Infectious Disease

Occult Bacteremia
5CLPH SG1 Armes, Janella V. Bagazin, Precious G.

Occult Bacteremia
Bacteremia s the presence of viable bacteria in the circulating blood.
Most episodes of occult bacteremia spontaneously resolve. Streptococcus pneumoniae and Salmonella, and serious sequelae are increasingly uncommon.

Occult Bacteremia
Patients with occult bacteremia by definition do not have clinical evidence other than fev
Occult bacteremia has been defined as bacteremia not associated with clinical evidence of sepsis or toxic appearance, underlying significant chronic medical conditions, or clear foci of infection upon examination in a patient.

Pathophysiology
Much of the pathophysiology of occult bacteremia is not fully understood.

bacterial colonization of the respiratory passages

bacteria may egress into the bloodstream of some children

Bacteria may be spontaneously cleared, they may establish a focal infection, or progress to septicemia

possible sequelae of septicemia include shock, disseminated intravascular coagulation, multiple organ failure, and death.

Signs and Symptoms

The condition is not manifested by any clinical signs. Duration of fever (fever is the only manifestation) History that indicates a specific illness History that indicates risk for occult bacteremia History of an underlying medical condition History of prematurity

Signs and Symptoms

History of another reason for an increased temperature History of gastroenteritis

Risk Factors
Studies of the prevalence of bacteremia in children in diverse settings have identified no racial, geographic, or socioeconomic predisposition.
No sex-based difference in the prevalence or course of bacteremia is known. Studies of occult bacteremia focus on children younger than 3 years.

Patient Demographics
Age 4 y/o

FEVER
Sex Female

Weight 13.5kg

Pt CJS
Height 103 cm Admitted Jan 1, 2014 Allergy NKA

Final Diagnosis

Occult Bacteremia

History of Present Illness

One day prior to admission Pt experienced intermittent fever with Tmax of 38C. Patient was given Paracetamol (125mg/5mL) 5 mL every 4 hours which provided temporary relief of fever. This was accompanied by 2 episodes of vomiting- 3 tablespoons of previously ingested food. No other symptoms noted. Interval History

persistence of fever with no dyspnea, hematuria, dysuria, abdominal pain and diarrhea noted.

History of Present Illness

Few hours prior to admission

due to persistence of fever patient sought consult to a local clinic . CBC and urinalysis were done advised admission. Due to financial constraints patient transferred to our institution.

HgB 111 Hct 0.33 WBC 17.08 N 0.81 L 0.18 E 0.01 platelet 378 yellow cloudy, pH 6.0 SG 1.020, Protein 0.3 g/dL Sugar (-) WBC 12-15/hpf RBC 1-3/ hpf Epithelial cell: few bacteria: moderate mucus threads: moderate

Patient Histories

PMH
Hospitalizations: none Operations: none Accidents: none Blood Transfusion: none Allergies/Drug Reactions: none

Patient Histories
Family History
(-) DM, HTN, Asthma, Allergies, Cancer, TB

Social History
patient lives with parents not exposed to cigar and air pollution

Medication History

Paracetamol (125mg/5mL) 5 mL every 4 hours

Vital Signs
Temp 38.3 C

BP 100/60 mmHg

Vital Signs
RR 24 bpm

PR 120 bpm

Review of Systems
General Appearance HEENT Skin
(-) wt loss, (-) diaphoresis, (-) anorexia (-) blurring of vision, (-) deafness, () epistaxis, (-) bleeding gums, (-) sores (-) itchiness, (-) color change, (-) pigmentation, (-) rash

Review of Systems

Lungs
CardioVascular

(-) colds, (-) dyspnea

(-) easy fatigability, no palpitations, (-) chest pain

Review of Systems

Abdomen

(-) constipation, (-) diarrhea, (-) incontinence

Extremities

(-) joint pain/effusion, (-) joint stiffness

Physical Examination

General Survey
HEENT

Conscious , coherent, carried by mother, ill-looking, not in cardiorespiratory distress

hair evenly distributed, no scalp lesions pink palpebral conjunctivae, anicteric sclera impacted cerumen AU (+) nasal discharge

