1.

Acute Gastroenteritis
Definition
 Acute gastroenteritis is an acute diarrheal illness lasting less than 14 days.
 It is often accompanied by:
o Vomiting
o Fever
o Abdominal pain
o Dehydration
 Diarrhea usually means:
o Decreased stool consistency, or
o Increased stool frequency, usually ≥3 loose stools/day
 In infants, change in stool consistency may be more meaningful than stool number.

Epidemiology
 Most children experience at least one episode of acute gastroenteritis by age 3 years.
 Before routine rotavirus vaccination:
o Rotavirus was a major cause of hospitalization for gastroenteritis in young
children in Israel.
 Since rotavirus vaccine was introduced into the Israeli routine immunization program in
2011:
o Rotavirus-related hospital visits decreased significantly.
 In vaccinated populations:
o Norovirus has become a major cause of medically attended gastroenteritis.
 Common bacterial causes in Israel:
o Shigella
o Campylobacter jejuni
o Salmonella
o Diarrheagenic E. coli
 Shigella remains an important cause of clinical dysentery in Israel.

Risk Factors for Severe or Prolonged Disease

 Age under 6 months
 Frequent vomiting
 High-volume diarrhea
 Daycare attendance
 Immunodeficiency
 Chronic medical conditions
 Low socioeconomic status
 Lack of breastfeeding in young infants
  Rotavirus is especially associated with severe dehydration because it:
o Causes significant vomiting
o Affects the upper intestine

Clinical Assessment
 The key clinical question is:
o How dehydrated is the child?
 Best predictors of dehydration:
o Weight loss
o Prolonged capillary refill time
o Reduced skin turgor
o Decreased urine output
o Abnormal breathing pattern
o Cold extremities
o Weak pulse
o Absence of tears
 Less reliable signs:
o Dry mucous membranes
o Sunken eyes
o Tachycardia
o Sunken fontanelle
o General appearance alone
 Important history:
o Urine output
o Number and volume of stools
o Vomiting frequency
o Oral intake
o Fever
o General behavior and alertness
o Underlying disease
o Recent travel
o Exposure or outbreak

When Medical Evaluation Is Needed

 Physician assessment is needed if there is:
o Age under 2 months
o Repeated vomiting
o More than 8 stools/day
o Large-volume diarrhea
o Significant chronic disease, such as diabetes or renal failure
o Parental report of signs suggesting severe dehydration
o Poor oral intake
 o Lethargy or altered consciousness
o Bloody diarrhea
o Bilious vomiting
o Bloody vomiting

Diagnostic Testing
 Most cases do not require laboratory testing.
 Routine testing is usually unnecessary:
o Serum electrolytes
o Kidney function tests
o Blood cultures
o Stool cultures
o CRP
o Procalcitonin
o Fecal calprotectin
o Fecal lactoferrin
 Stool culture may be considered in:
o Prolonged diarrhea
o Clinical dysentery
o Immunocompromised children
o Chronic disease, such as inflammatory bowel disease
o Suspected outbreak
o Recent travel to endemic areas
 Electrolytes should be checked in:
o Severe dehydration
o Moderate dehydration with atypical features
o Before or during IV rehydration
o Altered mental status
o Suspicion of electrolyte abnormality

Admission Criteria
 Hospitalization is recommended with:
o Shock
o Severe dehydration
o Neurologic symptoms, such as lethargy or seizures
o Persistent vomiting
o Bilious vomiting
o Bloody vomiting
o Failure of oral rehydration
o Suspected surgical abdomen
o Inability to ensure adequate home care or follow-up
  Admitted children with gastroenteritis should generally be managed with contact
isolation.

Main Treatment: Rehydration

 The cornerstone of treatment is:
o Fluid replacement
o Electrolyte replacement
 Preferred treatment is enteral rehydration:
o Oral rehydration solution, ORS
o Nasogastric ORS if oral intake is not possible
 Recommended ORS:
o Reduced-osmolarity ORS
 For vomiting:
o Give very small amounts frequently
o Example: 5 mL every few minutes
 IV rehydration is indicated in:
o Shock
o Severe dehydration
o Altered consciousness
o Severe acidosis
o Abdominal distension
o Ileus
o Worsening dehydration despite oral/enteral therapy
o Persistent vomiting preventing rehydration
 Hypovolemic shock:
o 20 mL/kg isotonic crystalloid bolus
o Normal saline or Ringer lactate
 Severe dehydration without shock:
o 0.9% saline 20 mL/kg/hour for 2–4 hours
o Then oral rehydration or maintenance fluids
 Ultra-rapid IV rehydration is not recommended:
o Example to avoid: 60 mL/kg in 1 hour
o Associated with more electrolyte disturbances and longer hospitalization

Nutrition
 Continue breastfeeding.
 Restart normal feeding during or soon after rehydration, usually within 4–6 hours.
 Usually no need to:
o Dilute formula
o Change formula
o Use BRAT diet
o Give sugary drinks
o Stop regular nutrition
  Routine lactose-free feeding:
o Not recommended in the community
o May be considered in hospitalized children under 5 years, because it may shorten
illness duration

