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8/13/2019 Sample Case Presentation- Occult Bacteremia
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Infectious DiseaseOccult Bacteremia
5CLPH SG1
Armes, Janella V.
Bagazin, Precious G.
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Bacteremia s the presence of viable bacteria in
the circulating blood.
Most episodes of occult bacteremiaspontaneously resolve.
Streptococcus pneumoniaeand Salmonella, andserious sequelae are increasingly uncommon.
Occult Bacteremia
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Patients with occult bacteremia by definition do
not have clinical evidence other than fev
Occult bacteremia has been defined asbacteremia not associated with clinical evidence
of sepsis or toxic appearance, underlying
significant chronic medical conditions, or clear
foci of infection upon examination in a patient.
Occult Bacteremia
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Much of the pathophysiology of occult bacteremia is not fully understood.
bacterial colonization of the respiratory passages
bacteria may egress into the bloodstream of somechildren
Bacteria may be spontaneously cleared, they may
establish a focal infection, or progress to septicemia
possible sequelae of septicemia include shock,disseminated intravascular coagulation, multiple
organ failure, and death.
Pathophysiology
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Signs and Symptoms
The condition is not manifested by any
clinical signs.
Duration of fever (fever is the only
manifestation)
History that indicates a specific illness
History that indicates risk for occult
bacteremia
History of an underlying medical condition
History of prematurity
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Signs and Symptoms
History of another reason for an increased
temperature
History of gastroenteritis
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Risk Factors
Studies of the prevalence of bacteremia in
children in diverse settings have identified no
racial, geographic, or socioeconomic
predisposition.
No sex-based difference in the prevalence or
course of bacteremia is known.
Studies of occult bacteremia focus on children
younger than 3 years.
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Patient Demographics
PtCJS
Age
4 y/o
SexFemale
Allergy
NKA
Admitted
Jan 1,2014
Height103 cm
Weight13.5kg
FEVER
Final
Diagnosis
Occult
Bacteremia
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History of Present Illness
One day prior to admission
Pt experienced intermittent
fever with Tmax of 38C.Patient was given
Paracetamol (125mg/5mL) 5
mL every 4 hours which
provided temporary relief of
fever. This was accompanied
by 2 episodes of vomiting- 3tablespoons of previously
ingested food. No other
symptoms noted.
Interval History
persistence of fever
with no dyspnea, hematuria,
dysuria, abdominal pain and
diarrhea noted.
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History of Present Illness
Few hours prior to admission
due to persistence of fever
patient sought consult to a
local clinic . CBC andurinalysis were done advised
admission. Due to financial
constraints patient
transferred to our institution.
HgB 111Hct 0.33
WBC 17.08
N 0.81
L 0.18
E 0.01
platelet 378yellow cloudy, pH 6.0
SG 1.020,
Protein 0.3 g/dL
Sugar (-)
WBC 12-15/hpf
RBC 1-3/ hpf
Epithelial cell: few
bacteria: moderate
mucus threads:
moderate
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PMH Hospitalizations: none
Operations: none
Accidents: none
Blood Transfusion: none Allergies/Drug Reactions: none
Patient Histories
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Family History
(-) DM, HTN,Asthma, Allergies,Cancer, TB
Social History
patient lives withparents
not exposed to
cigar and airpollution
Patient Histories
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Medication History
Paracetamol (125mg/5mL) 5 mL every
4 hours
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VitalSigns
Temp38.3 C
PR
120 bpm
RR
24
bpm
BP
100/60mmHg
Vital Signs
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(-) wt loss, (-) diaphoresis, (-)anorexia
GeneralAppearance
(-) blurring of vision, (-) deafness, (-) epistaxis, (-) bleeding gums, (-)sores
HEENT
(-) itchiness, (-) color change, (-)pigmentation, (-) rashSkin
Review of Systems
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(-) colds, (-) dyspneaLungs
(-) easy fatigability, nopalpitations, (-) chestpain
