Pediatric emergency medicine trisk 0655 0655
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may include suprapubic or costovertebral angle tenderness. Adolescent girls with
pelvic or abdominal pain and fever should be evaluated for pyelonephritis and
pelvic inflammatory disease (see Chapter 92 Gynecology Emergencies ). A
careful skin examination may reveal an abscess or cellulitis associated with
community-acquired methicillin-resistant S. aureus or Streptococcus pyogenes.
Differentiation of these diverse diagnoses depends on a thorough history, physical
examination, and at times, well-directed laboratory evaluation.
Continued advancements in immunizations have changed the frequency and
risk of certain febrile illnesses in children. The Centers for Disease Control and
Prevention reported that the Haemophilus influenzae type B (Hib) vaccine has
drastically changed the risk and causative agents for meningitis in children with a
94% reduction in the incidence of H. influenzae meningitis and a shift in the
median age of those affected from 15 months to 25 years of age. The current
rarity of epiglottitis in children is also due to this decline in H. influenzae
infections. In addition, the conjugate pneumococcal vaccine (PCV) has
significantly decreased the overall risk of invasive pneumococcal diseases in
children. However, after the initial heptavalent PCV vaccine introduction, there
was noted a small, but not inconsequential increase in invasive bacterial
infections in children due to nonvaccine pneumococcal serotypes. The current 13valent vaccine, with expanded serotype coverage, has continued to decrease
invasive pneumococcal disease in children, especially those less than 2 years of
age, but a small increase in pneumococcal disease due to nonvaccine serotypes
continues to be observed. Recognition of these epidemiologic changes is crucial
in evaluating and treating the febrile child. These findings obviously influence the
evaluation and treatment of febrile children with signs of meningitis, as well as
those young children without an identified source of infection after thorough
historical and physical examination.
Although vaccines have significantly changed the risk and epidemiology of
infectious diseases in children, the clinician must be aware of increasing and
important outbreaks of vaccine-preventable illnesses in children. Although
measles was declared eliminated (without year-round endemic transmission) in
the United States in 2000, there have been recent significant outbreaks due to
worldwide travel from endemic areas and infection in unvaccinated (due to
personal choice, missed vaccine opportunities, or in children too young to receive
the primary vaccine series) individuals in the United States. For example,
clinicians must continue to consider measles in suspicious cases with the
constellation of fever, rash, cough, coryza, and conjunctivitis, especially in un- or
underimmunized patients.