Physical Examination

Skin Lungs

Warm, dry skin, with good turgor, no jaundice, no cyanosis

Symmetrical chest expansion, no retractions, equal vocal and tactile fremiti, resonant, normal breath sounds

Physical Examination
CardioVascular Abdomen
Adynamic precordium, (-) heaves, thrills, lifts, S1>S2 at apex, S2>S1 at base, Apex beat at 5th LICS MCL Soft and flabby abdomen, normoactive bowel sounds, tympanic, non-tender, no masses palpated

Physical Examination
Extremities
(-) Edema, (-) Cyanosis, no deformities, pulses full and equal

Neurological Exam
Cerebrum: conscious, coherent Cranial Nerves: CN I not assessed CN II pupils 2-3mm ERTL CN III, IV, VI full and equal extraocular movement CN V1-V3 no sensory deficits

Neurological Exam
CN VII can raise eyebrows, puff cheeks, smile, nonshallow nasolabial fold, symmetrical CN VIII gross hearing intact CN IX, X can swallow, intact gag reflex CN XI can shrug shoulders and turn head against resistance CN XII tongue midline in protrusion

Neurological Exam
Motor: 5/5 bilateral upper extremities Cerebellum: no ataxia, no dysdiadochokinesia Sensory: no deficits Reflexes: +2DTR on all extremities Meningeal Irritation: (-) Babinski, (-) nuchal rigidity

LABORATORY AND ANCILLARY SERVICES

Laboratory and Ancillary Services

CBC with Plt
Hemoglobin PATIENT MLA 111g/L NORMAL VALUES 120- 160 g/L LOW

RBC
Hematocrit MCV

4.29x 106/L
0.34 78.20

3.6-5.2 x 106/L
0.28-0.46 76-100 fL

NORMAL
NORMAL NORMAL

MCH
MCHC RDW MPV PT WBC

26
33.20 12.50 IU/L 6.10 371 29.10

23-34 pg/cell
31.5 36.3 g/dL < 35 IU/L 6.4-10.4 fL 150-400 x 109/L 4.0-10.0 x 109/L

NORMAL
NORMAL NORMAL NORMAL NORMAL HIGH

Laboratory and Ancillary Services

PATIENT MLA Neutrophils Lymphocytes 0.86 0.14

NORMAL VALUES 0.54-0.62 0.25-30 HIGH LOW

UA

Laboratory and Ancillary Services

Color Transparency pH SG Protein Sugar Ketone Urobilinogen Bilirubin Nitrite Erythrocytes Light Yellow Slightly turbid 6.0 1.020 ++ (-) (+) Normal (-) (-) (+)

UA

Laboratory and Ancillary Services

Leukocytes RBC Pus cells Mucus threads Bacteria Renal Cells Amorphous Urates Casts (+) 0-1/hpf 2-3 hpf None Few None Few None

COURSE IN THE WARDS

Course in the Wards

Day 1 (January 1, 2014)

Meds IVF: D5 0.3% NaCl 500 mL to run at 16-17 gtts/min (100%) Ampicillin-Sulbactam 500mg/ SIV infusion over 30 mins based on Ampicillin content (q6 hrs) (-) ANST; 148mg/kg/day

Labs -blood C/S -CBC with platelet -urinalysis -peripheral blood smear

Others Diet for AGE Monitor vital signs every 4 hours and record Monitor input and output every shift Watch out for vomiting, abdominal pain, and diarrhea

Course in the Wards

Day 2 (January 2, 2014) 1:35AM

Meds Continue standing meds Paracetamol 120mg/5mL, give 6mL every 4 hours For temp > 38.3 degrees Celsius or as needed

Labs

Others:

Course in the Wards

Day 2 (January 2, 2014) 4AM

Meds Continue standing meds IVF to follow: D5 0.3% NaCl 500mL to run at 16-17 gtts/min

Labs blood CS with ARD Facilitate Peripheral Blood Smear

Others: Measure input, output accurately

Course in the Wards

Day 2 (January 2, 2014) 9:30AM

Meds Hydrogen peroxide, instill 2-3 drops each 3x/day for 5 days D5 IMB 500mL to run at 1213gtts/min

Labs

Others: Increase oral fluid intake

Course in the Wards

Day 3 (January 3, 2014)

