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Key Features

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Essentials of Diagnosis
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  • Purulent meningitis in children younger than age 4 years with direct smears of CSF showing gram-negative pleomorphic rods

  • Acute epiglottitis: high fever, drooling, dysphagia, aphonia, and stridor

  • Septic arthritis: fever, local redness, swelling, heat, and pain with active or passive motion of the involved joint in a child 4 months to 4 years of age

  • Cellulitis: sudden onset of fever and distinctive cellulitis in an infant, often involving the cheek or periorbital area

  • In all cases, a positive culture from the blood, CSF, or aspirated pus confirms the diagnosis

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General Considerations
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  • H influenzae type b (Hib) has become uncommon because of widespread immunization in early infancy

  • The 99% reduction in incidence seen in many parts of the United States is due to high rates of vaccine coverage and reduced nasopharyngeal carriage after vaccination

  • Hib may cause meningitis, bacteremia, epiglottitis (supraglottic croup), septic arthritis, periorbital and facial cellulitis, pneumonia, and pericarditis

  • Non–type b encapsulated strains may cause meningitis, bacteremia and other disease similar to Hib

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Clinical Findings

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  • Meningitis

    • Fever

    • Irritability

    • Lethargy

    • Poor feeding with or without vomiting

    • High-pitched cry

  • Acute epiglottitis

    • Evidence of dysphagia, characterized by a refusal to eat or swallow saliva and by drooling

    • High fever

    • Stridor is a late sign

  • Septic arthritis

    • Child is febrile and refuses to move the involved joint and limb because of pain

    • Examination reveals swelling, warmth, redness, tenderness on palpation, and severe pain on attempted movement of the joint

  • Cellulitis

    • Uncommon as a result of immunization

    • Cheek or periorbital (preseptal) area is often involved

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Diagnosis

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Laboratory Findings
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  • The WBC count in Hib infections may be high or normal with a shift to the left

  • A positive culture of blood, CSF, aspirated pus or fluid from the involved site proves the diagnosis

  • In untreated meningitis, CSF smear may show the characteristic pleomorphic gram-negative rods

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Imaging
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  • A lateral radiographic view of the neck may suggest the diagnosis in suspected acute epiglottitis, but misinter pretation is common

  • Intubation should not be delayed to obtain radiographs

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Treatment

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  • All patients with bacteremic or potentially bacteremic H influenzae diseases require hospitalization for treatment

  • Drugs of choice in hospitalized patients are a third-generation cephalosporin (cefotaxime or ceftriaxone) until the sensitivity of the organism is known

  • Meropenem is an alternative choice

  • Ampicillin is adequate for culture-proved susceptible strains

  • Persons with invasive Hib disease should be in droplet isolation for 24 hours after initiation of parenteral antibiotic therapy

  • Empiric intravenous therapy recommended for meningitis (until organism identified) is vancomycin in combination with either cefotaxime or ceftriaxone

  • Duration of therapy is 10 days for uncomplicated meningitis; longer treatment is reserved for children who respond slowly or have complications

  • Dexamethasone given immediately after diagnosis and continued for 4 days ...

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