREATMENT SHOULD BE INITIALLY GIVEN IF A VIRAL ETIOLOGY IS
STRONGLY CONSIDERED?

WHEN IS ANTIBIOTIC RECOMMENDED?

WHEN CAN A PATIENT BE CONSIDERED AS RESPONDING TO CURRENT

THERAPEUTIC MANAGEMENT?
WHAT EMPIRIC TREATMENT SHOULD BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA BE STARTED? DENGUE FEVER

WHAT ANCILLARY TREATMENT CAN BE GIVEN?

HOW CAN PNEUMONIA BE PREVENTED?

FLUID THERAPY

• Hypotonic Fluids are the most commonly used

ROLE OF BLOOD PRODUCTS
ASTHMA

 “short breath” or “panting

 Chronic inflammatory condition of the lung airways  episodic
airflow obstruction
 Cause: combination of environmental exposures + biologic
susceptibility
CLASSIFY ASTHMA
  For children with intermittent viral-induced wheeze and no
interval symptoms, if as-needed SABA is not sufficient,
consider intermittent ICS. Because of the risk of side-effects,
this should only be considered if the physician is confident
that the treatment will be used appropriately.

Step 2 (children ≤5 years) – initial controller

+ as-needed SABA
MANAGEMENT
Step
+ as-needed inhaled SABA
Step 1 (children ≤5 years) – as-needed inhaled SABA
 Preferred option: as-needed inhaled SABA
 Provide inhaled SABA to all children who experience
wheezing episodes
 Not effective in all children
 Other options
 Oral bronchodilator therapy is not recommended (slower
onset of action, more side-effects)
 Indication
 Child with symptom pattern consistent with asthma, and
symptoms not
well-controlled, or ≥3 exacerbations per year
 May also be used as a diagnostic trial for children with
frequent wheezing episodes
 Preferred option: regular daily low dose ICS + as-needed inhaled
SABA
 Give for ≥3 months to establish effectiveness, and review
response
 Other options depend on symptom pattern
 Persistent asthma – regular leukotriene receptor antagonist
(LTRA) leads to modest reduction in symptoms and need for
OCS compared with placebo
 Intermittent viral-induced wheeze – regular LTRA improves
some outcomes but does not reduce risk of exacerbations
 Frequent viral-induced wheeze with interval symptoms –
consider episodic or as-needed ICS, but give a trial of
regular ICS first
 Reduction in exacerbations seems similar for
regular and high dose episodic ICS
3 (children ≤5 years) – medium dose ICS
 Indication
 Asthma diagnosis, and symptoms not well-controlled on low
dose ICS
 First check symptoms are due to asthma, and check
adherence, inhaler technique and environmental exposures
 Preferred option: medium dose ICS with as-needed inhaled SABA
 Review response after 3 months
 Other options
 Low-dose ICS + LTRA is another controller option
  Blood eosinophils and atopy predict greater short-
term response to moderate dose ICS than to LTRA
(Fitzpatrick JACI 2016)
 Relative cost of different treatment options in some
countries may be relevant to controller choices

