Pediatric emergency medicine trisk 570

Management: If the node is fluctuant, aspiration provides useful etiologic information and speeds the rate of
resolution. Children who fail to respond to empiric antibiotic therapy and children with tuberculosis risk factors
who present with adenitis should have a TST placed. Children with cervical adenitis who are otherwise healthy
should receive an antibiotic effective against S. aureus and the GAS. While clindamycin (10 mg/kg/dose three
times daily; maximum: 600 mg/dose) has activity against both pathogens, trimethoprim-sulfamethoxazole (TMPSMZ) will not offer GAS coverage. The decision about which oral antibiotic to select depends on the level of
methicillin-resistant S. aureus (MRSA) in a community. Indications for inpatient admission and parenteral
antibiotics include: toxic appearance; young age (<3 months); immunocompromised host; suspicion of deeper neck
extension; development of a draining sinus track; or failure to improve with outpatient oral antibiotic therapy. For
these children, clindamycin (10 to 13 mg/kg every 8 hours; maximum: 600 mg/dose) or vancomycin (15 mg/kg
every 8 hours; maximum: 2 g/dose) offers alternatives in the face of penicillin and/or cephalosporin allergy or in
areas where coverage for MRSA must be considered. Standard precautions should be used unless children have
draining lesions (in which case contact precautions should be used) or if children are suspected of having
tuberculosis lymphadenitis (in which case airborne precautions should be used until pulmonary involvement is
excluded).

Other Neck Infectious Emergencies
Lemierre Syndrome
Lemierre syndrome refers to a deep neck abscess with a contiguous septic thrombophlebitis of the internal jugular
and septic pulmonary emboli. The most common cause historically has been Fusobacterium necrophorum; in
recent years, S. aureus has been the most common etiology. Examination is notable for a tender cord in the lateral
neck and dyspnea is common as the number of septic pulmonary emboli increases. The diagnosis can be made by
CT neck with contrast-showing flow voids in the jugular; apical cuts through the lungs on neck CT may show the
embolic lesions. Children with suspected Lemierre’s should receive broad-spectrum antibiotics covering both
MRSA and anaerobes (e.g., vancomycin plus metronidazole).
Cat-scratch Disease
Cat-scratch disease, caused by Bartonella henselae, is caused by cat scratches, cats licking abraded skin, or from
the bite of infected cat fleas. These most commonly occur to the upper extremities and result in tender, fluctuant
axillary or epitrochlear lymphadenitis, but cervical adenopathy can be seen if scratches or bites occur to the face.
In some pediatric series, Bartonella and EBV are the most common causes of fever of unknown origin. Diagnosis
is based on history (cat, especially kitten, exposure), examination (slowly healing papule at inoculation site), and
serologies. While most lesions will resolve in 1 to 2 months, antibiotics may decrease symptom duration and are

recommended for immunocompromised patients. Optimal antibiotics are unclear; rifampin, azithromycin, TMPSMZ, and fluoroquinolones have all been utilized. Standard precautions should be used.

RESPIRATORY TRACT INFECTIOUS EMERGENCIES
Upper Respiratory Tract Infectious Emergencies
Goals of Treatment
Infections in the neck can rapidly enter other tissue planes that can result in spread to contiguous structures,
including compromising the airway or neck vasculature. Clinicians need to be cognizant that while most upper
airway infections are relatively benign (e.g., pharyngitis), some can progress from benign etiologies to lifethreatening complications (e.g., Lemierre syndrome). The clinical manifestations, diagnosis, and treatment of
upper respiratory tract infections are summarized in Table 94.12 .
CLINICAL PEARLS AND PITFALLS


