|
1. Greg Conners, MD, Vice Chair of ED/UCC services and Chief of the Division of Emergency Medical Services,at Children's Mercy, has asked for clarification regarding antibiotics choices in the child with bacterial superinfection complicating influenza. Here are some caveats which might be helpful. Dr. Newland has released these to our medical staff at Children's Mercy.
Considerations for Treating Bacterial Complications of Influenza
- Azithromycin
- poor choice for bacterial complications of influenza.
- High dose amoxicillin
- uncomplicated AOM, sinusitis or pneumonia
- Clindamycin
- older child with sinusitis or uncomplicated pneumonia failing treatment with amoxicillin
- High dose amoxicillin-clavulanate
- outpatient AOM, sinusitis failing amoxicillin
- Clindamycin plus ceftriaxone
- hospitalized w/ lobar pneumonia as complication of influenza or complicated pneumonia (parapneumonic effusion/empyema) not requiring ICU care
- Vancomycin plus clindamycin plus ceftriaxone (or cefotaxime) s
- Critically ill with hemodynamic compromise, respiratory failure or multi-organ dysfunction
Chest radiograph recommended in child with influenza
- Tachypnea and/or decreased oxygen saturation (suggests possible pneumonia)
These recommendations do not cover every clinical scenario so as always, nothing replaces your own clinical judgment in such situations and you can contact any of the faculty in Infectious Diseases for additional questions or clarifications.
2. Stevie Wilson, one of our former hospitalist NPs called today from Turner House asking for any further clarifications on use of antivirals for children with influenza.
A new guideline has been disseminated by the AAP http://aapredbook.aappublications.org/news/PedAlg_AAP-CDC.pdf. The guideline is somewhat complicated to my eye but sheds some light on when and who to evaluate. While it tells the clinician which children require further evaluation, it does not elaborate on what the evaluation includes. After looking it over, I think it is probably worth confirming the following:
- Most patients with clinical illness consistent with uncomplicated influenza do not require diagnostic influenza testing or treatment.
- Currently when the majority of circulating influenza viruses are 2009 H1N1, a positive rapid test result for influenza A virus can be assumed to be 2009 H1N1 influenza (but a negative test does not exclude this diagnosis). For those with negative tests, further testing with an rRT-PCR assay specific for 2009 H1N1 influenza or viral culture should be performed—both available at CMH.
- Patients who should be considered for influenza diagnostic testing include
o Hospitalized patients with suspected influenza
o Patients for whom a diagnosis of influenza “will inform decisions regarding clinical care, infection control, or management of close contacts”
o Patients who died of an acute illness thought to be influenza.
- Early empiric treatment with oseltamivir or zanamivir should be considered for persons with suspected or confirmed influenza. Higher doses of oseltamivir, IV peramivir or zanamivir may be required in the hospitalized child who is not improving (consult ID in those instances). Here is the list of we believe is at higher risk for complications and a candidate for treatment:
- Children younger than 2 years old (consider severity of illness)
- Persons aged 65 years or older;
- Pregnant women and women up to 2 weeks postpartum (including following pregnancy loss);
- Persons of any age with certain chronic medical or immunosuppressive conditions
- Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), or metabolic disorders (including diabetes mellitus); Disorders that that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders); Immunosuppression, including that caused by medications or by HIV; Morbid obesity
- Persons younger than 19 years of age who are receiving long-term aspirin therapy
- Be alert for the child with bacterial complications of H1N1: the child with tachypnea, dehydration, intractable vomiting, decreased mental status, is worsening after starting to improve. Further evaluation is needed including hospitalization.
- Lastly, if you are wondering if we are at the plateau of H1N1, this graph from the CDC suggests the answer is unfortunately, no. Our guess in the ID section is that disease will be steady through January and decrease once vaccine is more widely implemented.
|