Step 4 (children ≤5 years) – refer for expert assessment

 Indication
 Asthma diagnosis, and symptoms not well-controlled on
medium dose ICS
 First check symptoms are due to asthma, and check
adherence, inhaler technique and environmental
exposures
 Preferred option: continue controller treatment and refer for
expert assessment
 Other options (preferably with specialist advice)
 Higher dose ICS and/or more frequent dosing (for a few
weeks)
 Add LTRA, theophylline or low dose OCS (for a few weeks
only)
 Add intermittent ICS to regular daily ICS if exacerbations
are the main problem
 ICS/LABA not recommended in this age group
MEASLES
Measles is a highly contagious viral disease affecting mostly
children. There is no specific treatment for measles and most of those
affected recover within 2-3 weeks. However, especially in malnourished
children and persons with reduced immunity, measles can cause serious
complications such as blindness, encephalitis, severe diarrhea, ear infection
and pneumonia.
Etiology
Measles virus is a single-stranded, lipid-enveloped RNA virus in the
family Paramyxoviridae and genus Morbillivirus.
Other members of the genus Morbillivirus affect a variety of
mammals, such as rinderpest virus in cattle and distemper virus in dogs, but
humans are the only host of measles virus.
Of the 6 major structural proteins of measles virus, the 2 most
important in terms of induction of immunity are the hemagglutinin (H)
protein and the fusion (F) protein.
Pathology
• Measles infection causes necrosis of the respiratory tract
epithelium and an accompanying lymphocytic infiltrate.
• Measles produces a small-vessel vasculitis on the skin and on the
oral mucous membranes.
• Histology of the rash and exanthem reveals intracellular edema and
dyskeratosis associated with formation of epidermal syncytial giant
cells with up to 26 nuclei.
• Viral particles have been identified within these giant cells. In
lymphoreticular tissue, lymphoid hyperplasia is prominent.
• Fusion of infected cells results in multinucleated giant cells, the
Warthin-Finkeldey giant cells that are pathognomonic for measles,
with up to 100 nuclei and intracytoplasmic and intranuclear
inclusions.
Clinical Manifestation
Measles is a serious infection characterized by
• high fever,
• an enanthem, cough, coryza, conjunctivitis,
• prominent exanthem.
After an incubation period of 8-12 days, the prodromal phase begins with a
mild fever followed by the onset of conjunctivitis with photophobia,
coryza, a prominent cough, and increasing fever. Koplik spots represent the
enanthem and are the pathognomonic sign of measles, appearing 1-4 days
prior to the onset of the rash They first appear as discrete red lesions with
bluish white spots in the center on the inner aspects of the cheeks at the
level of the premolars.
• Symptoms increase in intensity for 2-4 days until the 1st day of the
rash.
• The rash begins on the forehead (around the hairline), behind the
ears, and on the upper neck as a red maculopapular eruption.
• The exanthem frequently becomes confluent on the face and upper
trunk
With the onset of the rash, symptoms begin to subside.
• The rash fades over about 7 days in the same progression as it
evolved, often leaving a fine desquamation of skin in its wake.
• Of the major symptoms of measles, the cough lasts the longest,
often up to 10 days.
Supportive Care
1. Maintenance of good hydration and replacement of fluids lost through
diarrhea or vomiting
• IV rehydration may be necessary for severe dehydration
• Affected patients may be highly febrile and consequently become
dehydrated
2. Continue breastfeeding and continue feeding for older infants and
children
3. Antipyretics for fever at 10-15 mg/kg/dose given every 4 hours for fever.
• Paracetamol
4. Airborne precautions for hospitalized children during the period of
communicability, 4 days before to 4 days after the appearance of the rash
in healthy children and for the duration of illness in immunocompromised
patients.
5. Among susceptible health care workers, they should be excused from
work from the fifth to the 21st day after exposure
Vitamin A Supplementation
Vitamin A may reduce mortality from measles in children.
1. Vitamin A supplementation is given for 2 doses 24 hours apart as
follows:
• Infants <6 months of age: 50,000 IU/day PO
• Age 6-11 months: 100,000 IU/day PO
• >1 year old: 200,000 IU/day PO
The therapeutic doses of Vitamin A for measles should be given as soon as
diagnosis is made regardless of when the last dose of Vitamin A was given.
Anti Microbial Therapy
Antibiotics are indicated for patients who present with signs of pneumonia
or ear
infection.
1. Patients who present with rapid breathing (provided that this is not due
to fever) should be started on antibiotics and managed at home.
• Antimicrobial Treatment indicated as follows:

Anti-Viral Therapy
The measles virus has been shown to be susceptible to ribavirin in
vitro. There are however, no controlled trials conducted for the use of
ribavirin for measles in children. Thus, this is not recommended.

