UMANAND PRASAD SCHOOL OF MEDICINE

& HEALTH SCIENCES

PAEDIATRIC CASE WRITEUP

SIGATOKA PERIPHERY

CASE 3

NAME: SHAKSHI RAINA

ID: 20170017
COURSE CORDINATOR: DR DENNIS BUENAFE
CASE WRITEUP

GENERAL DATA

Name: Siteri Sawe DOB: 15/9/2021

Sex: Female Contact:

Race: Itaukei DOA: 24/07/2022

DOD: 29/07/2022

NHN: 990641125 Informant: Mother

Presenting complaint:

- Skin infection for 3 days

History of presenting illness:

- The child was brought to ED with sores all over the body. According to the
mother, the sores started to appear 3 days ago, she then took the child to
Cuvu health centre and the child was given an injection and topical cream,
but she did not recover. The child did have sores all over the body in the
past but it always seemed to be mild and resolved on its own.

Review of system:

(+) Fever

(-) cough

(+) running nose

 - Passing urine
- No bowel output since 5 days
- Loss of appetite
- Didn’t sleep well last night
- Not mobilizing well

Past medical history:

- NIL known
- Vaccination up to date
- Has asthma at 8 months old

Drug history:

- Flucloxacillin

Social history:

- Lives with her parents

Birth history:

- 4th child, normal vaginal delivery at term

- Hasn’t breast fed since birth (bottle feeding) lactogen formula

Upon examination:

- Uncomfortable
- Crying
- In mild distress
HEENT:

- No pallor or jaundice
- (+) ulcers on hard palate
- Moist oral mucosa

Chest:

- Regular S1S2, no murmurs heard

- Clear lung fields

Abdomen:

- Soft and non tender

Extremities:

- Good volume pulse

- No edema
- Capillary refill < 2 seconds
- Infected lesions all over on the limbs, face and trunks
- Pus noted

Assessment:

- Skin sepsis ( Scabies with superimposed bacterial infection)

Plan:

- Admit to children’s ward

- Start on medications: Cloxacillin 50mg/kg IV Q6H, Gentamicin 5mg/kg IV
OD, Permethrin cream Nocte, Benzathine penicillin Stat.
- Bloods ( Fbc, Uecr, Blood culture)
- Rapid antigen test negative
- Mum updated on plans
Treatment :

- Cloxacillin 365mg IV Q6H

- Gentamicin 36.5mg IV OD
- Paracetamol elixir 4.56ml PO Q6H
- Nystatin 1ml PO Q6H
- Flucloxacillin elixir 109mg PO Q6H

Follow up:

Bloods – FBC

15/07/22

- WBC – 9.5 x 10^3/uL

- Lymph – 2.4 x 10^3/uL
- HGB – 10.2 g/dl
- RBC – 3.92 x 10^6/uL
- HCT – 30.6 %
- MCV – 78.1 fL
- MCH – 26.1 pg
- MCHC – 33.3 g/dL
- PLT – 299 x 10^3/uL

Coagulation profile:

PT – 17 seconds

APTT – 36 seconds
Discharge medications:

- Flucloxacillin elixir 109mg PO Q6H

- Paracetamol elixir 4.56ml PO Q6H
- Savlon wash

Learning issues:

Staphylococcus aureus bacteremia in children: Epidemiology and clinical

features

INTRODUCTION
Staphylococcus aureus is a leading cause of both community- and health care-
associated bacteremia. S. aureus bacteremia (SAB) is associated with increased
morbidity and mortality, even with appropriate therapy.

Epidemiology

Classification — Bacteremia caused by S. aureus can be divided into the following

categories:

●Community-associated
●Health care-associated, which includes:
•Hospital-onset (previously known as hospital-acquired or nosocomial)
•Community-onset (previously called non-nosocomial health care-
associated infection [e.g., related to outpatient intravascular therapy or
underlying chronic conditions that affect host response to infection])

Antimicrobial resistance

Methicillin resistance — Methicillin-resistant S. aureus (MRSA) was initially a

health care-associated pathogen, with only small numbers of community-
acquired cases, but it has become a prevalent community-acquired pathogen.
Clindamycin resistance — Resistance to clindamycin may be constitutive or
inducible via the macrolide-lincosamide-streptogramin B resistance mechanism.
Isolates with constitutive clindamycin resistance are fully resistant to
both erythromycin and clindamycin and can be detected with routine
susceptibility testing. MRSA isolates with inducible resistance via the MLS(B)
mechanism can develop resistance during therapy; these isolates appear
susceptible to clindamycin and resistant to erythromycin by most standard
techniques but can be detected using the "D test".

