Quid Refert, Dummodo non Desinas, Tardius Ire

Bacterial Infections Part 1

Pedia II Dr. Lim

Part 1 Contents  DIAGNOSIS

 CBC: very high leucocyte count of 15,000 to 100,000 with absolute
1. Pertussis lymphocytosis (leukemoid reaction) *more of lymphocytes
2. Syphilis  CxR: perihilar infiltrate, atelectasis, or emphysema
3. Shigellosis  total duration of disease is up to 12 weeks
4. Cholera  Conditions similar to pertussis (Ddx)
5. E. Coli  Atypical pneumonia, Mycoplasma,Chlamydia, Adenovirus,
6. Tetanus Tracheobronchial TB (when lymph node has obstructed bronchus),
7. Staphylococcus Foreign body, Bronchiolitis, other causes of spasmodic cough
8. Streptococcus  Total duration of the disease: up to 12 weeks
9. Pneumococcal  Complications and hospitalizations occur most commonly in the young
10. Pseudomonas infant population under 6 months of age and include: Pneumonia, apnea,
otitis, conjunctival hemorrhage, epistaxis, seizures (not due to CNS
Introduction: In our country, bacteria is persistent because it’s very favorable infection but because of lack of oxygen from too much coughing), acute
(tropical environment, poverty, overcrowding). The disease course of infection encephalopathy, hernia, and pneumothorax (spontaneous, pumutok
in adults is the same as pediatrics, but due to weaker immune system of pedia, yung lungs sa sobrang intrapulmonary pressure)
the morbidity is bigger especially if with malnutrition which adds to the burden  Symptoms commonly mild and non-specific in older children and
of the disease. adults (sa adults hindi na obvious masyado, mga chronic cough ang
manifestation)
PERTUSSIS (WHOOPING COUGH)
 Confirmation of diagnosis can be made by isolation of organism from
Bordet Gengou culture of nasopharyngeal mucus. Best yield during first
 Bordetella pertussis → Gm (+) bacilli 3 weeks of illness (Catarrahal stage – MOST INFECTIOUS Stage)
 MOT: pertussis toxin transmitted thru close contact via  PCR, Fluorescent antibody, & Serology
resp. secretions → highly communicable (highly contagious)  TREATMENT
 IP: 6-20 days  most effective during first two weeks of illness (if given during the
 Now seen more often in adolescents and adults (milder) – serve as index violent stage, hindi na mashoshorten yung duration, course NOT
cases, but can occur in all ages altered anymore, probably only the reduced transmission or
 No lifelong immunity organism is affected)
 Nagrere-emerge sa teenager due to waning immunity (yung mga bata  Infants <6months and patient with severe disease commonly
dati na nabakunahan, nag-wane na yung immunity) require admission
 Also known as “100 days cough” – because patient is coughing in roughly  Drug of choice is oral ERYTHROMYCIN (Macrolides) 40-50mg/kg/d
abouth 3 mos. (max 1gm/day) for 14 days (ang problem sa erythromycin is gastric
irritation. Newer macrolides hindi na masyadong irritating)
3 Stages  Other drugs: Azithromycin, Clarithromycin
 All household contacts should receive chemoprophylaxis
1. Catarrhal (most contagious stage) regardless of age and immunization status as if they have pertussis
 Nonspecific manifestations, challenging diagnosis, just like regular themselves (Erythromycin for 14 days)
common cold and cough  Supportive – Paracetamol, IV fluids. Sa infectious disease, hindi
 Very important to diagnose early, because early treatment can lang antibiotics, malaking bagay ang supportive measures kasi ito
shorten the disease course (hindi na aabot ng 100days baka 2wks ang magpapatagal sa pasyente habang inaantay mo ang effect ng
lang matapos na) antibiotic.
 mild URI,  Vaccination-initiate, continue or booster (DTP, DTaP, Tdap) (‘a’
 low grade fever, stands for acellular NOT attenuated kasi dati nakakacause ng
 1 to 3 weeks seizures after bakunahan so binawasan ang antigenicity. DTP is
2. Paroxysmal (obvious) whole cell pertussis. Ano pinagkaiba ng DTaP sa Tdap, since small
 successive coughs ending with a high pitched inspiratory whoop, letter ung t & d ibig sabihin reduced yung amount ng antigen duon
 gagging, apnea, tongue protrude, eyes pop, face reddens sa vaccine. Kapag yung px ABOVE 7yo, hindi na nya kailangan ng
 coughing incessantly for the next 2 to 4 weeks whole dose of the d&t component so if you give booster shots,
 Clinical pertussis Tdap instead of DTap)
 Machine gun burst of coughing to the point na nangingitim na ung
mukha nga bata SYPHILIS
3. Convalescent (less violent cough)
 reduced frequency and severity of coughs
 Treponema pallidum → spirochete
 lasts for 100 days
 MOT: direct contact lesions, body fluids, perinatal intrauterine infection
(for congenital), also blood transfusion
*Infants may not have the characteristic
ADULT Syphilis CONGENITAL Syphilis
whoop (because of smaller size, sometime
 Sexually transmitted  Intra/perinatal (Vertical from infected
you just see them apneic/cyanotic because
 Prevalent in adolescents pregnant mother to baby)
their’s not enough repiratory effort, effort
 Transmission to fetus can occur at any
rin ang pag-ubo, yung mga premature or
stage
baby, hindi kayang umubo ng sunud-sunod
 Usually infected fetus die in utero or
so ihihinto na lang nila yung pag-hinga)
shortly after birth
 Surviving babies have severe congenital
& developmental anomalies