Meds D5 IMB 500mL to run at same rate (12-13gtts/min)

Labs Request CBC with plt

Others:

Course in the Wards

Day 4 (January 4, 2014)

Meds Ampicillin-Sulbactam 500mg/ SIVP shifted Co-amoxiclav 457mg/ 5mL, 3mL every 12 hours

Labs

Others:

Course in the Wards

Day 5 (January 5, 2014)

Take Home Meds Co-amoxiclav 457mg/5mL, 3mL every 12 hours Hydrogen peroxide 2-3 drops each ear 3x a day for 7 days

Labs

Others:

List of Problems
1. Fever 2. Occult Bacteremia 3. Impacted Cerumen

Medications
Standing Meds
Ampicillin-Sulbtactam 500mg/ SIV q6h Hydrogen Peroxide 2-3 drops each 3x/day for 5 days Co-Amoxiclav 457mg/ 5mL, 3mL every 12 hours PRN Meds

Indication/ Problem treated

Empiric treatment; antibacterial Impacted Cerumen antibacterial

Indication/ Problem Treated

Paracetamol 120mg/5mL, give 6mL every 4 hours PRN if Temp > 37.5

Fever

Ampicillin SulbactamRecommended Dose- Computation

>1 year old: 100-200 mg/kg/day IV/IM Q6 hr
Weight 13.5kg 13.5kg x 100mg/1kg= 1350mg 13.5kg x 200mg/1kg=2700mg =1350-2700mg/day IV/IM Q6 =patient was given 2000mg/day Q6

Paracetamol Recommended DoseComputation

10-15 mg/kg PO q6-8 hr not to exceed 2.6g/day
Weight 13.5kg 13.5kg x 10mg/1kg= 135.0mg 13.5kg x 15mg/1kg=202.50mg =135-202.50mg/day PO =patient was given 144mg of Paracetamol as needed for fever relief

Pharmacotherapeutic Goals
Normalize body temperature Treatment of occult bacteremia Removal of impacted cerumen

Restore Normal Body Function

Guidelines VS Actual Management

Guidelines/Algorithm
Children who are afebrile and well appearing can be treated on an ambulatory basis with a 10-day course of oral penicillin
Reference: Practice Guideline for the Management of Infants and Children 0 to 36 Months of Age With Fever Without Source

Actual Management

Co-amoxiclav 457mg/5mL, 3mL every 12 hours

Recommendations/ Intervention
S
N/A

Co-amoxiclav 457mg/5mL, 3mL every 12 hours

Unclear dosing regimen/duration. Children and who are afebrile and well appearing can be treated on an ambulatory basis with a 10-day course of oral penicillin.

Suggest to physician the duration of Co-amoxiclav therapy is 10 days. Reference: NICE clinical guidelines

Guidelines VS Actual Management

Guidelines/Algorithm
The recommended dose for coamoxiclav >3months is 25mg/kg/day q12h
Reference: Lexicomp

Actual Management

Co-amoxiclav 457mg/5mL, 3mL every 12 hours

Recommendations/ Intervention
S
N/A

Co-amoxiclav 457mg/5mL, 3mL every 12 hours

Underdosing. The recommended dose for co-amoxiclav >3months is 25mg/kg/day q12h .

Suggest to physician to increase the dose of Co-amoxiclav therapy up to 4.2 mL or 4mL. Reference: NICE clinical guidelines

Co-Amoxiclav Recommended DoseComputation

25 mg/kg/day PO divided q12hr
Weight 13.5kg 13.5kg x 25mg/1kg= 337.5mg/kg 400mg/5mL=X/3mL mg=240mg patient was given 240 mg of Co-Amoxiclav
337.5mg/x=400mg/5mL x=4.2mL

Recommendations/ Intervention
Based on amoxicillin content 13.5kgx25mg/kg= 337.5mg 400mg/5mL=x/3mL x=240 mg 337.5mg/x=400mg/5mL x=4.2mL

Reference: NICE clinical guidelines

References:
Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. Jul 1993;22(7):1198-210 Kramer MS, Shapiro ED. Management of the young febrile child: a commentary on recent practice guidelines. Pediatrics. Jul 1997;100(1):128-34 Medscape.com Medline.com Lexicomp MIMS

Thank you!