Vancomycin resistance — S. aureus isolates with intermediate susceptibility or

resistance to vancomycin are much less common than MRSA.

Risk factors:

The following clinical conditions predispose patients to develop SAB:

●Intravascular catheters
●Indwelling foreign body or prosthesis
●Underlying medical conditions (e.g., malignancy, end-stage kidney disease
[i.e., dialysis dependent], eczema and other dermatologic conditions)
●Nasal S. aureus colonization
●Injection drug use

Clinical features:

SAB frequently occurs in association with fever and other symptoms related to
the source of infection.

Sepsis — Septic shock is characterized by signs of inadequate tissue perfusion

with evidence of systemic inflammation (i.e., abnormal temperature, white blood
cell count, heart rate, and/or respiratory rate).

Toxic shock syndrome — Manifestations of staphylococcal toxic shock syndrome

include fever, hypotension, and skin manifestations (erythroderma). However,
bacteremia is rarely found in toxic shock syndrome.
Osteomyelitis — Children with hematogenous osteomyelitis usually present
acutely with fever, constitutional symptoms (e.g., irritability, decreased appetite
or activity), focal findings of bone inflammation (warmth, swelling, point
tenderness), and limitation of function (e.g., limp, limited use of extremity).

Septic arthritis — Bacterial arthritis classically presents with acute onset (two to

five days) of fever and joint pain, swelling, and limited range of motion. However,
the presentation varies depending upon the age of the child and the site of
infection. Osteomyelitis contiguous to the septic arthritis is common.

Pneumonia — SAB may be associated with pneumonia, with typical symptoms of

fever, cough, and tachypnea. Complications such as necrotizing pneumonia,
parapneumonic effusion, empyema, and lung abscess are frequently associated
with S. aureus pneumonia.

Skin and soft tissue infections — Skin and soft tissue infections in children,
particularly infections that are purulent/fluctuant, are commonly caused by S.
aureus. Bacteremia is uncommon in uncomplicated skin and soft tissue infections
but may occur in certain settings (e.g., surgical wound infections, burns, patients
with underlying risk factors).

Intravascular catheter infection — Patients with indwelling intravascular

catheters are at risk for developing SAB. Clinical manifestations may include fever,
inflammation or purulence at the insertion site, hemodynamic instability, and/or
catheter dysfunction.

Infective endocarditis — Infective endocarditis, especially in community-acquired

SAB, is much less frequent in children than in adults (1.4 percent in children
compared with up to 30 percent in adults). The risk is higher in children with
congenital heart disease and/or indwelling central venous catheters. Clinical
symptoms of infective endocarditis include a new or changing murmur and/or
septic 
Summary

Staphylococcus aureus is a leading cause of both community- and health

care-associated bacteremia. Most cases of S. aureus bacteremia (SAB) in
children are associated with a localizing infection source (e.g., bone and joint
infections, pneumonia, skin and soft tissue infections) or invasive device
(e.g., central venous catheter).

●Methicillin-resistant S. aureus (MRSA) was initially a health care-associated

pathogen, with only small numbers of community-acquired cases, but it has
become a prevalent community-acquired pathogen. S. aureus isolates have
also developed resistance to clindamycin and, in rare cases, vancomycin.

●Important risk factors for SAB include:

•Intravascular catheters
•Indwelling foreign body or prosthesis
•Underlying medical conditions
•Nasal S. aureus colonization
•Injection drug use

REFERENCE:

 Www-uptodate-com.unifiji.idm.oclc.org. 2022. [online] Available at:

<https://www-uptodate-com.unifiji.idm.oclc.org/contents/staphylococcus-
aureus-bacteremia-in-children-epidemiology-and-clinical-features?
search=skin
%20sepsis&source=search_result&selectedTitle=2~150&usage_type=defaul
t&display_rank=2#H2> [Accessed 28 July 2022].