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 3 Stages  CLINICAL FEATURES
1. S. typhi (Typhoidal) - can be mild to severe and prolonged in
1. Primary (site of penetration) – PAINLESS indurated ULCER (usually presentation
nakikita sa genitalia, also callced CHANCRE. Then after few wks, ulcer heals  congenital infection/fetal typhoid – mother with infection can be
then goes to secondary) transmitted to baby, baby with high fever and low BW, high risk of
2. Secondary (dissemination) – CONDYLOMA LATA (wart-like lesion on the miscarriage or stillbirth, very rare
anal verge), skin lesions, fever, rash  typhoid fever (acquired through feco-oral route) – high grade
3. Tertiary (deep organ involvement) – GUMMA (granulomatous lesion), intermittent fever (stepladder) on&off for 2wks, hindi ka lalagnatin
neurosyphilis (tabes dorsalis) →MOST prominent, cardiosyphillis ng isang linggo sa dengue, diarrhea (pea soup) or constipation,
 Not due to bacteria but by the tissue damage brought about by the abdominal pain, distention, rose spots (Salmon colored) appears on
the 7th to 2nd week of illness on the trunk (light pink), bradycardia,
bacteria
hepatosplenomegaly, meningeal signs – headache, convulsions,
psychosis, and apathy
*In a child, you MUST always suspect child abuse, if it’s a teenager, it could o not only a GIT infection, it only starts as a GIT inf. but the
also be part of adolescent curiosity bacteria disseminates so later it becomes a systemic inf.
which starts from the Peyer’s patches → lymph node →
 CONGENITAL Syphillis (acquire through VERTICAL transmission) reticuloendothelial system → blood → other organs (even to
 NO PRIMARY STAGE (Chancre) – kasi hematogenous the CNS: typhoid psychosis)
dissemination, from mother to baby, no sexual contact involved o Complications of typhoid fever occur 2nd to 3rd week of
 Transmision can occur at any time during pregnancy (1st/2nd/3rd ) illness – intestinal hemorrhage/perforation – MOST dreaded
EARLY Onset LATE Onset complication (bec. it invades the peyer’s patches, magang-
 First 2 years of life  2 yrs. old and above maga, numinipis ang lining and mabilis mag-rupture),
 hepatosplenomegaly,snuffles (bloody  bone malformations (frontal peritonitis, jaundice, splenic rupture, pneumonia,
nasal discharge, overwhelming bac. bossing, saddle nose, saber encephalitis, nephritis, meningitis, psychosis
inf. erodes bone of nasal cavity), shin – bowing of tibia), *Salmonella gastroenteritis – most common presentation of
lymphadenopathy, mucocutaneous neurosyphilis, mulberry salmonellosis
lesions, pneumonia, osteochondritis, molars (gilid), rhagades *the intestinal hemorrhage is secondary to Typhoid
rash, pseudoparalysis, hemolytic (fissures which appear at the Typhlitis/Typhoid Ileitis – ileum inflammation of the
anemia, thrombocytopenia mucocutaneous junction), colorectal area
 can be mistaken with neonatal sepsis Hutchinson’s triad 2. Other non typhoidal Salmonellas
– maternal Hx is important “bulag. bingi, bungal”  Bacteremia with or without metastatic focal infection – abscess
(Keratitis, Hutchinson’s formation in any organ
Teeth(cental incisor), 8th  Asymptomatic chronic carrier state – among those with previous
Nerve Deafness) AGE/enteric like fever. Occur in 7% of <5 years old
 Salmonellosis/Salmonella gastroenteritis – can also cause food
*stigmata of congenital syphilis: snuffles, saddle nose, rhagades, poisoning
hutchinson’s teeth  Enteric fever – includes Typhoid Fever and infection due to
S.paratyphi and S. enteritidis, S. cholerasius
 DIAGNOSIS
1. Fecalysis – pus cells, RBC in stools
2. Culture of blood (1 -3wks.), stool/rectal swab (2nd-4th
week),duodenal fluid, urine(first 2 weeks), bone marrow aspirate
(90% sensitive)-last resort na ang bone marrow kasi invasice pero
ito ang highest specificity; culture ang confirmatory *BUS (Blood-
Urine-Stool)
3. Widal Test – useful in nonendemic areas (hindi na ginagamit
because it’s endemic already, maraming nagpapositive na Ab kahit
 DIAGNOSIS (in some Px hindi obvious agad) wala naming typhoid fever, although useful in the provinces)
 Darkfield or DFA 4. CBC –
 Serology (MAINSTAY beause very hard to culture) a) leukopenia- in typhoid fever (like viral infection)
o Non-treponemal – VDRL, RPR (Screening, monitor response b) Leukocytosis – nontyphoid fever
to therapy → quantitative test to measure Ab titers), uses c) Lymphocytosis – typhoid fever
beef heart or reagin antigen, d) Thrombocytosis
o Treponemal – FTA, TPHA (Confirmatory) 5. Serologic tests – latex particle, agglutination, ELISA, Typhidot –
 TREATMENT detects specific IgM and IgG
 DOC: IV PENICILLIN G  Mean IP: 24hrs
 Newborn: Aqueous crystalline PenG or Procaine Pen-G  Clinical features: watery, mucoid/bloody diarrhea, fever, abdominal
 Children: Benzathine Pen G cramping, myalgia, headache
 Alternatives: Erythromycin or Tetracycline  Diagnosis: History (poultry, pork, eggs, dairy products, vegetable, fruit)-
hindi naluto ng maayos yung pagkain, Fecal leukocytes on stool exam –
SALMONELLOSIS aside from RBC bec. it is invasive, stool culture is confirmatory test

