SHANZ – PEDIA II 2.

04
SEPSIS AND DISASTER RELATED DISEASES

SIRS (CRITERIA > 2) SEPSIS

• Abnormal core temp (<36 C or >38.5) • SIRS + infection
• Abnormal HR (>2 SD for normal age of <10th % for <1yo) • Inflammatory response syndrome + suspected/proved infection
• Raised RR (>2 SD for age)
• Mechanical ventilation or acute lung disease SEPSIS-INDUCED HYPOTENSION
• Abnormal WBC (above or below normal) • SBP <90 mmHg or SBP decrease of >40 mmHg or <2SD below normal
• >10% immature WBC • MAP < 70 mmHg
• Can be infectious or nervousness

SEPSIS
GENERAL INFLAMMATORY HEMODYNAMIC ORGAN DYSFUNCTION TISSUE PERFUSION
• Fever >38.3 C • WBC > 12,000 Arterial hypotension: • Arterial hypoxemia (PaO2/FiO2 • Hyperlactatemia > 1
• Hypothermia < 36 • WBC < 4,000 • SBP < 90 mmHg < 300) mmol/L
• HR > 90 or >2SD above • Normal WBC with > 10% • SBP decrease > 40 • Acute oliguria (UO < 0.5 • Decreased capillary
normal immature forms mmHg or <2 SD below mL/kg/hr for > 2 hr despite refill or mottling
• Tachypnea • CRP > 2 SD above normal normal fluid resuscitation)
• MSA (monitor effect of • MAP < 70 mmHg • Creatinine increase >0.5
• Edema/ positive fluid treatment) mg/dL
balance >20 mL/kg/day • Procalcitonin > 2 SD above • Coag abnormality INR > 1.5 or
• Hyperglycemia >140 normal APTT > 60s)
mg/dL without DM • Ileus (absent bowel sound)
• Platelet < 100,000
• Total bilirubin >4 mg/dL

SEPTIC SHOCK REFRACTORY SEPTIC SHOCK SEVERE SEPSIS

• Sepsis • Shock persisting after > 60 mL/kg • Sepsis-induced hypotension
• CVS dysfunction > 40 mL/kg • Catecholamine resistant septic shock: • Lactate above normal
of fluid resuscitation in 1 hr shock persisting despite catecholamine • UO <0.5 mL/kg/hr for > 2hr despite adequate fluid resuscitation
• Hallmark: fluid treatment (Infusion: DOPA/EP/NE) • Acute lung injury PaO2/FiO2 < 250 without pneumonia
resuscitation 40 cc/kg • Acute lung injury PaO2/FiO2 < 200 with pneumonia
• Creatinine >2.0 mg/dL
• Bilirubin >2 mg/dL
• Platelet <100,000
• Coagulopathy (INR > 1.5)

PATHOGENS
EARLY ONSET LATE ONSET INFANT, YOUNG CHILDREN INFANT, HOSPITALIZED ASPLENIC/
NEONATAL SEPSIS NEONATAL SEPSIS CHILDREN FUNCTIONAL ASPLENIA
• 1st 72 hr of life • After 1st 72 hr – 1 • S.pneumoniae (major invasive bacterial • Depends on local • Salmonella
• Group B streptococci mon of life infection in childhood) bacterial epidemiology (osteomyelitis in sickle
• Gram negative • Coagulates • N.meningitidis (bimodal age) • Coagulase negative cell)
Bacilli (E.coli) negative • S.aureus, Group A Strep (severe sepsis in staphylococci (vascular • Encapsulated org
• S.aureus staphylococci previously healthy) catheter infection) (S.pneumoniae,
• Coagulase negative (most common, • H. influenzae type B (important worldwide • MRSA H.influenzae)
staph high incidence in pathogen) • Gram negative: • Schistosomiasis w/
• H.influenzae vascular catheter • B.pertussis (severe before primary P.aeurginosa, Klebsiella, splenectomy
• Enterococci infection) vaccination) E.coli, Acinetobacter (pneumococcal, Hib,
• L.monocytogenes • Most common: diarrhea & pneumonia meningococcal)