Medications
 Ondansetron:
o May reduce vomiting
o May reduce IV fluid use
o May reduce admissions
o May increase diarrhea frequency
o Use cautiously in moderate/severe dehydration or electrolyte abnormalities
because of QT prolongation risk
 Other antiemetics are not routinely recommended:
o Metoclopramide
o Domperidone
o Dimenhydrinate
o Dexamethasone
o Granisetron
 Loperamide:
o Not recommended in children with acute gastroenteritis
 Diosmectite:
o May shorten diarrhea by about one day when used with ORS
o Does not clearly reduce hospitalization or IV fluid need
 Racecadotril:
o May reduce diarrhea duration and severity
o Can be considered
 Zinc:
o Mainly recommended in developing countries or significant malnutrition
o Not routinely recommended in Israel unless meaningful malnutrition exists
 Probiotics:
o Some evidence supports selected strains:
 Lactobacillus rhamnosus GG
 Saccharomyces boulardii
o Evidence is mixed
o ESPGHAN gives weak recommendations for selected strains
o American Gastroenterological Association recommends against routine probiotic
use in infectious gastroenteritis

Antibiotic Treatment
 Most acute gastroenteritis is viral.
 Antibiotics are usually not recommended.
 Antibiotics should be reserved for selected cases.
Shigella

 Treat proven or strongly suspected Shigella, especially:

o Moderate to severe disease
o Immunodeficiency
 First-line:
o Azithromycin for 3 days
 Severe disease or hospitalized immunocompromised children:
o Ceftriaxone, usually 5 days
o Shorter courses may be enough in selected uncomplicated cases

Salmonella

 Antibiotics are not recommended for healthy children.

 Reason:
o Do not shorten illness
o May prolong carriage
 Treat high-risk children:
o Age under 3 months
o Immunodeficiency
o Asplenia
o Inflammatory bowel disease
o Steroid therapy
o Immunosuppressive therapy
o Risk of invasive disease

Campylobacter

 Usually does not require antibiotics.

 Consider antibiotics:
o Early in disease
o Severe disease
o Immunodeficiency
 Preferred:
o Azithromycin

E. coli

 Antibiotics may be considered for severe:

o ETEC
o EPEC
o EAEC
 Antibiotics are not recommended for STEC:
o No clear benefit
o Concern for HUS
C. difficile

 Mild disease:
o Stop triggering antibiotic if possible
 Moderate/severe disease:
o Oral vancomycin, or
o Fidaxomicin
 Metronidazole:
o Only if preferred agents are unavailable

Parasites

 Giardia:
o Usually no treatment unless diarrhea is severe or prolonged
o Options:
 Metronidazole
 Tinidazole
 Nitazoxanide
 Cryptosporidium:
o Usually resolves spontaneously in immunocompetent children
o Nitazoxanide may be used in prolonged disease or immunodeficiency

Viral Gastroenteritis
 Usually self-limited.
 Supportive care is enough.
 Antivirals are rarely needed.
 Exception:
o Selected immunocompromised patients
o Example: severe CMV colitis treated with ganciclovir

Discharge Criteria
 Child can usually be discharged when:
o Hydration is restored
o Clinical condition improves
o IV fluids are no longer needed
o Oral intake matches ongoing losses
o Reliable follow-up is available
 Return to daycare/social activity:
o Wait until diarrhea has clearly improved
o Not merely when the child leaves hospital
2. Febrile Infants ≤3 Months
Core Problem
 Fever in infants younger than 3 months is common.
 The challenge:
o Serious bacterial infection may present subtly.
o Clinical signs may be nonspecific or unreliable.
 Goal:
o Identify infants at risk for serious bacterial infection
o Avoid unnecessary invasive testing and hospitalization when safe

Definition of Fever
 Fever is:
o Rectal temperature ≥38.0°C
 Fever measured reliably at home counts as true fever, even if the infant is afebrile in the
clinic or ED.
 Hypothermia may also represent serious infection.

Serious Bacterial Infection, SBI

 SBI includes:
o Bacterial meningitis
o Sepsis/bacteremia
o Urinary tract infection
o Bone or joint infection
o Soft tissue infection
o Pneumonia
o Bacterial enteritis
 Most common SBI in febrile infants up to 3 months:
o Urinary tract infection

Toxic Appearance
 Any febrile infant up to 3 months with toxic appearance requires immediate evaluation
and treatment.
 Toxic appearance may include:
o Unusual irritability
o Lethargy
 o Seizures
o Poor feeding
o Vomiting
o Hypotonia
o Poor perfusion
o Hypoventilation
o Hyperventilation
o Cyanosis
o Pallor
o Grunting
o Respiratory distress
o Apnea

Management of Toxic-Appearing Infant

 Full sepsis workup
 Blood culture
 Urine analysis and culture
 Lumbar puncture if hemodynamically stable
 Chest X-ray if:
o Respiratory symptoms
o Very high inflammatory markers
 Stool culture if dysentery is suspected
 Admission
 Immediate empirical antibiotics
 If shock is suspected:
o Stabilize first
o Lumbar puncture can wait

Non-Toxic Febrile Infant Without Source

Age Up to 1 Month

 Highest SBI risk group.