Cardio-Vascular
Review of Systems
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(-) constipation, (-)
diarrhea, (-) incontinenceAbdomen
(-) joint pain/effusion, (-) jointstiffnessExtremities
Review of Systems
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Conscious , coherent, carriedby mother, ill-looking, not incardiorespiratory distress
General
Survey hair evenly distributed, no scalp lesions
pink palpebral conjunctivae, anicteric
sclera impacted cerumen AU
(+) nasal dischargeHEENT
Physical Examination
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Warm, dry skin, with goodturgor, no jaundice, no cyanosisSkin
Symmetrical chest expansion,
no retractions, equal vocal andtactile fremiti, resonant, normalbreath soundsLungs
Physical Examination
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Adynamic precordium, (-)heaves, thrills, lifts, S1>S2 atapex, S2>S1 at base, Apex beat
at 5th
LICS MCL
Cardio-
Vascular
Soft and flabby abdomen,
normoactive bowel sounds,tympanic, non-tender, nomasses palpated
Abdomen
Physical Examination
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(-) Edema, (-) Cyanosis, nodeformities, pulses full and
equal
Extremities
Physical Examination
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Cerebrum: conscious, coherent
Cranial Nerves:
CN I
not assessedCN II pupils 2-3mm ERTL
CN III, IV, VI full and equal
extraocular movementCN V1-V3 no sensory deficits
Neurological Exam
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CN VII can raise eyebrows, puff cheeks,smile, nonshallow nasolabial fold,
symmetrical
CN VIII gross hearing intact CN IX, X can swallow, intact gag reflex
CN XI can shrug shoulders and turn
head against resistance
CN XII tongue midline in protrusion
Neurological Exam
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Neurological Exam
Motor: 5/5 bilateral upper extremities
Cerebellum: no ataxia, no
dysdiadochokinesia
Sensory: no deficits
Reflexes: +2DTR on all extremities
Meningeal Irritation: (-) Babinski, (-) nuchalrigidity
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LABORATORY AND ANCILLARYSERVICES
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PATIENT MLA NORMAL VALUES
Hemoglobin 111g/L 120- 160 g/L LOW
RBC 4.29x 106/L 3.6-5.2 x 106/L NORMAL
Hematocrit 0.34 0.28-0.46 NORMAL
MCV 78.20 76-100 fL NORMAL
MCH 26 23-34 pg/cell NORMAL
MCHC 33.20 31.5 36.3 g/dL NORMAL
RDW 12.50 IU/L < 35 IU/L NORMAL
MPV 6.10 6.4-10.4 fL NORMAL
PT 371 150-400 x 109/L NORMAL
WBC 29.10 4.0-10.0 x 109/L HIGH
CBCwith Plt
Laboratory and Ancillary Services
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PATIENT MLA NORMAL VALUES
Neutrophils 0.86 0.54-0.62 HIGH
Lymphocytes 0.14 0.25-30 LOW
Laboratory and Ancillary Services
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Laboratory and Ancillary Services
UA Color Light YellowTransparency Slightly turbid
pH 6.0
SG 1.020
Protein ++
Sugar (-)
Ketone (+)
Urobilinogen Normal
Bilirubin (-)
Nitrite (-)
Erythrocytes (+)
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Laboratory and Ancillary Services
UALeukocytes (+)
RBC 0-1/hpf
Pus cells 2-3 hpfMucus threads None
Bacteria Few
Renal Cells None
Amorphous Urates FewCasts None
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COURSE IN THE WARDS
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Course in the Wards
Day 1(January 1, 2014)
Meds
IVF: D5 0.3% NaCl 500 mL torun at 16-17 gtts/min (100%)
Ampicillin-Sulbactam 500mg/SIV infusion over 30 mins
based on Ampicillin content(q6 hrs) (-) ANST;
148mg/kg/day
Labs
-blood C/S
-CBC withplatelet
-urinalysis
-peripheralblood smear
Others
Diet for AGEMonitor vital signsevery 4 hours and
record
Monitor input and
output every shiftWatch out for
vomiting, abdominalpain, and diarrhea
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Course in the Wards
Day 2
(January 2, 2014) 1:35AM
Meds
Continue standing meds
Paracetamol 120mg/5mL,give 6mL every 4 hours
For temp > 38.3 degreesCelsius or as needed
Labs Others:
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Course in the Wards
Day 2
(January 2, 2014) 4AM
Meds
Continue standing meds
IVF to follow: D5 0.3% NaCl500mL to run at 16-17
gtts/min
Labs
blood CS with ARD
Facilitate Peripheral
Blood Smear
Others:
Measure input, outputaccurately
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Course in the Wards
Day 2
(January 2, 2014) 9:30AM
Meds
Hydrogen peroxide, instill 2-3drops each 3x/day for 5 days