FEBRILE WITH INCREASED RISK FOR SERIOUS INFECTION

IMMUNOCOMPETENT IMMUNOCOMPROMISED
<28 days Sepsis & meningitis Sickle cell anemia Pneumonoccal sepsis, meningitis
(Group B Strep, E.coli, L.monocytogenes, gram neg, asplenia Encapsulated bacteria
HSV) Complement/ properdin def Meningococcal sepsis
< 3 mo Serious bacterial disease, Bacteremia Agamma globulinemia Bacteremia, sinopulmonary infection
3 – 36 mo Occult bacteremia AIDS S.pneumoniae, Hib, Salmonella, opportunistic pathogens
T >41 C Meningitis, bacteremia, pneumonia, heat stroke, CHD Inc. risk for endocarditis central venous line, CONS, S.aureus, candida
hemorrhagic shock, encephalopathy *native valve endocarditis: Viridans Strep
Fever + Bacteremia, meningitis (N. meningitidis, Hib, *Valve replacement endocarditis: CONS
petechiae S.pneumoniae) Malignancy Gram neg enteric, S.aureus, CONS, candida
 PATHOGENS BY SITE OF INFECTION
LUNGS ABDOMEN SKIN/SOFT TISSUE URINARY TRACT CNS
Community • S.pneumoniae • E.coli • S.pyogenes • E.coli • S.pneumoniae
acquired • H.influenzae • B.fragilis • S.aureus • Klebsiella • N.meningitidis
• Legionella • Clostridium • Enterobacter • L.monocytogenes
• C.pneumoniae • Polymicrobial infection • Proteus • E.coli
• Aerobic gram neg bacilli • H.influenza
• P.aeruginosa
• Anaerobes
• Staphylococcus
Nosocomial • Aeorbic grab neg • Aerobic gram neg bacilli • S.aureus • Aerobic gram neg bacilli • p/aeruginosa
pathogens bacilli • Anaerobes • Aerobic gram neg bacilli • enterococcus • e.coli
• Candida • Klebsiella
• staphylococcus

EFFECTS OF ENDOTOXIC SHOCK

METABOLIC
• Hyperglycemia
• Hypoglycemia
• Muscle proteolysis
• INC. ACTH, GH, ADH
• INC Trig & FFA
• INC Calcitonin
• INC TxA
• DEC Iron, transferrin, Zn
• DEC Ca
• DEC T3 & T4
CVS PULMONARY CNS
• DEC PVS • Tachypnea • DEC regional & total cerebral blood flow
• DEC CO • hyperpnea • INC Cerebral O2 consumption
• DEC Myocardial function • Congestive atelectasis
• DEC Systemic BP • INC capillary permeability
• PE: • Vasoconstriction
Cold clammy extremities, prolonged • bronchoconstriction
CRT, weak peripheral pulses

SKIN KIDNEYS LIVER DIGESTIVE TRACT

• Ecthyma gangrenosum (p.aeruginosa in neutropenia) Acute renal failure: • elevated serum bilirubin • Nausea
• Petechia/purpura (N.meningitidis/ R.rickettsia on tick • Oliguria • elevated ALP • Vomiting
bite), V.vulnificus in hemorrhage/bullous from raw oyster • Anuria • Cholestatic jaundice • Diarrhea
• Generalized erythroderma (TSS; S.aureus/ S.pyogenes) • Azotemia • ileus
• proteinuria

MENINGOCOCCEMIA STREPTOCOCCAL TSS STAPHYLOCOCCAL TSS

• Stellate Purpura: N.meningitidis
• Fulminant meningococcemia:
gangerene + DIC + small BV thrombosis
• Soft tissue infection: localized swelling,
peripheral tenderness, pain, erythema
• Diffuse erythroderma
• Abrupt hypotension (within 4-8 hr)
• Necrotizing fasciitis/flesh eating of hand
• Violaceous bullae: pathognomonic (ominous
sign: rapid swelling à vesicles, bullae)
• Abrupt: high fever, myalgia, headache,
dizziness, diarrhea
• Diffuse, sunburn like erythema
• Within 24-48 hr: shock, hypotension,
severe watery diarrhea, oliguria
• Erythroderma that blanches on pressure

DIAGNOSIS
FIRST TEST TO ORDER TESTS TO CONSIDER EMERGING TEST
CBC w/diff SIRS: High/low WBC for age • LUMBAR PUNCTURE: • Serum
SEPSIS: Plt <80k or 50% decrease from highest value within 3 days exclude meningitis procalcitonin:
COAGULOPATHY • Meningococcal PCR: DX & Monitor
Serum glucose MOD Hypo: 2-3 mmol/L, Severe Hypo: <2 mmol/L, Hyper: stress, corticosteroid confirm sepsis & septic
Blood C/S ASAP. Std aerobic culture bottle: min 4 ml for valid neg at 48 hr meningococcal sepsis shock
Neonatal aerobic culture bottle: min. 1 ml • Bronchoalveolar • Emerging
UA CS Nitrites, microscopy, G/S, C/S: All neonates with sepsis, Older children with symptoms lavage culture: child biomarkers:
ABG in ICU with suspected CD64, IL18,
Lactate INC: Inadequate O2 delivery: septic shock ventilator associated Mass
Electrolytes Deranged in sepsis pneumonia spectrometry,
Creatinine INC > 2x upper limit or >2 baseline level = sepsis-renal failure • HSV PCR: Blood, CSF specific mRNA
(Neonatal herpes expression.
LFT INC bilirubin/ INC ALT= Sepsis-liver dysfunction
simplex: CNS/ Not widely
Coag Sepsis + thrombocytopenia = DIC:
disseminated) used
INR>2, increased APTT, decreased Fibrinogen, increased d-dimer
CRP DX & MONITORING of sepsis, septic shock
Not as specific as procalcitonin, more commonly available
CXR Infants & small children with respiratory distress
Assess for: lobar consolidation in bronchopneumonia
 TREATMENT (Goals: immediately stabilize CVS derangement, ensure tissue oxygenation, treat infection)
Neonates <7 Neonates > 7 days Health 2-3months Health 3mo-3yr
days
• GBS None, respi, None, respi, none, respi, CNS, NEC (None, respi, CNS, blood) (none, respi, CNS, blood)
• E.coli CNS CNS, central endotracheal tube
• Listeria line Anaerobes GBS Hib
• Gram neg GBS P. aeruginosa Gram neg Gram neg enteric S.pneumoniae
enteric Listeria S. epidermidis (DOC: carbapenem) enteric S.aureus N.meningitidis
• HSV S. aureus S.epidermidis
• AMPICILLIN • AMPICILLIN Add • CEFTAZIDIME Add Ampicillin/ Ceftriaxone • Hib: ampicillin/
• Gentamicin • Gentamicine VANCOMYCIN (pseudomonas) Metronidazole/ +/- aminoglycoside chloramphenicol
• Cefotaxime • cefotaxime • Piperacillin- Clindamycin +/- oxacillin/ vancomycin • S.pneumoniae: PCN
• Acyclovir Tazobactam • N.menigitidis:
• Ticarcillin- ceftriaxone
clavulanate
• Imipenem
(seizure)
• Meropenem
• Cefepime