 Even well-appearing neonates can have serious infection.
 Traditional low-risk criteria are not reliable enough.
 Usually perform:
o Full sepsis workup
o Blood culture
o Urine testing and culture
o Lumbar puncture
o Admission
o Empirical IV antibiotics if high risk
 Discharge without LP or antibiotics:
o Only very cautiously
 o Only if all low-risk criteria are met
o Requires senior pediatrician or senior pediatric ED physician approval
o Requires detailed parental instructions
o Requires reliable contact with family
o Requires ability to return immediately if deterioration occurs
o Requires next-day pediatric follow-up
 If next-day follow-up cannot be guaranteed:
o Admit or return to hospital next day for review

Age 1–2 Months

 SBI risk lower than neonates but still significant.

 Low-risk criteria are more reliable.
 If any high-risk criterion exists:
o Admit
o Consider full sepsis workup including LP
o Close observation
o Consider empirical antibiotics
 If all low-risk criteria are met:
o Discharge may be considered
o No antibiotics required
o Close community follow-up mandatory
o Decision by senior pediatrician or senior pediatric ED physician

Age 2–3 Months

 Intermediate group.
 Clinical assessment becomes more reliable.
 For well-appearing infant with fever without source:
o Partial infectious workup usually sufficient
o Blood tests
o Urine analysis and culture
 If initial workup is normal:
o Discharge may be considered with close follow-up
 If high-risk features:
o Option 1:
 Admit for observation
 Consider full sepsis workup including LP
 Consider empirical antibiotics
o Option 2:
 Perform LP
 Give antibiotics
 Discharge only if strict follow-up is guaranteed

Low-Risk vs High-Risk Criteria

  Based on Rochester-type criteria.
 High-risk history:
o Chronic underlying disease
o Abnormal medical history
o Previous hospitalization
o Late discharge after birth
o Prematurity under 37 weeks
o Previous antibiotic treatment
 High-risk clinical findings:
o Toxic appearance
o Bloody or mucous diarrhea
o Focal bacterial infection on exam, except acute otitis media
 High-risk lab findings:
o WBC >15,000
o WBC <5,000
o Abnormal urinalysis, especially leukocytes or nitrites
 If none of these are present:
o Infant may be considered low risk

CRP and Procalcitonin

 CRP may be more useful than WBC for predicting SBI.
 Important CRP values:
o CRP >2 mg/dL is abnormal
o CRP >5 mg/dL is associated with high likelihood of SBI
 Routine CRP for every febrile infant under 3 months is not recommended because:
o Not uniformly used in Israeli pediatric EDs
o Evidence not definitive enough
 Procalcitonin:
o May be useful
o Not routinely available in many Israeli EDs
o Routine use not recommended

Empirical Antibiotics
Infants up to 2 Months

 Recommended:
o IV ampicillin + gentamicin
 Covers:
o Gram-negative enteric bacteria, especially E. coli
o Group B Streptococcus
o Listeria monocytogenes
o Enterococcus
 Use ampicillin + third-generation cephalosporin instead of gentamicin if:
 o Toxic appearance
o Suspected sepsis
o Suspected meningitis
o LP cannot rule out meningitis
o Bloody LP
o Failed LP
o Contraindication to aminoglycosides
 Contraindications to gentamicin:
o Known hearing disorder
o Unexplained deafness in a first-degree relative
o Renal impairment
o Suspected neuromuscular disease

Infants 2–3 Months

 For admitted febrile infants:

o IV ceftriaxone
 If suspected bacterial meningitis caused by Streptococcus pneumoniae:
o Ceftriaxone + vancomycin
o Continue until organism identification and sensitivities are available

UTI in Febrile Infants

 UTI is the most common SBI under 3 months.
 Symptoms may be nonspecific:
o Fever without source
o Poor appetite
o Vomiting
o Diarrhea
o Irritability
o Jaundice
o Poor weight gain
 Urine testing and urine culture are mandatory in every febrile infant under 3 months
without a clear focus.

HSV Infection
 Neonatal HSV is uncommon but dangerous, especially under 1 month.
 HSV presentations:
o Skin, eye, mouth disease
o Encephalitis
o Disseminated disease involving brain, lungs, liver, heart, adrenal glands, skin
 Give empirical IV acyclovir if:
o Skin lesion compatible with HSV
 o Toxic appearance
o Neurologic symptoms, especially seizures
o CSF pleocytosis with mononuclear predominance
o Significant HSV exposure, such as maternal active lesions or close exposure to
herpes labialis
o Thrombocytopenia
o Markedly elevated liver enzymes
 Dose:
o IV acyclovir 60 mg/kg/day divided into 3 doses
 Adjust dose in renal impairment.
 Send diagnostic PCR samples from appropriate sites.