Postexposure Prophylaxis
Postexposure prophylaxis should be considered in unvaccinated
contacts.
1. Postexposure prophylaxis with the measles vaccine within 72 hours
or 3 days after exposure • Proper advice to caretakers and/or mother on home care and
2. Human Immunoglobulin. Indications for the use of the Human Ig compliance with antibiotic treatment instructions
include the following: • Instruct mothers to return for further treatment if the child’s
• Immunocompromised general condition worsens or any of the danger signs develop (
• Infants 6 months to 1 year (this is because morbidity is high in increased sleeping time, inability to feed or drink, seizures, chest
children <1 year of age) indrawing)
• Infants <6 months of age born to mothers w/o measles immunity 2. Patients who present with chest indrawing, inability to feed or drink,
• Pregnant women seizures or convulsions should be admitted to hospital.
Dose for Human Ig:
For those for whom the vaccine should be deferred ( eg. Pregnant patients): 3. Patients with rapid breathing, difficulty of breathing and chest indrawing
0.25 ml/kg (not >15 ml) IM immediately after exposure should be started on parenteral antibiotics
• Measles vaccine may be given may be given 6 months later • Antibiotic recommendation, dose and duration
• For children who receive Ig for measles postexposure prophylaxis,
should receive the measles vaccine 6 months later provided the
child is at least 12 months of age
Immunocompromised in whom the vaccine is contraindicated: 0.5 ml/kg
(not >15 ml) IM
The Human Ig however is expensive. It is therefore preferable and
recommended
to administer the vaccine within 72 hours of exposure instead if not
contraindicated.
 • Allergy to eggs is not a contraindication to measles vaccination
• For patients with treated tuberculosis, measles vaccine may be
administered
• For patients with untreated tuberculosis, it is recommended to
4. Patients who present with ear discharge and red/immobile eardrum start them on anti-tuberculous treatment before administration of
should be treated with antibiotics as follows: the vaccine
• Amoxicillin 80-90 mg/kg/day 2/day for 10-14 days • Individuals who have received Human Immunoglobulin for measles
• Alternative: Cefuroxime 30 mg/kg/day in 2 divided doses post-exposure prophylaxis, may be given the measles vaccine at the
Cefdinir 14 mg/kg/day in 1 or 2 doses appropriate interval, at least 6 months
Cefpodoxime 10 mg/kg/day once daily
Azithromycin or clarithromycin INH Prophylaxis
Ceftriaxone 50 mg/kg single dose Intramuscular
5. For patients with chronically draining ear: There is no evidence of giving INH prophylaxis to children with
• Keep ears always dry measles.
• Antibiotics are not indicated
With increasing resistance to the most commonly used antibiotics,
prophylactic antibiotic is not recommended for patients who are sent Febrile seizures
home without pneumonia or acute Otitis media
 seizures associated with fever, usually occurring in infants and
Vaccine young children, in the absence of intracranial (CNS) infection, acute
Administration of measles vaccine to children, adolescents and adults electrolyte imbalance or a defined cause for the seizure.
with incomplete or no vaccination using the monovalent or trivalent vaccine  Age: 3 months to 6 years of age
(contains measles, mumps and rubella). A tetravalent vaccine, MMRV  Fever: axillary temperature of 37.8*C
(contains measles, mumps, rubella and varicella) may be used for infants 12
months to 12 years of age Epidemiology
• For those who have of the measles vaccine, they snot received any  Common with a prevalence rate of 3-7% in children up to 7 years of
dose should receive 2 doses 1 month apart age
• For those who have received 1 dose of measles vaccine at 12
months of age or older, administer the second dose
• For those with unknown history of measles vaccination, give
measles vaccine for 2 doses 1 month apart
• Children 6 months to 11 months of age should receive measles
vaccine and followed by 1 dose administered on or after the first
birthday, preferably between 12-15 months of age, then another
dose at least 1 month after and usually given at 4-6 years.
• In outbreak areas, where measles involves infants <12 months of
age and have ongoing risk of exposure, measles vaccine can be
given as early as 6 months
• Individuals exposed to measles should receive measles vaccine
(monovalent or trivalent vaccine) within 72 hours of exposure
  Simple  Genetic (Generalized) Epilepsy with febrile seizure plus (GEFS+)
 brief (<10 mins)  Autosomal dominant identified in children who persists to
 Generalized (usually tonic-clinic) have febrile seizures beyond 7 years of age and later
 Single event develops afebrile seizure.
 Complex  Febrile infection related to epilepsy syndrome (FIRES)
 Prolonged (>10mins)  Febrile illness precedes febrile status epilepticus that last
 Focal in character for several days or weeks and is resistant to treatment.
 Recurrent (>1 seizure occurring within the same febrile  Dravet syndrome or Severe myoclonic epilepsy of infancy (SMEI)
illness, within a 24 hour period)  Onset of epilepsy syndrome is febrile seizure or febrile
 Febrile myoclonus status epilepticus at around 6 months of age, followed by
 seizure type myoclonus and is usually associated with a multiple seizure types (myoclonic, atypical absence and
family history of febrile seizures focal seizures) and slowing of developmental and cognitive
 Febrile Status epilepticus (FSE) skills. Resistant to anticonvulsant.
 continuous seizure or intermittent seizures without
neurologic recovery lasting for 30 mins or longer. Management
 Febrile seizure plus
 refers to syndromes associated with children who have
febrile and afebrile seizure or those who remain to have
persistent febrile seizures beyond 7 years of age.