LEPTOSPIROSIS
Transmission Household exposure PH cases Reservoir in PH
• Drinking or contact with contaminated water • Pets: dogs, cats • Poor resident in low lying area • Rats: principal
• Skin breaks • Domesticated livestocks (pigs, cattle) • Workers on rice paddies, source of infection
• Intact mucous membrane (eyes, female genitals) • Rain water catchment system (gutter) vendors
• Skin immersed in water for prolonged periods • Rodent infestation • Lack of sanitary disposal
• Exposure to urine/ body fluids • Increasing rat population

DIAGNOSIS
TOP 4 SYMPTOMS TOP 3 SIGNS S/S Predictive for severity
• Fever • calf tenderness • pulmonary symptoms
• Abdominal pain • jaundice • shock
• Myalgia • hepatomegaly • MSA
• headache • Bleeding signs

GOLD STANDARD
MICROSOCOPIC AGGLUTINATION
TEST (MAT)
• Ab titer rise and peak only in 2nd
and 3rd week (less sensitive)
TEST
RAPID DIAGNOSIS FOR CHILDREN CORE GROUP RECOMMENDATION Predict Possible Complication
• ELISA IgM: • Rapid IgM test for early diagnosis • CBC (low platelet)
• Slide agglutination test (<1 week at least 5 days) • Chem (high creatinine, lactate,
• Lepto dipstick test • MAT: not routine amylase, abnormal K,)
• Lepto agglutination test • leptospiremia

TREATMENT (moderate evidence, strong recommendation)

UNCOMPLICATED MODERATE-SEVERE
1ST LINE 2ND LINE 1ST LINE ALTERNATIVE
• Doxycycline 2-4 mg/kg/day for • Amoxicillin 50 mg/kg/day q8h for • PCN 250k-400k IU • Cefotaxime 100-150 mg/kg in 3-4
7d 7d • Ampicillin 100 mg/kg/day q6h doses
• Azithromycin: 10 mg/kg/day 7d • Ceftriaxone 80-100 mg/kg/day OD

PREVENTION
NOTE 1ST LINE ALTERNATIVE GENERAL GUIDELINES
• SHORT TERM Doxycycline as chemoprophylaxis • Doxycycline : 4mg/kg • Amoxicillin: 50 mg/kg/day q8h • Don’t swim in floor waters
for children <8yo single dose for 3-5 days • Wash boil clean fresh vege
• No permanent discoloration of teeth • Azithromycin: 10 mg/kg single and fruits
dose • Boil drinking water for 10-
15 mins
• Protect foods against
rodent attack
• Prophylactic antibiotic
• No human vaccine
 DISASTER RELATED DISEASES
NATURAL DISASTER PHASE 1: IMPACT PHASE 2: POST IMPACT PHASE 3: RECOVERY
• Catastrophic events with • Upto 4 days • 4 days – 4 weeks • After 4 weeks
atmospheric, geologic and • Extricated victims • 1st waves of infectious disease • Clinically apparent
hydrologic origins • Initial tx provided (airborne, food borne, water • Endemic à epidemic
borne) emerging

PH TYPHOON HAIYAN RISK ASSESSMENT GENERAL INFECTION PREVENTION TECHNIQUES

• Most common syndrome: communicable disease • Wash hands
• Most common among 21 syndrome: acute respiratory infection • Clean environment
• Good personal hygiene
• Screening
• Cough etiquette

HAND WASHING IMMUNIZATION

• Alcohol based: • With vit A supplementation
Gel = dime sized • Priority age group 6 mon-5 years
Foam = egg sized
• Handwashing: 15-20 seconds