 S. typhi (Typhoidal, human source) and S. Enteritidis, S.cholerasuis (Non-

typhoidal, animal/zoonitic source)
 Animals: poultry, reptiles, pets
 MOT: feco-oral, contaminated food and water (Ingestion – bacteria go to
terminal ileum submucosal lymph nodes, monocytic infiltration of
Peyer’s patches)
 Nontyphoidal: Contaminated meat, dairy products, water, pastries, rare
fruits, vegetables
 Typhoidal: humans
 <5 years old – at high risk (outbreaks during summer)

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  TREATMENT
 Kung sa typhoid fever, may antibiotics, sa SALMONELLOSIS →
Supportive, Antibiotics prolong colonization – NO ANTIBIOTICS!
 If bacteremic – 3rd gen cephalosphorins while cultures pending
1. Typhoid Fever DOC: CHLORAMPHENICOL 50-75
mg/kg/d PO/IV divided q 6h for 14
days
- Others: Amoxicillin, ceftriaxone,
cefotaxime
- be aware of the susceptibility
pattern in your area due to
prevalence of drug resistance
*no antibiotic for salmonellosis
(self-limiting)
2. Salmonella gastroenteritis - fluids and electrolytes, supportive
antibiotics given only if:
1. <3 months old,
2. immunodeficient,
3. undernourished and blood
culture positive for Salmonella
- exception sila kasi kung hindi mo
bibigyan, pwedeng kumalat yung
bacteria sa blood
3. Extraintestinal - antibiotics prolonged to 4-6
weeks (bone infection), 4 weeks
(meningitis)
4. Chronic carrier - high dose ampicillin, even
cholecystectomy
CHOLERA
 Vibrio cholerae, V. Parahemolyticus
 Toxin producing strains 01 and 0139 are responsibe for epidemic
 The toxin (also known as choleragen) causes a severe secretory diarrhea
 Voluminous diarrhea (rice water) with or without fish odor- this is the most
characteristic seen in cholera, parang pinaghugasan ng bigas medyo cloudy
sya na may sediments pang lumulutang lutang and occasionally there are
mucus, my mga phlegm na lumulutang lutang din.. The problem is not the
diarrhea but the volume loss due to massive diarrhea, severe dehydration is
the main problem
 Emesis, low grade fever
 Shock due to volume depletion
 History (shellfish)- this is associated with Vibrio parahaemolyticus food
poisoning or pwede my nakain na hindi nailuto
DIAGNOSIS
 stool, rectal swab
 basta lahat ng bacteria, ang GOLD STANDARD is CULTURE except for syphilis
(serology test)