Many clinical entities can be differentiated on the basis of the child’s age, history, and oropharyngeal
examination.
Airway instrumentation in a child with suspected epiglottitis should be performed in the more
controlled environment of the operating room.
Many upper airway infections are caused by streptococcal and staphylococcal species, simplifying
empiric ED antibiotic selection.
Epiglottitis
Epiglottitis is characterized by fever, drooling, dysphagia, and inspiratory stridor in a toxic-appearing child who is
not hoarse and does not have a barky cough. The illness is rapidly progressive over hours and is most common in
children 1 to 8 years of age. The most common organism historically was Hib, but now S. pneumoniae,
Streptococcus pyogenes, and S. aureus comprise many of the cases. Soft tissue lateral neck radiographs can show
an enlarged epiglottis (“thumbprint sign”), and visualization demonstrates a swollen, erythematous epiglottis.
However, instrumentation is best performed in the operative setting to prevent airway compromise. Immediate
involvement of otolaryngology and broad-spectrum antibiotics (e.g., vancomycin and cefotaxime) and attempting
to keep the child calm are the mainstays of ED management. Standard precautions should be used.
Retropharyngeal Abscess
Retropharyngeal abscesses (RPAs) are characterized by nuchal rigidity or torticollis, difficulty swallowing,
drooling, stridor, and fever. Anterior bulging of the posterior pharynx can be difficult to appreciate. Children with

RTAs usually are preschool aged, and GAS and S. aureus are the most common organisms. A soft tissue lateral
neck radiograph can suggest the diagnosis if there is increased prevertebral space; however, a contrast CT neck is
better to delineate the anatomy prior to operative intervention. Empiric antibiotics should target streptococci and
staphylococci (e.g., clindamycin). Standard precautions should be used.
TABLE 94.12
PRESENTATION OF AIRWAY AND NECK INFECTIONS

Peritonsillar Abscess
Peritonsillar abscesses (PTAs) are characterized by unilateral swelling of the tonsils, change in caliber of the voice,
trismus, unilateral odynophagia, displacement of the uvula toward the unaffected side, and fever. PTAs are most


common in adolescents, and GAS and S. aureus are the most common organisms. The diagnosis is clinical,
although in some cases ultrasound can be used to aid the diagnosis and CT may be useful to evaluate for deeper
extension of the abscess. Empiric antibiotics should target streptococci and staphylococci (e.g., clindamycin).
Standard precautions should be used.
Ludwig Angina
Ludwig angina is a rapidly progressive cellulitis of the floor of the mouth with spread to other tissue planes,
resulting in thrombophlebitis, carotid rupture, and mediastinitis. This can be a complication of dental abscesses,
especially of the mandibular molars. Children with Ludwig angina develop fever, halitosis, odynophagia,
submandibular lymphadenopathy, and induration to the floor of the mouth. The most feared complication is airway
obstruction. Anaerobes, including microaerophilic (non-pneumococcal, non-group A) streptococcal species, are
most commonly isolated. Diagnosis is clinical, but imaging by CT can help evaluate the extent of infection.
Antibiotics should not be held pending imaging or other diagnostic evaluation. Surgical consultation and
admission to a critical care unit are necessary with strong consideration for early endotracheal intubation,
anticipating that these children may be difficult to intubate. Broad-spectrum coverage for aerobes and anaerobes
(e.g., clindamycin, piperacillin/tazobactam) should be considered for this fulminant infection. Standard precautions
should be used.
Pharyngitis
GAS accounts for 15% to 36% of exudative pharyngitis cases in older children and adolescents; the majority of the

remaining etiologies are viral. The Centor criteria (absence of cough, tender anterior cervical adenopathy, fever,
and tonsillar exudate or swelling) were developed to identify adults at higher risk for streptococcal pharyngitis in
whom empiric treatment without testing could be considered. Testing is recommended prior to treatment to avoid
unnecessary antibiotic usage in children; testing is generally not recommended for children younger than 3 years
of age. Throat swabs should be obtained from both tonsillar pillars and swabs that first touch the tongue should be
discarded, as saliva can result in false-negative rapid streptococcal assay results. Rapid streptococcal assays show
variable sensitivity based on the experience of the person collecting the specimen. Reported sensitivities range
from 60% to 99%; as such, throat cultures should be sent for all children in whom rapid streptococcal assays are
negative. The treatment of choice is amoxicillin or penicillin. There are good data behind the use of a single-daily
dose of amoxicillin (50 mg/kg daily, maximum: 1 g/day) for 10 days. For children with difficulty swallowing or in
whom nonadherence is a concern, a single intramuscular dose of penicillin should be considered (penicillin G
benzathine [Bicillin] ≤27 kg: 600,000 units; >27 kg: 1.2 million units). Regimens for penicillin-allergic patients
include cephalosporins and macrolides. There are no data suggesting that the use of cephalosporins decreases the
risk of relapse or leads to symptoms resolution faster than more narrow-spectrum antibiotics. Amoxicillinclavulanate offers no advantages over amoxicillin or penicillin, as there have been no GAS isolates found to be
resistant to beta-lactams. Use of antibiotics other than amoxicillin in the non-allergic patient represents poor
antimicrobial stewardship. Up to 20% of U.S. GAS isolates are resistant to macrolides and 20% to 25% to
clindamycin. Standard precautions should be used.

