treatment plan

Managing Bacterial Infection in Children

BY BRUCE E. ONOFREY, RPH, OD
JULY 1998

Just like adults, children are susceptible to the typical bacterial infections of the conjunctiva -- preseptal cellulitis, orbital cellulitis, dacryocystitis, canaliculitis and keratitis. They differ from adults in the spectrum of pathogens that produce these infections, the drugs of choice, the dosage of the medications and the potential complications of mismanagement.

Sources of Ocular Pathogens

Otitis media (middle ear inflammation) and pharyngitis (sore throat) are two of the most common pediatric disorders seen by primary care physicians. Nearly one-half of all children experience otitis media by age one, and over 70 percent have had it by age three. The pathogens that most often produce these infections in children are Streptococcus pneumonia, Hemophilus influenza and Moraxella catarrhalis. The most common cause in adults is Staphylococcus. Pharyngitis and otitis media are the primary causes of pediatric eye disease. Pathogens migrate to the middle ear via the eustachian tubes and through the nasolacrimal duct to the lacrimal sac, canaliculus, conjunctiva and orbit.

Pediatric Evaluation

When evaluating pediatric patients with suspected bacterial ocular disease, broaden the exam beyond the eye and adnexa. Undertreatment of bacterial disease can lead to the development of meningitis. Inquire about activity levels and habits, including questions about appetite and the presence of malaise and fever. Does the child appear to be in discomfort? Is he sleeping well? Does he have colic? Is he coughing? Is there any purulent discharge from his nose or mouth?

Following a careful history, perform a careful physical examination or comanage the patient with his pediatrician or practitioner. Record the child's vital signs, including pulse, respiration, blood pressure and body temperature. A physical exam should include inspection of the throat and ears, as well as auscultation of the chest. If a fever is present, a complete blood count may be ordered to determine if there is an elevated white blood cell count. Elevation of polymorphonuclear leukocytes is a sign of bacterial infection, in which case, blood and spinal fluid cultures may be necessary. Culture the eye in suspected cases of ocular bacterial disease. If there is any doubt about a concurrent pharyngitis, take a throat culture. This is particularly important in cases of strep throat because it is highly contagious and can lead to secondary heart and kidney damage if undertreated.

Treatment

Most childhood pathogens respond well to topical therapy with Polytrim, by Allergan, which is approved for children as young as one month old. Other options include the fluoroquinolones Ocuflox, by Allergan, and Ciloxan, by Alcon. Topical erythromycin is generally effective, but is available only in ointment form.

It's important to weigh children before treating them with systemic medications because dosage is always determined by the child's weight. One of the most popular drugs for treating childhood otitis media and pharyngitis has been amoxicillin. Unfortunately, three to 15 percent of the population is allergic to amoxicillin, and a study by Lisby-Sutch has shown that traditionally penicillin-sensitive organisms have become resistant to it. Even second-generation cephalosporin agents, used as alternatives to penicillin derivatives, are becoming ineffective. Fortunately, Zithromax, by Pfizer, has won approval for pediatric usage. Drug allergy is extremely low with this compound, which is effective against the most common pediatric pathogens.

Dr. Onofrey, editor and author of various ophthalmic texts, practices in Albuquerque.