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Respiratory Virus Encephalitis

Clinical Presentation:  Encephalitis may occur during or immediately after an acute respiratory illness.. Influenza encephalitis, although rare, may be especially severe with a number of deaths reported every year in previously healthy children and adolescents..

Diagnostic Considerations:  Rarely, adenoviruses have been recovered from CSF or brain in cases of encephalitis.. Encephalitis has also been described very rarely in association with RSV and parainfluenza infections as well..

Pitfalls:  Most cases of encephalitis remain undiagnosed, in part due to failure to consider and test for respiratory viruses..

Therapeutic Considerations:  No evidence to date suggests a benefit of anti-influenza therapy in influenza encephalitis..

Prognosis:  Generally self-limited with recovery, but death has been reported with influenza encephalitis.. Adenovirus, measles, and mumps encephalitis in immunocompromised hosts may also be severe..

Empiric Therapy of HEENT Infections

Periorbital (Preseptal) Cellulitis/Orbital Cellulitis

	Usual	Preferred IV	Alternate IV	IV-to-PO
Subset	Pathogens	Therapy†	Therapy†	Switch†
Periorbital cellulitis	S.. pneumoniae	Combination	Ampicillin-	Amoxicillin/
	H.. influenzae	therapy with	sulbactam ×	clavulanate or
	M.. catarrhalis	Nafcillin* plus	10–14 days	Cefuroxime or
	S.. aureus	either Ceftriaxone		Cefpodoxime or
		or Cefotaxime ×		Cefdinir ×
		10–14 days		10–14 days
Orbital cellulitis	S.. pneumoniae	Combination	Piperacillin/	Amoxicillin/
	H.. influenzae	therapy with	tazobactam or	clavulanate or
	M.. catarrhalis	Nafcillin plus	Ampicillin-	Cefuroxime or
	S.. aureus	Ceftriaxone ×	sulbactam or	Cefpodoxime or
	Anaerobes	10–14 days	Ticarcillin/	Cefdinir ×
	Group A		clavulanate ×	10–14 days
	streptococci		10–14 days

Duration of therapy represents total time IV or IV + PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy after clinical improvement..

* Clindamycin or vancomycin if CA-MRSA likely..

†See pp.. 414–422 for drug dosages..

Clinical Presentation:  Periorbital and orbital cellulitis are bacterial infections.. Fever, lid swelling, and erythema around the eye often in conjunction with acute sinusitis.. In periorbital cellulitis the infection is

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anterior to the orbital septum.. Orbital cellulitis involves the orbit proper, extraocular muscles/nerves, and possibly the orbital nerve.. Proptosis and limitation of ocular mobility define orbital cellulitis.. Diagnostic Considerations:  CT scan is used to differentiate preseptal from periorbital cellulitis and identify the extent of orbital involvement when present..

Pitfalls:  Failure to recognize orbital involvement leading to optic nerve damage or CNS extension/cavernous sinus thrombosis.. CT scan cannot differentiate phlegmon from abscess..

Therapeutic Considerations:  Orbital cellulitis is more emergent than periorbital cellulitis and should be treated with IV antibiotics initially.. Surgical drainage may be indicated if a well defined abscess is present or in more severe disease..

Prognosis:  Good with prompt antimicrobial therapy and ophthalmologic surgery if needed..

Sinusitis

		IV Therapy†	PO Therapy or IV-to-PO
Subset	Usual Pathogens	(Hospitalized)	Switch† (Ambulatory)
Acute	S.. pneumoniae	Ceftriaxone or	Amoxicillin or Amoxicillin/
	H.. influenzae	cefuroxime × 1–2 weeks	clavulanic acid or 2nd or 3rd
	M.. catarrhalis		generation cephalosporin or
			Clarithromycin* × 10–14 days
			or Azithromycin* × 5 days
Chronic	Same as acute + oral	Requires prolonged antimicrobial therapy (2–4 weeks)
	anaerobes

Duration of therapy represents total time IV, PO, or IV + PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy soon after clinical improvement (usually < 72 hrs)..

* Macrolides may be less effective and should be reserved for penicillinand cephalosporin-­allergic patients­ ..

†See pp. 414–422 for drug dosages.

Clinical Presentation:  Nasal discharge and cough frequently with headache, facial pain, and lowgrade fever lasting > 10–14 days.. Can also present acutely with high fever (≥ 104°F) and purulent nasal discharge ± intense headache for ≥ 3 days..

Diagnostic Considerations:  Acute sinusitis is a clinical diagnosis.. Imaging studies are not routinely­ indicated.. Overlap with acute viral infection and allergic symptoms may make diagnosis difficult.. Pitfalls:  Transillumination, sinus tenderness to percussion, and color of nasal mucus are not reliable indicators of sinusitis..