3. Community-Acquired Pneumonia in
Children
Background
 Community-acquired pneumonia, CAP, is a common reason for pediatric visits and
antibiotic use.
 In most children, the pathogen is not identified.
 Treatment decisions are based on:
o Age
o Clinical presentation
o Vaccination status
o Local epidemiology
o Disease severity
o Likely pathogen
 Guideline applies mainly to immunocompetent children.
 Immunodeficiency or significant chronic lung disease requires specialist input.

Epidemiology
 Pneumonia is common, especially in young children and infants.
 Since pneumococcal conjugate vaccines were introduced in Israel:
o PCV7 in 2009
o PCV13 in 2010
 There has been reduction in:
o Pneumococcal pneumonia
o Pneumococcal carriage
o Antibiotic-resistant pneumococcal strains
 Most cases occur in autumn/winter.
  Some pathogens appear in spring/summer:
o Adenovirus
o Parainfluenza
 During influenza or COVID-19 waves, consider:
o Viral pneumonia
o Secondary bacterial pneumonia triggered by viral infection

Common Pathogens by Age

Neonates / Under 1 Month

 Gram-negative rods, especially E. coli

 Group B Streptococcus
 Staphylococcus aureus
 Streptococcus pneumoniae
 Respiratory viruses
 Rarely Haemophilus influenzae

1–3 Months

 RSV
 Influenza
 Parainfluenza
 Adenovirus
 Streptococcus pneumoniae
 Haemophilus influenzae
 Chlamydia trachomatis, importance in Israel unclear

3 Months–5 Years

 Most cases are viral.

 Common pathogens:
o RSV and other respiratory viruses
o Streptococcus pneumoniae
o Non-typeable Haemophilus influenzae
o Less commonly Staphylococcus aureus
o Less commonly Streptococcus pyogenes
 Mycoplasma pneumoniae is less common but possible.

Over 5 Years

 Respiratory viruses
 Streptococcus pneumoniae
 Mycoplasma pneumoniae
 Chlamydophila pneumoniae
  Atypical pneumonia becomes more relevant.

Clinical Patterns
Typical Bacterial Pneumonia

 Usually caused by Streptococcus pneumoniae.

 Features:
o Sudden onset
o High fever
o Toxic or ill appearance
o Tachypnea
o Respiratory distress
o Chest pain
o Focal auscultatory findings:
 Decreased breath sounds
 Crackles
 Bronchial breathing
 Up to about 30% may have no clear auscultatory findings.
 Chest X-ray:
o Lobar or segmental alveolar infiltrate
 Blood tests:
o WBC >15,000
o Elevated CRP or procalcitonin
 Clinical, radiologic, and lab findings overlap between viral and bacterial pneumonia.

Atypical Pneumonia

 Usually caused by:

o Mycoplasma pneumoniae
o Chlamydophila pneumoniae
 More common from age 5 years and older.
 Features:
o Gradual onset
o Prolonged upper respiratory symptoms
o Persistent dry cough
o Headache
o Myalgia
o Mild auscultatory findings
o Similar cases in close contacts
 Chest X-ray:
o Interstitial infiltrates
o Bronchopneumonia pattern
 WBC usually normal.
Viral Pneumonia

 Most common under age 5.

 Features:
o Gradual onset
o Lower-grade fever, although RSV/adenovirus may be severe
o Bilateral diffuse auscultatory findings
o Wheezing
o Crackles
o Interstitial or bilateral bronchopneumonia pattern on X-ray
o Air trapping
 Usually no leukocytosis.
 Adenovirus can cause marked inflammation.
 Mixed viral-bacterial infection is common.

Diagnosis in the Community

 Diagnosis is mainly clinical.
 Based on:
o Fever
o Tachypnea
o Respiratory distress
o Accessory muscle use
o Auscultatory findings
o Age
o Vaccination status
o Season/epidemiology
o Underlying disease, such as asthma
 Chest X-ray is not required for every child.
 Especially not required if clinical impression is viral lower respiratory tract infection.

When to Perform Chest X-Ray or Tests

 Consider chest X-ray and additional tests if:
o Suspected pneumonia with moderate respiratory distress
o Lack of response after 48–72 hours of antibiotics
o Clinical worsening after 48–72 hours of antibiotics
o Suspected aspiration pneumonia
 In these cases, ED referral should also be considered.
 CBC/CRP/ESR/serology/molecular tests:
o Only if expected to change management

When to Refer to ED
  Age under 2 months
 Hypoxemia / low oxygen saturation
 Severe respiratory distress
 Toxic appearance
 Apathy
 Altered mental status
 Significant dehydration
 Inability to drink
 Suspected complicated pneumonia
 Pleural effusion
 Empyema
 Necrotizing pneumonia
 Pneumothorax
 Poor clinical condition
 Failure of outpatient antibiotics after 48–72 hours

Community Treatment
Viral-Suspected Pneumonia

 No antibiotics needed.

