Bacteremia, Sepsis, and Meningitis in Children

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Bacteremia, Sepsis, and Meningitis in Children

• Tintinalli Chapter 116

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Serious Bacterial Infections

• Pathophysiology
• Birth to 3 years at increased risk
• Immature reticuloendothelial system

Bacteremia
Septicemia
Spontaneous resolution
Focal serious bacterial infection (SBI)
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Serious Bacterial Infections

• Risk by age

Group Risk Pathogens
028 days High Group B Strep E. Coli Listeria monocytogenes Enterococcus sp.
29-90 days Moderate Neonatal pathogens (above) Community acquired pathogens (below)
3-36 months Low S. Pneumoniae N. Meningitidis H. Influenzae (unimmunized) Group A Streptococcus E. Coli (pyelonephritis) Salmonella sp. (gastroenteritis) S. Aureus (osteomyelitis)
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Serious Bacterial Infections

• Associated with bacteremia
• Meningitis
• Pneumonia
• Pyelonephritis
• Bacterial enteritis
• Facial cellulitis
• Septic arthritis
• Osteomyelitis

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Serious Bacterial Infections

• Clinical features
• Fever gt100.4 or lt 98.0
• Overall ill appearance
• Decreased feeding / activity
• Poor head control in young
• Lethargy
• Irritability

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Serious Bacterial Infections

• Clinical features
• Minor source does not exclude bacteremia or SBI

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Serious Bacterial Infections

• Low Risk
• Full term
• No prior infections / medical problems
• Well appearing
• No focus of infection
• WBC 5000-15000 with lt1500 bands
• Urine lt10WBC, negative esterase, nitrite
• Stool smear lt5WBC (if diarrhea)
• Normal chest X-ray
• Reliable parents / follow up

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Serious Bacterial Infections

• Diagnosis
• Sepsis workup
• CBC
• Blood culture
• Urine and culture (catheter)
• CSF
• Chest film

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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 lt6 mo or requiring admission)
• Bacterial enteritis
• Facial cellulitis
• Septic arthritis
• Osteomyelitis

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Documented fever, age lt90 days
yes
Age lt 30 days
no
yes
Full sepsis workup Antibiotics in ED Admit
High risk (Low risk criteria not met)
yes
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
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Documented fever, age gt 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 Femaleslt 6 months
Management febrile Infant and children 3 months
and older
Option 1 Blood culture Rocephin IM If WBC gt 15K
or No blood culture or antibiotics Outpati
ent management Follow up in 24 hours
Age 3 6 months
yes
no
No blood culture No antibiotics Outpatient
management Follow up in 24 hours
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Sepsis

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

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Sepsis

• Clinical features
• Altered mental status
• Poor feeding
• Irritability
• Hyperpyrexia (rectal gt106) not uncommon
• Hypothermia
• Tachypnea
• Metabolic acidosis

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Sepsis

• Diagnosis
• Clinical diagnosis
• WBC gt30,000 is supportive (no count is
  diagnostic)
• WBC lt 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

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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

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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.

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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)

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Meningitis

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

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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

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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