Pediatric emergency medicine trisk 593

Generalized
lymphadenopathy

Nontuberculous mycobacteria a
Large DNA viruses: CMV, EBV,
HSV, VZV
Brucella
HIV infection (acute or chronic a )
Leishmaniasis
Leptospirosis
Lyme disease
Measles
Mumps
Syphilis a
Toxoplasmosis a
Tuberculosis a
Tularemia

a More

chronic infections.
CMV, cytomegalovirus; EBV, Epstein–Barr virus; HSV, herpes simplex virus; VZV, varicella zoster virus;
HIV, human immunodeficiency virus.

e-TABLE 94.7
INDICATIONS FOR ADMISSION FOR CHILDREN WITH
COMMUNITY-ACQUIRED PNEUMONIA
<3–6 mo of age
Immunocompromised child
Failure to respond to oral antibiotics in 24–48 hrs
Dehydration or other intolerance of oral intake

Moderate to severe pneumonia ( Table 94.21 )
Suspected staphylococcal pneumonia (e.g., empyema, pneumatocele)
Children whose families are unable to comply with follow-up


e-TABLE 94.8
INFECTIOUS DISEASES SOCIETY OF AMERICA AND AMERICAN
THORACIC SOCIETY GUIDELINES FOR ASSESSING DISEASE
SEVERITY IN CHILDREN WITH COMMUNITY-ACQUIRED
PNEUMONIA a
Major

Minor

Invasive mechanical ventilation
Fluid-refractory shock
Acute need for noninvasive positive-pressure
ventilation
Hypoxemia requiring supplemental oxygen
concentration or flow beyond what is
feasible in a general ward setting

Tachypnea
Apnea
Increased work of breathing
Pao2 /FiO2 ratio <250
Multilobar infiltrates
PEWS score >6
Altered mental status
Hypotension

Presence of pleural effusion
Comorbid conditions (e.g.,
sickle cell anemia,
immunodeficiency, or
immunosuppression)
Unexplained metabolic
acidosis

a The

clinician should consider intensive care unit care for children with ≥1 major or ≥2 minor criteria.
PaO2 , arterial oxygen pressure; FiO2 , fraction of inspired oxygen; PEWS, pediatric early warning score.


e-TABLE 94.9
PLEURAL FLUID CHARACTERISTICS OF PLEURAL EFFUSIONS
Variable

Exudate a

Transudate b

Appearance
Cell count (mean WBC/mm3 )

Purulent
>25,000

Serous
1,000

Neutrophilic predominance
Protein (fluid/serum ratio)
LDH (IU/L) c
LDH (fluid/serum ratio) c
Glucose (mg/dL) c
pH c

>95%
>0.5
>200
>0.6
<60
<7.2

50%
<0.5
low
<0.6
>60
7.4–7.5

a Exudate:

neoplasia, infection, pulmonary embolus, hemo- or chylothorax, pericardial disease, intraabdominal abscesses, post liver, lung, or bone marrow transplantation, autoimmune or collagen vascular
diseases, drug reaction.
b Transudate: congestive heart failure, superior vena cava obstruction, Fontan, nephritic syndrome or other
causes of hypoalbuminemia, glomerulonephritis, peritoneal dialysis, myxedema, cirrhosis, cerebrospinal
fluid leak to pleura.
c Not recommended by the Infectious Diseases Society of America because rarely changes clinical

management in children.
WBC, white blood cell count; LDH, lactate dehydrogenase.


e-TABLE 94.10
TREATMENT INDICATIONS FOR NONTYPHI SALMONELLA
Scenario

Management

Asymptomatic carriage
None
Gastroenteritis, uncomplicated None needed, unless patients are at risk for
complications: <3 mo of age, HIV-infected,
functionally or anatomically asplenic,
immunosuppressed or
immunocompromised, or in presence of
chronic GI tract disease
Treatment options: ampicillin, TMP-SMX
based on local susceptibilities; azithromycin
or fluoroquinolones in regions where
resistance to penicillins and TMP-SMX is
common
Localized invasive disease
(meningitis, osteomyelitis,
abscess) in HIV-infected
children
Bacteremia, sepsis

Empiric ceftriaxone, then either ampicillin or

ceftriaxone for 4–6 wks

Empiric ceftriaxone, then change to oral
regimen (fluoroquinolone or azithromycin)
after patient becomes afebrile, for a total
course of therapy of 10–14 days

HIV, human immunodeficiency virus; GI, gastrointestinal; TMP-SMX, trimethoprim-sulfamethoxazole.