Suspected Bacterial Pneumonia

 First-line:
o Amoxicillin
 Dose:
o 60–90 mg/kg/day PO divided into 2–3 doses
 Maximum:
o 1.5 g/day
 Duration:
o 5–7 days in most cases
o May extend up to 10 days depending on age, severity, risk factors
 Routine first-line amoxicillin-clavulanate or second-generation cephalosporins:
o Not recommended

Community Antibiotic Options

 First-line:
o Amoxicillin 60–90 mg/kg/day PO divided 2–3 times daily
o Duration 5–7 days
 Second-line:
o Amoxicillin-clavulanate:
 45–60 mg/kg/day for standard formulations
 90 mg/kg/day for high-dose formulation
  Duration about 7 days
o Cefuroxime axetil:
 30 mg/kg/day PO divided twice daily
 Duration 7 days
o Ceftriaxone:
 50 mg/kg/day IM/IV once or twice daily
 Only in special community situations depending on condition and follow-
up ability

Beta-Lactam Allergy
 Minor allergy:
o Non-immediate rash without respiratory symptoms
o Cefuroxime may be used
o Many children labeled beta-lactam allergic are not truly IgE-allergic
o Allergy evaluation is recommended
 Major allergy:
o Clindamycin 30–40 mg/kg/day PO divided 3–4 times daily
o Duration about 7 days
o Macrolides may be considered depending on suspected pathogen

Atypical Pneumonia Treatment

 Consider mainly in children over 5 years with compatible features.
 Azithromycin:
o 10 mg/kg/day PO once daily
o Either:
 3 days at 10 mg/kg/day
 Or 5 days: 10 mg/kg day 1, then 5 mg/kg/day for 4 days
o Max 500 mg/day
 Clarithromycin:
o 15 mg/kg/day divided twice daily
o Duration 7 days
 Roxithromycin:
o 5–8 mg/kg/day divided twice daily
o Duration 7 days
 Doxycycline:
o Age over 8 years
o 2 mg/kg/day, max 200 mg/day, divided once or twice daily
o Duration 7 days

Fluoroquinolones
 Newer quinolones, such as levofloxacin:
 o Generally not recommended under age 18
o Use only unusual cases after specialist consultation

Admission Criteria
 Hypoxemia
 Dehydration
 Inability to maintain oral intake
 Need for IV hydration
 Inability to ensure oral therapy at home
 Moderate/severe respiratory distress
 Respiratory rate:
o 70/min in infants under 1 year
o 50/min in children over 1 year
 Dyspnea
 Apnea
 Grunting
 Toxic appearance
 Decreased consciousness
 Apathy
 Significant cardiac, pulmonary, or neurologic disease
 Complicated pneumonia
 Failure of outpatient antibiotics after 48–72 hours

Evaluation of Hospitalized Child

 Chest X-ray AP and lateral
 CBC
 Blood culture
 Inflammatory markers if bacterial infection suspected
 Sputum Gram stain/culture in older children who can produce sputum
 Molecular tests for respiratory viruses if they affect:
o Isolation
o Antibiotic decision
o Antiviral treatment
 Mycoplasma pneumoniae molecular test if atypical pneumonia suspected
 If pneumonia diagnosed by POCUS in ED and admission is needed:
o Complete chest X-ray for follow-up

Inpatient Antibiotic Treatment

 Healthy, fully vaccinated child with bacterial CAP:
o IV ampicillin
o IV penicillin G
 Age 2 months–1 year or incompletely vaccinated child:
 o Ampicillin
o Penicillin G
o Cefuroxime
o Amoxicillin-clavulanate
 Over 1 year and fully vaccinated:
o Ampicillin:
 200 mg/kg/day IV divided 4 times daily
o Or penicillin G:
 150,000–300,000 units/kg/day IV divided 4–6 times daily
 Second-line after failure or worsening after 48–72 hours:
o Cefuroxime
o Amoxicillin-clavulanate
o Ceftriaxone
 Ceftriaxone:
o 50–100 mg/kg/day IV/IM once or divided twice daily
o Especially severe life-threatening disease, significant pleural effusion, or
empyema
 Severe/complicated cases after infectious disease consultation:
o Clindamycin
o Vancomycin
 Add macrolide in children over 5 years if atypical pneumonia suspected.

Follow-Up
 Routine repeat chest X-ray is not needed if child recovers clinically.
 Repeat X-ray if:
o Treatment failure/worsening after 48–72 hours
o Recurrent pneumonia in same lobe
o Significant atelectasis
o Suspected anatomical lung abnormality
o Suspected lung mass
o Suspected foreign body aspiration
o Round pneumonia
o Unusual clinical course
o Major mismatch between symptoms and X-ray findings
 For recurrent same-lobe pneumonia, atelectasis, suspected anomaly, mass, or foreign
body:
o Repeat imaging about 4–6 weeks after diagnosis

Prevention
 Pneumococcal conjugate vaccine, especially PCV13
 Influenza vaccination
 RSV prophylaxis for eligible premature infants or infants with underlying disease
 COVID-19 vaccination according to age approval and national guidance
4. Acute Bacterial Bone and Joint Infections
Definitions
 Acute osteomyelitis:
o Acute bacterial infection of bone
 Acute septic arthritis:
o Acute bacterial infection of a joint
 Acute:
o Symptoms present up to 2 weeks before diagnosis
 Subacute:
o 2 weeks to 3 months
 Chronic osteomyelitis:
o More than 3 months
 Guideline focuses on:
o Hematogenous
o Community-acquired
o Otherwise healthy children

Epidemiology
Acute Osteomyelitis

 Most common in young children.