Etiology and pathogenesis

 Still uncertain
 Combination of genetic and environmental factors may predispose
a child to febrile seizures
 Mutations in sodium channel and gamma aminobutyric acid (GABA)
A receptor genes
 Fever induced factors such as interleukin 1beta
 Febrile seizures often occur in the context of otitis media, roseola
and human herpesvirus (HHV) 6 infection, shigella, or similar
infections, making the evaluation more demanding. In patients with
febrile status, HHV-6B (more frequently) and HHV-7 infections were
found to account for one-third of the cases
 Vaccines : DPT, MMR
 Gastroenteritis-related seizure
 Clusters of generalized and/or focal afebrile seizures occur
2-3 days after an episode of gastroenteritis without clinical
signs of dehydration or electrolyte imbalance, with body
temperature of <38°C
 Medical treatment
Investigation  Simple seizures –not recommended
 Lumbar puncture –all children with febrile status epilepticus  Complex febrile seizure – no guidelines
 Electroencephalogram (EEG)  But if prolonged (>5mins), can be given rectal diazepam,
 Neuroimaging buccal midazolam or nasal midazolam at home
administered by parents
Management  Febrile status epileptics
 Should be treated with anticonvulsants

Prognosis
 Children with febrile seizure has excellent outcome
Central nervous system infections CSF FINDINGS
 Most common cause of fever associated with signs and symptoms
of CNS disease in children
 Specific pathogens are identifiable and are influenced by the age
and immune status of the host and the epidemiology of the
pathogen.
 In general, viral infections of the CNS are much more common than
bacterial infections, which, in turn, are more common than fungal
and parasitic infections.

Clinical manifestations
 Regardless of etiology, most patients with CNS infection have similar
clinical manifestations.
 Common symptoms include headache, nausea, vomiting, anorexia,
restlessness, altered state of consciousness, and irritability
 Common signs of CNS infection, in addition to fever, include
photophobia, neck pain and rigidity, obtundation, stupor, coma,
seizures, and focal neurologic deficits.
 The severity and constellation of signs are determined by the specific
pathogen, the host, and the area of the CNS affected.

Types of cns infections

A. Diffuse
1. Meningitis – primary involvement of the meninges,
2. Encephalitis – brain parenchymal involvement
B. Focal
1. Brain Abscess

Definitive test
 Examiniation of Cerebrospinal Fluid, obtained by Lumbar Puncture
 What is the role of imaging tests in the diagnosis of Bacterial meningitis?

 COMPLICATIONS
 H ydrocephalus
 A bscess
 C erebritis/ Cranial nerve involvement
 T hrombosis
 I nfarct
 V entriculitis/Vasculopathy
 E xtra-axial fluid collection

Most common pathogens (phils.)