 PREVENTION
 Personal hygiene
 Public health measures – food processing and storage and
preparation
 Infection control
 Vaccine - Vi capsular polysaccharide vaccine 'one dose IM (used for
people who are travelling to endemic areas)
SHIGELLOSIS
 Mean IP: 24 hours. As few as 10 organisms can cause diarrhea
(shiga toxin)
 TRIAD sa infants is dysentery, high grade fever, & seizures (seizures is
due to shiga toxin), baby na mataas ang lagnat, may dugo sa dumi, and
convulsions
 Bloody diarrhea (dysentery), fever, abdominal cramps, neurologic
(seizure, confusion, hallucinations)
 History of egg, salad, lettuce, fecal leucocytes (invasive), stool culture
 According to WHO: Shigella is the MOST COMMON cause of bloody
diarrhea in the whole wide world
 Cx: septicemia, seizure, HUS (just like your EHEC), crampy
(borborygmous) abdominal pain, pneumonia
o Because shiga toxin incites a cytotoxic, neurotoxic, and
enterotoxic effect
 Treatment: supportive and 3-5 day course antibiotic (cefixime,
ceftriaxone, ciprofloxacin, azithromycin)
o Nirereserba pa ang ciprofloxacin sa mga <18yo kasi
natutunaw yung cartilage, hindi na tumatangkad. If you’re
going to give it for 3-5d, baka naman hindi mangyari yung
cartilage degeneration
o Pag di na gumagana yung iba, ciprofloxacin na yung
binibigay kahit sa pediatric age group
 Cotrimoxazole & Ampicillin – NOT recommended unless organism still
susceptible
 Ciprofloxacin: previous backup drug, now the DOC for bloody diarrhea
for all ages (WHO) - wala talagang DOC, kung ano lang yung major
effective
COMPLICATIONS
 Renal- Renal and pre-renal failure
 Cardiac- due to hypovolemic shock
 Coma- due to poor cerebral perfusion, volume depletion, due to diarrhea
TREATMENT
 correct hydration and electrolyte- very important supportive measure,
antibiotic is not enough since it is given for 3 days only
 Antimicrobial: doxycycline, tetracycline, TMP-SMZ, erythromycin,
ciprofloxacin, cotrimoxazole
 Doxycycline and tetracycline- not recommended to 8 y/o patients because of
its side effects: yellowish teeth staining, since 3 days m lang naman ibbigay
to, hindi mgkakaroon ng yellow stain unless one week m ibigay
E.COLI
 K1 capsular-associated with neonatal sepsis, meningitis
 Diarrhea strains: ETEC, EPEC, EAEC, EIEC
 UTI strains
 Gram negative bacteria, belongs to enterobacteriaceae
 EPEC and EAEC- watery stool
 ETEC and EHEC- boody stool
 ETEC- traveller’s diarrhea, watery stool
 EHEC – Enterohemorrhagic E. Coli
 0157 H7- it produces shiga-like toxins
 Colitis with bloody diarrhea
 In history, kumain sila ng beef hindi masyado naluto dahil lang sa
hamburger na alanganin 
 22%develop HUS (microangiopathic hemolytic anemia,
thrombocytopenia, acute renal dysfunction), Hemocolitis
 Watery or bloody mucoid diarrhea with tenesmus (dysentery)
 Most Common: Fecooral route
 EPEC – infantile diarrhea

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  Most common cause of UTI is E. Coli, it is a coliform, normal flora sya ng III. CEPHALIC TETANUS
colon and kung poor perineal hygiene and ascending infection from vaginal
area goin up into ureter and kidney
 History (undercooked beef), stool culture (GOLD STANDARD)

TREATMENT
 rehydration
 ETEC -most are self limited
 To give or not to give anitibiotic?sa ETEC kahit hindi ka na mgbigay since self
 involve bulbar musculature, retracted eyelids, deviated gaze, trismus, risus,
limited pero kung hirap na ang patient sa kakamove,, mgbigay ka na. iba kc
spastic paralysis of tongue and pharyngeal muscles (cranial nerves 3,4,7,9,10
sa theory and actual scenario na
and 11)
 Antibiotic is contraindicated in EHEC (or STEC or VTEC) as it may increase in  notice his grimace, it is called sardonic smile and there is clenching of teeth
likelihood of developing HUS- kapag napatay mo bacteria sa EHEC, nawasak,  kung saan lang distribution ng facial nerve, doon lang
release lahat ng toxin
 UTI: Amoxicillin-claculanate or ampicillin-sulbactam, cotrimoxazole IV.LOCALIZED TETANUS
 Sepsis, meningitis, pneumonia (invasive disease) : Ceftriaxone or cefotaxime