 Usually involves long bones, especially lower limbs.
 Common sites:
o Femur
o Tibia
o Humerus
o Fibula
o Calcaneus
 More common in boys, except first year of life.

Septic Arthritis

 Occurs at all ages.

 Peaks under age 3 years.
 Usually monoarticular.
 Common joints:
o Knee
o Hip
o Ankle
 o Elbow
o Shoulder
 Knee is most common, then hip and ankle.

Pathogenesis
 Most cases occur via hematogenous spread.
 Bacteria reach:
o Bone
o Synovium
 Osteomyelitis usually begins in the metaphysis near the growth plate.
 Delayed diagnosis can damage growth plates.
 Infants under about 18 months:
o Blood vessels connect metaphysis and epiphysis
o Infection can spread from bone into joint
o Causes combined osteoarticular infection
 Hip and shoulder are high-risk because of anatomy.

Main Pathogens
 Most common overall:
o Staphylococcus aureus
 In Israel:
o Most strains are still MSSA
o MRSA should be monitored
o Routine empirical MRSA coverage not recommended unless risk factors, poor
response, culture result, or epidemiologic exposure
 Clindamycin alone should not be used empirically because:
o Does not cover Kingella kingae
o Inducible clindamycin resistance in S. aureus may be significant

Pathogens by Age
Neonates

 Staphylococcus aureus
 Group B Streptococcus
 Gram-negative rods, including E. coli
 Rarely Candida
 Rarely Neisseria gonorrhoeae

3 Months–5 Years

 Staphylococcus aureus
  Kingella kingae
 Group A Streptococcus
 Streptococcus pneumoniae
 Very rarely Hib in under-immunized or immunodeficient children

Over 5 Years

 Staphylococcus aureus
 Group A Streptococcus
 Neisseria gonorrhoeae in sexually active adolescents

Special Pathogens in Israel

Kingella kingae

 Important under age 5 years, especially under 2 years

 Often mild:
o Low inflammatory markers
o Normal WBC
o Subtle clinical findings
 May follow:
o Upper respiratory infection
o Oral ulcers
o Diarrhea
 Sensitive to:
o Ampicillin
o Cephalosporins
o TMP-SMX
 Resistant to:
o Clindamycin
o Vancomycin
 Some strains produce beta-lactamase.
 Suspected Kingella:
o Treat empirically with first- or second-generation cephalosporin
o Or amoxicillin-clavulanate
o Switch to penicillin only after organism and susceptibility confirmed

Brucella

 Consider with:
o Unpasteurized dairy exposure
o Animal exposure
o Family cluster
o Sacroiliitis
o Vertebral osteomyelitis
 o Subacute course
 Diagnosis:
o Blood culture
o Serology, including Rose Bengal test
 Treatment:
o Combination therapy for at least 6 weeks
o Longer sometimes needed, especially vertebral osteomyelitis
 Age >8 years:
o Doxycycline + gentamicin
o Or doxycycline + rifampin
 Age <8 years:
o TMP-SMX + rifampin
 Infectious disease consultation recommended.

Q Fever

 Caused by Coxiella burnetii.

 Rare in children.
 Can present as chronic or subacute bone infection.
 May be multifocal.
 Consider with:
o Poor response to standard therapy
o Chronic/subacute presentation
o Multifocal disease
 Diagnosis:
o Serology
o PCR from biopsy material
 Treatment:
o Prolonged
o Infectious disease consultation recommended

Acute Osteomyelitis Presentation

 Bone pain
 Refusal to use limb
 Limp
 Refusal to walk
 Fever
 Local tenderness
 Swelling
 Warmth
 Redness
 Infants:
o Fever
o Irritability
 o Reduced limb movement
o Pseudoparalysis
 Neonatal osteomyelitis:
o May be subtle
o May involve multiple sites in 20–50%

Diagnosis of Osteomyelitis
 Based on:
o History
o Physical exam
o Labs
o Microbiology
o Imaging
 Recommended labs:
o Blood culture before antibiotics
o CBC
o CRP
o ESR
 Blood cultures positive in about 30–40%
 WBC:
o High, low, or normal
 CRP:
o Rises earlier than ESR
o Useful for monitoring
 Normal inflammatory markers do not exclude infection, especially Kingella.
 Bone biopsy/culture:
o Not routinely required before antibiotics
o Consider if:
 Abscess
 Sequestrum
 Local complication
 No improvement after several days of antibiotics
 If fluid/tissue sampled:
o Put part of sample into blood culture bottle
o Improves Kingella detection
 PCR:
o Improves pathogen detection, especially Kingella