LOWER RESPIRATORY TRACT INFECTIOUS EMERGENCIES
Lower respiratory tract infections are one of the most common causes of death in children younger than 5 years of
age in developing nations. The morbidity of these infections in industrialized nations remains high. The following
section will review the diagnosis and management of pneumonia and other common lower respiratory tract
infections. Tuberculosis is covered separately later in this chapter in the section on infection in returned travelers,
reflecting the epidemiology of this disease in industrialized nations.

Pneumonia
CLINICAL PEARLS AND PITFALLS


The most common causes of community-acquired pneumonia are viral infections.

Beyond the neonatal period, the most common bacterial cause is pneumococcus.
Less common, but more severe bacterial causes of pneumonia include S. aureus and GAS.
While chest radiography can be useful to evaluate for complications of pneumonia, such as empyema
or lung abscess, radiographic appearance alone is not useful for differentiating viral from bacterial
etiologies.
Current Evidence
The most common causes of pneumonia in different age groups are listed in Table 94.13 . The most common
causes are viral. Among the bacteria, S. pneumoniae predominates at every age beyond the newborn period. S.
aureus causes a severe, rapidly progressive but uncommon pneumonia in young children; 60% of these infections
occur in the first year of life. GAS is also uncommon but may also be severe. Anaerobic bacteria play a role
primarily following aspiration.
TABLE 94.13
MOST COMMON CAUSES OF PNEUMONIA BY AGE
Age

Viral

Pyogenic bacteria

Other

<3 wks

CMV
RSV
hMPV
HSV
Rubella

Group B streptococcus (S. agalactiae )

Gram-negative enterics (E. coli, Klebsiella )
S. pneumoniae
S. aureus, especially in hospitalized
neonates

Bordetella pertussis
Chlamydia trachomatis
Mycobacterium hominis
Treponema pallidum (syphilis)
Ureaplasma urealyticum

3 wks–3
mo

RSV
hMPV
Parainfluenza
Adenovirus
Influenza
RSV
hMPV
Parainfluenza
Adenovirus
Influenza
hMPV
Influenza
Adenovirus

S. pneumoniae
S. aureus

H. influenzae (nontypeable)

Bordetella pertussis
Chlamydia trachomatis

S. pneumoniae
S. pyogenes (group A streptococcus)
S. aureus

Mycoplasma pneumoniae
Chlamydia pneumoniae
Mycobacterium tuberculosis

S. pneumoniae
S. pyogenes (group A streptococcus)
S. aureus

Mycoplasma pneumoniae
Chlamydia pneumoniae
Mycobacterium tuberculosis

3 mo–5
yrs

5–18 yrs

CMV, cytomegalovirus; RSV, respiratory syncytial virus; hMPV, human metapneumovirus; HSV, herpes simplex virus.

Goals of Treatment
Early recognition of children with respiratory distress and findings consistent with bacterial pneumonia is ideal.

The clinical team should be cognizant of indications for imaging other than chest radiographs, as well as what
radiographic patterns may be more consistent with certain pathogens. Clinical outcomes for patients with
pneumonia include appropriate antibiotic utilization and indications for admission for treatment.
Clinical Considerations
Clinical recognition: Bacterial pneumonia generally has an abrupt onset with fever, often accompanied by chills. A
cough is a common but nonspecific complaint. Younger children may have decreased activity level or appetite.
Pleuritic chest pain may be seen. The most common examination finding other than pyrexia is tachypnea. The
observation of the child at rest before the examination often provides the key to the diagnosis of pneumonia. A
hasty effort at auscultation that disturbs the quiet infant obscures this finding. Grunting respirations in a young