TETANUS
 C.tetani, anaerobic, sporeformer, neurotoxin
 Source: soil, dust, human and animal feces, unsterile suture, rusty
instruments, nails, scissors or pins
 MOT: spores introduced into an area of injury or wound (direct inoculation)
 Neonate-cut umbilical cord with unsterile scissors perhaps by traditional 
birth attendant—leading to neonatal tetanus, unimmunized mothers  painful spasms of muscles adjacent wound site
 Older child –dahil malikot, nalagyan ng lupa ang sugat, ayan tetano!   kung saan lang my sugat, dun lang ngkakaroon ng spasm
contamination of wound
 Dental carries, otitis media are portals of entry DIFFERENTIALS
 Penetrating wounds, illicit drug injections, abscesses, ear piercing, firecracker  rabies
injuries  Tetany
 Greatest risk in deep punctures wound (wag nyo ismall ung gatuldok nyong  Polio
sugat kc mas delikado yan kasi yan gatuldok nay an kung malalim naman  baterial meningitis
sugat nyo) avulsions, crushing injuries  drug reaction or withdrawal syndrome
 IP: 2-14 days after injury
 Clinical: tetanospasmin-bind NMJ prevent neurotransmitter release - DIAGNOSIS
hypersympathetic state due to blocked inhibitory neurons—leading to  Diagnosis based mainly on clinical, lab testing can't confirm or exclude
nonstop tetanic spasm disease
 CBC: mild PMN leucocytosis, CSF normal with mild elevation opening
 Clinical Forms: pressure
I. NEONATAL TETANUS
COMPLICATIONS
 aspiration pneumonia
 atelectasis
 Laryngospasm
 vertebral fractures
 IM hematoma
 tongue lacerations- if the patient bites his tongue while seizuring
 usually at 3-10 days old after delivery, kasi kung day 1 usually ang cause is
TREATMENT
meningitis or metabolic disease
 3 important things to remember: Neutralize toxin from diffusing, eliminate
 difficulty in sucking, jaw stiff, excessive cry-hoarse to strangled,
bacteria producing toxin and support the patient
opisthotonous, apnea, paralysis, constipation or urinary retention, spasms
 Tetanus immune globulin (TIG) 500 units IM for infants. 3000-6000 units IM
(children and adults)
II. GENERALIZED TETANUS (MOST COMMON)  Alternative: Antitetanus Serum (ATS) Caution (side effect) serum sickness
 Active immunization against tetanus should be started with other DTP for
children <7years old or tetanus toxoid for older children andR adults
 Antibiotic: prevent multiplication of C.tetani and stop exotoxin release.
 Recommended are Pen G and metronidazole
 Aqueus Pen G: Neonates -100,000u/kg/day IV in 2 divided doses (7 days
old) or 4 divided doses (>7 days old) ; Children - 100,000 unit/kg/day IV
 stiffness of voluntary muscles -trismus/lockjaw, risus sardonicus (grimace), in 4 divided doses for 10 days
dysphagia, opisthotonous (arching of the back), board-like rigid abdomen,  Metronidazole: 30-50mg/kg/day
flexed arms, extended legs, laryngeal spasm, airway obstruction, respiratory  Alternatives: erythromycin, tetracycline (>8 years old)
muscles spasm, high fever, tachycardia, sweats  Wound care/debridement
 Excitants provoke painful spasms and seizures, kahit pagsara lang ng pinto,  Supportive: airway - tracheostomy, ventilator, seizures - use either diazepam
mgspasm na yung patient and usually madilim dapat room nila or else or midazolam, muscle relaxant, nutrition -NGT feedings or TPN, etc
maninigas na sila  Good nursing care : admit to a quiet area with minimal stimuli, pulmonary
 Sensorium is intact, he is aware of what is happening but cannot control it toilet, bed sore precautions
 Dysuria, urinary retention  Tetanus-an "inexcusable disease"
 Accumulation of secretions
 Intact sensorium Prevention and control: Tetanus prophylaxis post injury
 Hyperactive DTR