Imaging in Osteomyelitis
 X-ray:
o Baseline recommended
o Available, cheap, low radiation
o Helps exclude fracture/tumor
 o Early X-ray may be normal
o Suspicious findings usually after 10–14 days
 Ultrasound:
o Useful for joint effusion
o Useful for subperiosteal abscess
o Useful in some superficial/localized areas
o Not sensitive enough to rule out osteomyelitis
 Bone scan:
o Useful if site unclear
o Useful if multifocal disease suspected
o Radiation
o May need sedation
o Less sensitive in neonates
 MRI:
o Imaging test of choice for localized osteomyelitis
o High sensitivity
o No radiation
o Detects soft tissue and bone complications
o Limited by availability, cost, and anesthesia need
 CT:
o Reserved when MRI unavailable and urgent surgical decision needed

Empirical Antibiotic Treatment

 Initial treatment usually IV.
 Should cover:
o Staphylococcus aureus
o Kingella kingae in young children
o Age-specific pathogens
 High doses recommended due to partial bone/joint penetration.

Neonates / Under 3 Months

 Anti-staphylococcal penicillin + gentamicin

 Or cefazolin + gentamicin
 Or cefotaxime in selected cases

3 Months–5 Years

 Cefazolin
 Cefuroxime
 Anti-staphylococcal penicillin
 Amoxicillin-clavulanate, less preferred due to broader unnecessary coverage and more GI
effects
Over 5 Years

 Anti-staphylococcal penicillin
 Cefazolin

Antibiotic Doses
 Oxacillin IV:
o 200 mg/kg/day divided every 4–6 hours
o Max 12 g/day
 Cefazolin IV:
o 150 mg/kg/day divided every 8 hours
o Max 6 g/day
 Cefuroxime IV:
o 150 mg/kg/day divided every 8 hours
o Max 6 g/day
 Clindamycin IV/PO:
o 30–40 mg/kg/day divided every 6–8 hours
o Not single empirical therapy
 Cephalexin PO:
o 75–120 mg/kg/day divided every 8 hours
o Max 3–4 g/day
 Amoxicillin-clavulanate PO:
o Amoxicillin component up to 120 mg/kg/day divided every 8 hours
o Max 3 g/day amoxicillin
 Vancomycin:
o 60 mg/kg/day divided every 8 hours
o Adjust by levels
 Ampicillin:
o 200 mg/kg/day divided every 8 hours
 TMP-SMX:
o TMP component 8–12 mg/kg/day divided every 12 hours

Osteomyelitis Duration
 Total duration usually:
o 3–6 weeks
 Most uncomplicated cases:
o Around 3–4 weeks
 Depends on:
o Clinical response
o CRP/ESR trend
o Complications
o Pathogen
o Underlying disease
 o Adherence and follow-up
 Treatment can usually stop when:
o Symptoms clearly improved
o CRP low, often <20 mg/L / <2 mg/dL
o No clinical evidence of ongoing infection
 Abnormal X-ray alone does not necessarily mean antibiotics must continue.

IV-to-Oral Switch in Osteomyelitis

 Early switch possible when:
o Afebrile
o Pain improved
o Limb movement improved
o CRP/ESR clearly declining
o Clinically stable
o Reliable oral intake
o Reliable adherence and follow-up
 ESPID guidance:
o 30–50% CRP decline from peak/start supports switch
 Many children can switch after 4–7 days IV, sometimes earlier.

Surgical Treatment in Osteomyelitis

 Most early cases respond to antibiotics.
 Surgical drainage indicated if:
o Subperiosteal pus
o Intraosseous abscess
o Sequestrum
o Local complication
o Poor response to antibiotics

Septic Arthritis Presentation

 Fever
 Irritability
 Poor appetite
 Joint pain
 Joint swelling
 Redness
 Warmth
 Reduced range of motion
 Refusal to walk
 Limp
 Refusal to use limb
  Pseudoparalysis in infants
 More than 90% are monoarticular.
 Multiple joints suggest:
o Neisseria meningitidis
o Salmonella
o Neisseria gonorrhoeae
o Rarely Staphylococcus aureus

Septic Arthritis Diagnosis

 Based on:
o Clinical findings
o CBC
o Blood culture
o CRP
o ESR optional
o Synovial fluid analysis/culture if aspiration performed
o Imaging
 CRP:
o Elevated in about 95%
o Peaks within 48 hours
o Usually normalizes within about a week
 ESR:
o Elevated in about 90%
o Peaks later
o May take about a month to normalize
 WBC >12,000:
o Present in only about 60%
 Blood cultures:
o Positive in 10–40%
 Synovial fluid cultures:
o Positive in 50–60%
 Synovial PCR useful:
o After antibiotics started
o Young children
o Suspected Kingella
o May remain positive for about 8 days after antibiotics begin