Empiric antibiotics
 Neonates (0-28 days old)
 Ampicillin or Cefotaxime or Ceftriaxone PLUS an
What are the Ancillary Tests in the Diagnosis of Bacterial Meningitis? What
aminoglycoside
is the Value of each Diagnostic Test?
 1 month to 18 years old
 Ceftriaxone or Chloramphenicol
 a. Complete Blood Count (CBC)
 b. Blood Culture
Drug of Choice for a specific etiologic agent
 c. C-Reactive Protein (CRP)
 Haemophilus influenza
 d. Polymerase Chain Reaction (PCR)
 Ceftriaxone for 7-10 days. Alternative treatment would be
 e. Latex Agglutination Test (LAT)
chloramphenicol.
 f. Procalcitonin
 Streptococcus pneumonia
 penicillin for 10-14 days. Alternative agents are
What is the role of imaging tests in the diagnosis of Bacterial meningitis?
chloramphenicol and ceftriaxone.
 Neisseria meningitides
 Neuroimaging is used to identify the presence of of complications
 Penicillin x 7 days. Alternative agents are ampicillin,
of bacterial meningitis and to rule out contraindications in doing a
ceftriaxone, chloramphenicol, and cefotaxime
lumbar tap. Neuroimaging is not used to diagnose the presence or
 Escherichia coli
absence of a CNS infection.
  Cefotaxime x 21 days
 Group B Streptococcus (GBS)
 cefotaxime OR ceftriaxone to be given for at least 14 days.
Antibiotic dosages
Chemoprophylaxis
 Prophylaxis is mainly given to individuals living in the same quarters
as the index case or those with history of body fluid exchange with
an infected patient (i.e. kissing).
 The administration of prophylaxis aims to eradicate nasopharyngeal
carriage in household contacts, prevent secondary cases from
occurring and hopefully to treat individuals currently incubating the
disease
 Haemophilus influenza
 Rifampicin prophylaxis is recommended for all household contacts
or child care contacts in cases of H. influenzae type B especially if
there is an infant of <2 years old or an immunocompromised person
in the house.
 B. Neisseria meningitides
 Rifampicin:
 <1 month old: 5mg/kg orally every 12 hours x 2 days
 ≥1 month old: 10mg/kg (max 600 mg) orally every 12 hours x 2 days;
 Ceftriaxone:
 <15 years old: 125 mg, IM sing
 ≥15 years old: 250mg, IM single dose;
 Ciprofloxacin:
 >18 years old: 20mg/kg (max 500 mg) orally, single dose
High risk groups
1. Household contacts especially children below 2 years old;
2. Child care contacts within 7 days prior to onset of illness of index patient
3. People with direct exposure to oral secretions of the index patient
(kissing, sharing personal items such as toothbrush and utensils) within 7
days prior to onset of illness of index patient;
4. Individuals who performed mouth to mouth resuscitation to an infected
patient unprotected contact during an endotracheal intubation at any time
prior to the onset of illness of index patient;
5. Persons who often shared the same living quarters as the patient within 7
days prior to the onset of illness of index patient;
6. Passengers in transportation vehicles (buses, trains, airplane) who were
seated next to the index case for at least 8 hours.
What is the recommended duration of treatment for acute bacterial
meningitis in patients wherein the organism was not isolated?
 The recommended duration of empiric therapy for acute bacterial
meningitis is 10- 14 days.
 The duration of therapy may need to be individualized on the basis
of the patient’s clinical response.
every 6 hours for 4 days. Administer dexamethasone along with or
shortly before the first parenteral dose of antib
 Note: If dexamethasone was not given before or along with the 1st
dose of antibiotics despite its indication, try to administer the first
dose within 4 hours of starting antibiotics, but do not start
dexamethasone >12 hours after starting antibiotics.
 Level of evidence: Moderate; Strength of recommendation: Strong

What are the indications to shift to another antibiotic agent? What are the infection control measures necessary to prevent
transmission?
 Modification of the antimicrobial regimen should be made after
careful assessment of both clinical and microbiological parameters  Hand hygiene with proper hand washing using soap and water
which include but not limited to the following: before and after handling the patient;
 1. Absence of or limited improvement despite adequate  Wear personal protective equipment especially for procedures that
antibiotic coverage (e.g. persistent fever after 36-48 hours may involve contact with blood or body fluids;
of adequate antibiotics);  Respiratory etiquette: symptomatic patients are advised to wear
 2. Clinical deterioration masks to prevent spread of infected respiratory droplets; as well as
 3. Drug intolerance to maintain separation distance of at least 3 feet from nearby
 4. Resistant isolate based on cultures and clinically people in waiting areas;
compatible with the clinical course.  Dispose of wastes accordingly in their proper bins;
 In pediatrics patients who bring toys to hospitals, avoid furry ones,
Is it appropriate to step down to oral therapy? only bring those that are easy to clean;
1. Switching from intravenous to oral antibiotic therapy for bacterial  Aseptic technique in all procedures to be done;
meningitis is generally not recommended due poor penetration of most oral
antibiotics into the CSF.
2. Chloramphenicol is the only antibiotic which could be used orally for
treating community acquired CNS infections. If necessary, IV
chloramphenicol can be switched to oral form after 3 to 4 days of initial
therapy in children >3 months old and are well nourished.
3. Antibiotic resistance patterns should be considered when
chloramphenicol is used due to reports of resistant strains of influenzae.
4. Drug interactions should be monitored when there is concomitant
use of chloramphenicol and phenobarbital or phenytoin.

What is the value of using steroids for acute bacterial meningitis?

 Dexamethasone has NO role in treating neonatal meningitis.

 In children 2months to 5 years of age wherein Hib meningitis is
suspected, give dexamethasone 0.15 mg/kg (maximum of 10 mg)
PEDIATRIC DOSAGE