Therapeutic Considerations:  Microbiology/antibiotics are similar to acute otitis media, but duration of therapy is 10–14 days.. Failure to respond to initial antibiotic therapy suggests a resistant pathogen or an alternative diagnosis.. There are insufficient data to support long-course antibiotic treatment.. Rarely, quinolones may be considered as 3rd line alternative..

Prognosis:  Good.. For frequent recurrences, consider radiologic studies and ENT/allergy ­consultation..

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Otitis Externa
Subset	Usual Pathogens	Topical Therapy
“Swimmer’s	Pseudomonas sp..	Polymyxin B plus neomycin plus hydrocortisone (eardrops)
ear”	Enterobacteriaceae	q6h × 7–10 days
	S.. aureus	or
		Ciprofloxacin (otic solution) q12h × 7–10 days
		plus
		Dexamethasone or hydrocortisone ear drops
		or
		Ofloxacin (otic solution) q12h × 7–10 days

Clinical Presentation:  Ear pain, itching, and sensation of fullness.. Pain is exacerbated by tugging on the pinna or tragus of the outer ear.. Purulent discharge may be visible in the external ear canal.. Fever is generally absent..

Diagnostic Considerations:  Otitis externa is a clinical diagnosis. . A recent history of swimming or cleaning with cotton swabs is often elicited.. Malignant otitis externa, as seen in elderly adults with diabetes mellitus, is extremely rare in children but may be seen in immunocompromised hosts..

Pitfalls:  Failure to recognize a ruptured tympanic membrane may lead to a misdiagnosis of otitis externa based on purulence in the canal..

Therapeutic Considerations:  Local cleansing (e..g.., 2% acetic acid) and topical therapy with cortico- sporin-polymixin B-neomycin suspension is usually sufficient.. Oral antibiotics should be considered for fever/cervical adenitis..

Prognosis:  Excellent.. Cleansing with 2% acetic acid drops after swimming prevents recurrences..

Acute Otitis Media

	Usual	IV/IM
Subset	Pathogens	Therapy†	PO Therapy†
Initial	S.. pneumoniae	Ceftriaxone	Amoxicillin × 10 days or Azithromycin§
uncomplicated	H.. influenzae	× 1 dose	(1-, 3-, or 5-day regimen) or Erythromycin-
bacterial infection	M.. catarrhalis		sulfisoxazole × 10 days** or TMP–SMX ×
			10 days**
Treatment failure	MRSP Beta-	Ceftriaxone	Amoxicillin/clavulanic acid or
or resistant	lactamase positive	q24h × 3	cephalosporin × 10 days‡*
organism*	H.. influenzae	doses

DRSP = drug-resistant S. pneumoniae. Pediatric doses are provided; acute otitis media is uncommon in adults.. For chronic otitis media, prolonged antimicrobial therapy is required..

†See pp. 414–422 for drug dosages.

*Treatment failure = persistent symptoms and otoscopy abnormalities 48–72 hours after starting initial antimicrobial therapy. . For risk factors for DRSP, see Therapeutic Considerations, below. . If still fails after recommended therapy, consider clindamycin for resistant S.. pneumoniae or tympanocentesis for gram stain and culture..

**In children > 6 years of age with mild-moderate acute otitis media, a 5–7 day course of antimicrobial theory may be adequate..

†† ES-600 = 600 mg amoxicillin/5 mL..

‡10-day course with either cefuroxime axetil 15 mg/kg (PO) q12h or cefdinir 7 mg/kg (PO) q12h or 14 mg/ kg (PO) q24h or cefpodoxime 5 mg/kg (PO) q12h may be used..

§   Macrolides and TMP-SMX may be less effective and should be reserved for penicillin or cephalosporin allergic patients..

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Clinical Presentation:  Fever, otalgia, hearing loss. . Nonspecific presentation is more common in younger children (irritability, fever).. Key to diagnosis is examination of the tympanic membrane.. Acute otitis media requires evidence of inflammation and effusion.. Uncommon in adults..

Diagnostic Considerations:  Diagnosis is made by finding an opaque, hyperemic, bulging tympanic membrane with loss of landmarks and decreased mobility on pneumatic otoscopy..

Pitfalls: Otitis media with effusion (i. .e. ., tympanic membrane retracted or in normal position with decreased mobility or mobility with negative pressure; fluid present behind the drum but normal in color) usually resolves spontaneously and should not be treated with antibiotics..

Therapeutic Considerations:  American Academy of Pediatrics guidelines suggest initial observation without antibiotics for non-severe otitis media or in children > 6 month of age.. Risk factors for infection with drug-resistant S.. pneumoniae (DRSP) include antibiotic therapy in past 30 days, failure to respond within 48–72 hours of therapy, day care attendance, and antimicrobial prophylaxis. . Quinolones not approved for therapy..