D5 IMB 500mL to run at 12-
13gtts/min
LabsOthers:
Increase oral fluidintake
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Course in the Wards
Day 3
(January 3, 2014)
Meds
D5 IMB 500mL to run atsame rate (12-13gtts/min)
Labs
Request CBC with pltOthers:
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Course in the Wards
Day 4
(January 4, 2014)
Meds
Ampicillin-Sulbactam 500mg/SIVP
shifted
Co-amoxiclav 457mg/ 5mL,3mL every 12 hours
Labs Others:
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Course in the Wards
Day 5
(January 5, 2014)
Take Home Meds
Co-amoxiclav 457mg/5mL,3mL every 12 hours
Hydrogen peroxide 2-3 drops
each ear 3x a day for 7 days
Labs Others:
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1. Fever
2. Occult Bacteremia
3. Impacted Cerumen
List of Problems
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Medications
Standing Meds Indication/ Problem treated
Ampicillin-Sulbtactam 500mg/ SIV q6h Empiric treatment; antibacterial
Hydrogen Peroxide 2-3 drops each
3x/day for 5 days
Impacted Cerumen
Co-Amoxiclav 457mg/ 5mL, 3mL every
12 hours
antibacterial
PRN Meds Indication/ Problem Treated
Paracetamol 120mg/5mL, give 6mL every 4
hours
PRN if Temp > 37.5
Fever
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Ampicillin Sulbactam-
Recommended Dose- Computation
>1 year old: 100-200 mg/kg/day IV/IM Q6
hrWeight 13.5kg
13.5kg x 100mg/1kg= 1350mg13.5kg x 200mg/1kg=2700mg
=1350-2700mg/day IV/IM Q6
=patient was given 2000mg/day Q6
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Paracetamol Recommended Dose-
Computation
10-15 mg/kg PO q6-8 hr not to exceed
2.6g/day
Weight 13.5kg13.5kg x 10mg/1kg= 135.0mg
13.5kg x 15mg/1kg=202.50mg
=135-202.50mg/day PO
=patient was given 144mg of Paracetamol as needed for
fever relief
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Pharmacotherapeutic Goals
Restore
NormalBodyFunction
Treatmentof occultbacteremia
Normalizebody
temperature
Removal ofimpactedcerumen
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Guidelines VS Actual Management
Guidelines/Algorithm Actual Management
Children who are afebrile and well
appearing can be treated on an
ambulatory basis with a 10-day course
of oral penicillin
Reference: Practice Guideline for the Management of Infants
and Children 0 to 36 Months of Age With Fever Without
Source
Co-amoxiclav 457mg/5mL, 3mL every
12 hours
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S N/A
O Co-amoxiclav 457mg/5mL, 3mL every 12 hours
A
Unclear dosing regimen/duration. Children and who are afebrile and wellappearing can be treated on an ambulatory basis with a 10-day course of oralpenicillin.
P Suggest to physician the duration of Co-amoxiclav therapy is 10 days.
Recommendations/
Intervention
Reference: NICE clinical guidelines
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Guidelines VS Actual Management
Guidelines/Algorithm Actual Management
The recommended dose for co-
amoxiclav >3months is 25mg/kg/day
q12h
Reference: Lexicomp
Co-amoxiclav 457mg/5mL, 3mL every
12 hours
d /
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S N/A
O Co-amoxiclav 457mg/5mL, 3mL every 12 hours
A Underdosing. The recommended dose for co-amoxiclav >3months is
25mg/kg/day q12h .
P Suggest to physician to increase the dose of Co-amoxiclav therapy up to 4.2 mL
or 4mL.
Recommendations/
Intervention
Reference: NICE clinical guidelines
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Co-Amoxiclav Recommended Dose-
Computation
25 mg/kg/day PO divided q12hr
Weight 13.5kg
13.5kg x 25mg/1kg= 337.5mg/kg
400mg/5mL=X/3mL mg=240mg
patient was given 240 mg of Co-Amoxiclav
337.5mg/x=400mg/5mL
x=4.2mL
R d i /
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Recommendations/
Intervention
Reference: NICE clinical guidelines
Based on amoxicillin content
13.5kgx25mg/kg= 337.5mg
400mg/5mL=x/3mL x=240 mg
337.5mg/x=400mg/5mL
x=4.2mL
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Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline forthe management of infants and children 0 to 36 months of
age with fever without source. Agency for Health Care
Policy and Research. Ann Emerg Med. Jul
1993;22(7):1198-210 Kramer MS, Shapiro ED. Management of the young febrile
child: a commentary on recent practice guidelines.
Pediatrics. Jul 1997;100(1):128-34 Medscape.com
Medline.com Lexicomp
MIMS
References:
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Thank you!