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 Doc: I will not ask this table, sa surgery nyo na alamin yan  DIAGNOSIS
TYPE NON IMMUNE IMMUNE IMMUNE  Gram stained smear, culture of exudates, pus, abscess, blood, or bone,
INCOMPLETE BOOSTER >10 BOOSTER <10 pleural aspirate - grape like clusters
YEARS YEARS  CONS- pathogen or contaminant
Clean, minor DT/DTP/ TT/Td None  Cultures of exudates, pus and abscess, blood, bone and pleural aspirate
wounds DTaP  CBC: moderate leukocytosis with polymorphonucleosis
Tetanus DT/DTP/T TT/Td TT/Td if >  Total WBC < 5000/mm or a PMN response, 50% = GRAVE SIGN
prone d plus TI 5 years
G/ATS None if < TREATMENT
5 years  Serious life threatening
Neglected DT/DTP/T TT/Td plus TT/Td plu  DOC: OXACILLIN 100-200 m/k/d
wound d plus TI TIG/ATS s TIG/ATS  CLOXACILLIN OR NAFCILLIN IV 4-6 div.dose
G/ATS  cefazolin, Clindamycin, Amoxy-clav, Ampicillin, Sulbactam, Imipinem,
meropenem
STAPHYLOCOCCAL INFECTION  MRSA: VANCOMYCIN
 S. aureus (most common)- abscesses and toxin related  Skin, soft tissue infection: oral antibiotic or brief parenteral followed by oral
 colonizer of anterior nares antibiotic
 C.O.N.S (Coagulase Negative Staph)  Cloxacilin, cephalexin, amoxyclav
*in culture, can be a pathogen or contaminant  MUPIROCIN TOPICAL; intranasal for carriers eto ung mga bacitracin
 S. epidermidis – dismissed as contaminants but can cause bacteremia in  Incision and drainage
NICU, immunocompromised and in catheters and shunts
 normal skin flora II. TOXIN MEDIATED DISEASES
 opportunistic infection (artificial medical devices)
 Food poisoning = preformed enterotoxins
 S. saphrophyticus- UTI in young sexually active adulkts
 IP: 2-6 hours. No antibiotic needed
 Reservoir: humans
 Skin- S. epidermidis, anterior nares – S. aureus A. TOXIC SHOCK SYNDROME TOXIN 1 (TSST1)
 MOT: hands, nasal discharge, infection may follow colonization  tampon, nasal pack, cutaneous lesion, childbirth or abortion, surgical wound
 Yung mga nursery personnel na nghahandle ng baby dapat nghuhugas infection
ng kamay otherwise mgkakaroon ng epidemic pigsa sa loob ng nursery  fever, macular erythroderma (eto ung keyword) with desquamation,
na galing lang sa ilong hypotension, organ dysfunction (multiorgan dysfunction)
 direct contact  associated with shock
 IP: variable, usually within a week  dahil toxin ang culture, magiging negative ang culture
 DDx: Kawasaki disease, scarlet fever, measles, leptospirosis, strep TSS

TREATMENT
 antistaph antibiotic – oxacillin or cloxacillin to eradicate focus of TSST 1
producing S. aureuS
 Supportive Management
 Manage hypotension
Abscess – hallmark of staph. Infection
*pus - Staph. Aureus B. SCALDED SKIN SYNDROME (RITTER’S DISEASE)
Can cause direct bacterial or toxin mediated disease
*hematogenous means (not by direct contact)

 Can cause infection through:

I. DIRECT BACTERIAL INVASION
 Skin
 Folliculitis (maliit na pigsa), furuncles, carbuncles (malaking pigsa),
impetigo  Negative results in blood, throat, CSF, cultures
 Abscesses and surgical wound infections
 Negative for RMSF, leptospirosis, measles
 Most common cause of osteomyelitis and septic arthritis in children
 Epidermolytic toxin or exfoliatin
(acquired hematogenously)
 Focus infection:
 Example: Bullous impetigo
 Erythema > bullae > rupture  Impetigo, conjunctivitis, gastroenteritis, pharyngitis
 *non-bullous impetigo – Streptococcus
 Staph. pneumonia MANIFESTATIONS
 rapid, progressive necrotizing, empyema, pneumatocoeles or abscesses  Fever, skin tenderness
(malaking bubble sa loob ng lungs), pyopneumothorax  rapid extension of brightly erythematous skin
 rapidly progressive pneumonia  large peeling epidermidis (+ Nikolsky sign)
 empyema (thoracic cavity)  Blister, perioral erythema
 pneumatocoeles (bullae inside lungs)  Abortive type - eruption no blister
 Septicemia
 Complications: cellulitis, pneumonia, septicaemia
 Meningitis following bacteremia or iatrogenic; brain abscess
 Enterocolitis, endocarditis, renal abscess, myositis
DIAGNOSIS & TREATMENT
 based on clinical grounds, skin biopsy, frozen histologic exam skin
 Antistaph antibiotics, saline compress or burrows solution
 Wound care is important