Prognosis:  Excellent, but tends to recur. . Chronic otitis, cholesteatomas, mastoiditis are rare complications.. Tympanostomy tubes/adenoidectomy for frequent recurrences of otitis media are the leading surgical procedures in children..

Mastoiditis

		Preferred IV	Alternate IV	PO Therapy or
Subset	Usual Pathogens	Therapy†	Therapy†	IV-to-PO Switch†
Acute	S.. pneumoniae	Nafcillin or	Ampicillin-	Amoxicillin/clavulanate
	S.. aureus	Clindamycin or	sulbactam ×	or Cefpodoxime or
	Group A	Vancomycin (if CA-	10–14 days	Cefdinir or Cefuroxime
	streptococci	MRSA suspected)		axetil × 10–14 days
	H.. influenzae	plus either
		Ceftriaxone or
		Cefotaxime ×
		10–14 days
Chronic	Polymicrobial,	Piperacillin/	Meropenem or	None
	including	Tazobactam or	Imipenem ×
	P.. aeruginosa,	Ticarcillin/clavulanate	10–14 days
	S.. aureus,	× 10–14 days
	anaerobes,
	Enterobacteriaceae

Duration of therapy represents total time IV, IV + PO, or PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy after clinical improvement..

†See pp. 414–422 for drug dosages.

Clinical Presentation:  Fever and otalgia with postauricular swelling/erythema pushing the ear superiorly and laterally.. The presentation may be more subtle (e..g.., less toxic, less swelling, Bell’s palsy alone) in older children partially treated with antibiotics.. Concomitant otitis media is rare..

Diagnostic Considerations:  Acute mastoiditis is diagnosed clinically, but CT scan is definitive. . Tympanocentesis­ through intact ear drum for aspirate and insertion of tympanostomy tube are helpful for microbiology and drainage, respectively.. Chronic mastoiditis is often polymicrobial, including anaerobes and P.. aeruginosa.. Tuberculosis rarely presents as chronic mastoiditis..

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Pitfalls:  Do not overlook mastoiditis in older child with unresponsive otitis.. Orbital involvement may lead to optic nerve damage or CNS extension/cavernous sinus thrombosis..

Therapeutic Considerations:  Treatment is based on microbiology and requires at least 3 weeks of antibiotics..

Prognosis:  Good with early treatment..

Pharyngitis

	Usual		PO Therapy or
Subset	Pathogens	IV or IM Therapy­†	IV-to-PO Switch†
Exudative (culture)	Group A	Benzathine penicillin	Penicillin V or Amoxicillin ×
	streptococci	IM × 1 dose	10 days.. Alternate: Azithromycin
			12 mg/kg/day ×
			5 days or Cephalexin or
			Cefadroxil or Erythromycin or
			Clarithromycin or Clindamycin ×
			10 days
Asymptomatic carrier	Group A	No treatment	No treatment indicated
	streptococci	indicated
Persistent/recurrent	Group A	Clindamycin	Amoxicillin/clavulanate ×
disease	streptococci		10 days or combination
			therapy with either Penicillin
			V or Amoxicillin × 10 days plus
			Rifampin added on days 7–10
Exudative, sexually	N.. gonorrhoeae	Ceftriaxone (IM) ×
active		1 dose
Lemierre’s Syndrome	Fusobacterium	Clindamycin (IV) or	Clindamycin or Penicillin VK ×
(jugular vein septic	necrophorum	Penicillin G (IV) × 4–6	4–6 weeks
thrombophlebitis)‡		weeks
Vesicular, ulcerative	Enteroviruses	Primary HSV: Acyclovir	Primary HSV: Acyclovir or
	HSV 1 or 2	× 5–7 days	Valacyclovir × 5–7 days

Duration of therapy represents total time IV, IM, IV + PO, or PO.. Most patients on IV therapy able to take PO meds should be switched to PO therapy after clinical improvement..

† See pp. 414–422 for drug dosages.

‡Treat only IV or IV-to-PO switch..

Clinical Presentation:  Acute sore throat and fever with tender cervical lymphadenitis. . Primary clinical consideration is differentiating Group A streptococci (GAS) from viral/other causes (e..g.., adenovirus, enterovirus, respiratory viruses, other strep groups [C, G], Arcanobacterium hemolyticum, M.. pneumoniae, C.. pneumoniae, EBV).. GAS is less likely with concomitant coryza, conjunctivitis, hoarseness,­ cough, acute stomatitis, discrete oral ulcerations, or diarrhea—children with these manifestations­ should not be cultured routinely..