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 STREPTOCOCCAL INFECTION B. STREPTOCOCCAL SKIN INFECTION
I. GROUP A STREPTOCOCCUS/ STREP PYOGENES
 MOT: Droplet or direct contact (Skin to skin)
 Age: any age but most frequent among school age (6-12yr old)
 Most common clinical illness produced by GAS is acute tonsilitis and
pharyngitis

A. STREPTOCOCCAL PHARYNGITIS

 MOT: Scratching insect bites, wounds or objects with dirty fingernails

 Most common in children under 6 years old, more common in summer
 Impetigo or pyoderma-bulluous, honey colored crust
 non-bullous impetigo (pyoderma)
 ecthyma
 cellulitis -warm, tender, erythema and edema, with lymphangitis and fever
 Erysipelas (St. Elmos fire)
 Most important cause of bacterial sorethroat  Necrotizing fascitis –gangrene(*”flesh-eating”)
 Infants under 6 mos of age-febrile nasopharyngitis, wala pa silang tonsils
 Children above 3 years old-Acute exudative tonsillopharyngitis- meron na
sila tonsils
C. IMPETIGO CONTAGIOSA
 white tonsillopharyngeal exudates with enlarged cervical lymph nodes
 Question: yung pamamaga ba ng lalamunan, cause ba ng bacteria or
virus?one clue, kapag bacteria or step ang cause, no cough, no cold and no
upper respiratory infection, lagnat lang and tonsillitis  guide lang yan ha..
 Bacterial or viral throat
 Strep pharyngitis - no cough,cold,URI
 Bacterial pharyngitis - enlarged "beefy red" tonsils with patchy exudate,
palatal petecchiae – another important clue
 Red edematous uvula, tender anterior cervical adenopathy  honey crusted, cigarette burn appearance (mamaso in tagalong)
 Tonsil or throat swabculture  poor hygiene, local injury
 papulovesicular
DIAGNOSIS  associated with Acute Glomurolonephritis
 CBC: moderate leucocytosis with polymorphonucleosis  Cigarette burn appearance
 Rapid diagnostic test-kits – ELISA base  Papulovesicular lesion
 Immunologic response to strep antigen-rise in titer 2-4weeks apart ASO  More in lower extremities
titer>166 Todd units- body is producing Antibody against Streptolysin O
D. ERYSIPELAS (ST. ELMOS FIRE)
DIFFERENTIAL DIAGNOSIS
 diptheria
 herpangiana
 infectious mononucleosis (EBV)

COMPLICATIONS
 cervical adenitis, peritonsillar (Quinsy)
 Sharply defined, slightly elevated border, swollen, red, tender
 retrophryngeal or pharyngeal abscess, meningitis, empyema, septic
 Deeper layers skin and subcutaneous tissue
arthritis,otitis media
 generalized redness
 sinusitis, mastoiditis, pneumonia, osteomyelitis, septicaemia
 para syang apoy na kumakalat sa ilalim ng balat 
 Sequelae: Rheumatic Fever, AGN—this is not because of the bacteria
anymore but because of the immunity against the bacteria
 if you have recurrent sorethroat, you can develop rheumatic fever and if you E. ECTHYMA
have recurrent pyoderma, you can develop AGN

TREATMENT
 DOC: BENZATHINE PEN G 600,000(<5yr old) to 1.2 M units (>5yr old) IM,
single dose Phenoxymethylpenicillin25-50mg/kg/day in 4 divided doses
orally for 10 days
 Penicillin allergic: Erythromycin, clarithromycin, azithromycin  Associated with strep. Pyogenes
 Secondary prophylaxis in RHD  Produced necrotic ulcer
 Patients diagnosed to have rheumatic fever and those who have
definite evidence of RHD should be given continuous antibiotic F. CELLULITIS DUE TO GROUP A STREPTOCOCCUS
prophylaxis because aymptomaticas well as optimally treated GAS
infection may trigger recurrence.
 Long term prophylaxis should be initiated as soon as the diagnosis of
active RF or RHD is made
 Benzathine Pen G 1.2 units IM every 21 days or
phenoxymethylpenicillin 200,000-4,000,000 units (125-250mg) orally
twice a day Painful IM
 Acutely, rapidly spreading skin and subcutaneous tissue
 Abrasion, insect bite, and etc.
 Inflammation of soft tissue
 Warm, tender, erythematous, edematous with lymphangitis and fever

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 DIAGNOSIS DIAGNOSIS
 Gram stain exudates from lesions  Gram stain + lancet diplococci
 Culture of pus  Culture (blood, body fluids and secretions)
 WBC (*neutrophils), leukocytosis with neutrophilia WBC>15,000mm in
COMPLICATIONS infacnt increase likelihood bacteremia and positive blood culture
 pneumonia, necrotizing fascitis, osteomyelitis, arthritis, endocarditis  Carrier state: culture recovery not proof of infection
 Non-suppurative sequelae: acute hemorrhagic glomerulonephritis  Capsular antigen detection ( latex, ELISA)

TREATMENT TREATMENT
 Pen G or Pen V  Drug of choice: PENICILLIN G
 Alternative: Ceftriaxone cefotaxime, meropenem
G. SCARLET FEVER  Allergy to Pen G – erythromycin or TMP-SMZ
 Treatment of carriers not needed

PREVENTION
 Prevention: 13 valent conjugate pneumococcal vaccine –eto na yung bagong
bagong ginagamit for pedia up to geriatric age group, recent
recommendation
 For >2yrs old : polysacharide vaccine
 Special indication: at least 2 weeks before splenectomy, cancer
 GAS strains with erythrogenic exotoxin
chemotherapy, radiotherapy
 Manifestation:
 acute exudative tonsillopharyngitis
 characteristic changes in tongue with confluent PSEUDOMONAS
 red finely papular sand paper like rash which later desquamates
 Scarlet fever strawberry tongue or mouth- swollen tongue, magenta tongue
or purple

H. TOXIC SHOCK SYNDROME 2 (STREPTOCOCCUS)

 Super antigen exotoxin TSST-2
 Focus of infection: associated with soft tissue like cellulitis, abscess,
necrotizing fascitis, may also be associated with invasive infections  Pseudomonas Aureginosa
 Highest among young children, particularly those with varicella  Nosocomial infection
 TX: Penicillin + Supportive Mgt  Produces: endotoxin, exotoxin A. exoenzyme S
 Important cause of nosocomial infection in children with cystic fibrosis,
II. GROUP B STREPTOCOCCUS/ STREP AGALACTIAE neoplastic disease, extensive burn, prlonged spectrum antibiotics,
 Common in obstetrics history and newborn baby important!- yan ang target immunocompromised
ng infection na to   Most common cause of infection in burn patients
 GBS is a part of normal maternal vaginal flora  Can be community acquired
 Cause: Neonatal sepsis
 source: maternal genitalia, contaminated supplies, or septic surrounding CLINICAL MANIFESTATION
 MOT: transplacental, direct or indirect contact (unsterile scissors,
 Endocarditis,
contaminated hands)
 Predisposing factors: prematurity, traumatic, septic delivery  Pneumonia,
 TYPES:  CNS infection,
 Early onset-critically within hours after birth with unexplained  Chronic mastoiditis, osteomyelitis, septic arthritis
respiratory failure and shock  UTI, GIT infection,
 Delayed onset-occurs between first and twelfth weeks of life. Purulent  Skin - ecthyma gangrenosum
meningitis  Wound with blue green pus with fruity /grape like odor
 Treatment: PEN G OR AMPICILLIN WITH AMINOGLYCOSIDE
DIAGNOSIS & TREATMENT
III. PNEUMOCOCCAL INFECTION  Culture- blood, CSF, lung aspirate
 Upper Respiratory Tract Infection (URTI)  Treatment : Carebenecillin, Ticarcillin, gentamicin, tobramicin, amikacin
 Streptococcus pnuemonia, encapsulated diplococcic 90 seroytypes identified ceftazidime
 Part of the flora of repiratory tract
 Transient colonizer of nasopharynx END
 Most common type of strep pneumonniae Black – from power point
 Most common cause of pneumonia and meningitis in children > 5 years old Blue – trans from lecturer
 Source: upper respiratory tract(many person are carriers) Red – from book
 MOT: droplet direct person-person
 Predisposing factors: viral respiratory disease, immunodeficient, cardiac,
pulmonary diseases CSF leak, chronic renal insufficiency, Diabetes Mellitus
 This bacteria can go anywhere of the body but most commonly in respiratory
tract and CNS
 Causes:
1. Acute pneumonia dati ang pinakacommon na ngcacause is
2. Acute otitis media, sinusitis H. influenza but d/t vaccine, it was
overtake by Strep Pneummoniae
3. Bacteremia in infants in 1-24 months, with fever without localizing signs
4. Meningitis
5. Others: septic arthritis, osteomyelitis

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