Septic Arthritis Imaging

 Ultrasound:
o Usually first-line
o Highly sensitive for joint fluid
o Cannot distinguish sterile fluid from pus
 X-ray:
 o Usually not diagnostic in first week
o Useful for baseline comparison
o Helps assess fracture, tumor, osteomyelitis, follow-up
 MRI:
o Consider if:
 Multifocal disease suspected
 Neonatal infection
 Combined septic arthritis + osteomyelitis
 Pelvic/deep joint involvement
 Complications suspected

Septic Arthritis Treatment Duration

 Uncomplicated septic arthritis:
o 14–21 days
o Generally 2–3 weeks
 Early oral switch after short IV phase of at least 3–4 days if:
o Afebrile for 24–48 hours
o Clinical improvement
o CRP decreased by at least 30–50%
o Blood cultures negative
o No complications
o Reliable adherence/follow-up
 Stop treatment when:
o Most symptoms resolved
o CRP <20 mg/L / <2 mg/dL
 Continue treatment if:
o Symptoms persist
o CRP remains elevated

When Not to Shorten Treatment

 Avoid rapid oral switch or short-course therapy in:
o MRSA
o PVL-positive S. aureus
o Salmonella
o Immunodeficiency
o Infants under 3 months
o Major bone destruction
o Abscess
o Poor response to empirical therapy
o Multifocal disease
o Necrotizing infection
o Deep vein thrombosis
o Pelvic involvement
 o Vertebral involvement

Joint Aspiration and Drainage

 Aspiration recommended for suspected infected accessible joint.
 Goals:
o Reduce pressure
o Remove pus
o Prevent cartilage damage
o Obtain microbiologic diagnosis
 Superficial joints often aspirated under sedation/sterile conditions:
o Knee
o Ankle
o Wrist
o Elbow
 Deep joints usually need ultrasound-guided aspiration or OR drainage:
o Hip
o Shoulder
o Sacroiliac joint

Hip Septic Arthritis

 Hip is especially high risk due to cartilage and blood supply.
 No complete consensus.
 Options:
o Early surgical drainage
o Aspiration and lavage
o Repeated ultrasound-guided aspirations
o Repeat ultrasound after 24 hours
o Surgical drainage if fluid reaccumulates or no improvement after 48 hours
 Traditional teaching favors early arthrotomy.
 Newer data suggest selected children may avoid open surgery with close monitoring and
repeat aspiration.

Adjunctive Steroids in Septic Arthritis

 Steroids may be considered.
 Suggested regimen:
o Dexamethasone 0.6 mg/kg/day IV divided into 4 doses for 4 days
o Start with first antibiotic dose
 Evidence suggests faster recovery and possibly shorter antibiotics.
 More data needed.
 Caution:
o Steroids may obscure noninfectious inflammatory arthritis.
Follow-Up After Discharge
 Goals:
o Infection resolution
o Decline of inflammation
o No relapse
o No growth plate injury
o No limb length discrepancy
o No joint damage
 Early follow-up:
o Clinical exam
o CBC
o CRP
o ESR
o Imaging only if needed
 Follow-up usually with:
o Pediatric orthopedics
o Pediatric infectious disease early after discharge
 Typical visits:
o 6 weeks
o 3 months
o 1 year
 Longer follow-up if:
o Infection near growth plate
o Complicated disease
 If growth plate injury risk:
o Follow until skeletal maturity
 First 2 years are especially important for detecting growth disturbance.

5. Urinary Tract Infection in Children

Definitions
 UTI may involve:
o Lower urinary tract
o Upper urinary tract

Cystitis

 Bladder/lower urinary tract infection.

 Usually:
o No fever
 o Dysuria
o Frequency
o Urgency
o No renal scarring

Pyelonephritis

 Upper urinary tract and renal tissue infection.

 Usually:
o Fever
o Systemic symptoms
o Risk of renal scarring

Febrile UTI

 UTI accompanied by fever.

 In young children, fever is usually treated as possible kidney involvement.

Asymptomatic Bacteriuria

 Significant bacterial growth in urine without symptoms.

 Usually:
o No antibiotics
o May resolve spontaneously
 Treatment may:
o Increase resistance
o Increase future UTI risk
 Exception:
o Treat before invasive urologic procedures involving mucosal injury

Epidemiology
 UTI is one of the most common bacterial infections in children.
 Higher-risk groups:
o Uncircumcised boys under 3 months
o Girls under 1 year
o Girls beyond infancy
o Urinary tract anomalies
o Bladder-bowel dysfunction
o Recurrent UTIs
 Recurrence risk after first UTI within 6–12 months:
o 12–30%
 Most recurrences are new infections from intestinal flora.
Risk Factors
 Female sex
 Young age
 White ethnicity
 Uncircumcised male infant
 CAKUT
 VUR
 BBD
 Constipation
 Urinary catheter/foreign body
 Previous antibiotic exposure
 Recurrent UTIs
 Sexual activity in adolescents
 Diabetes
 Kidney stones
 Circumcision is protective.
 In first year:
o UTI much more common in uncircumcised boys than circumcised boys.

Renal Scarring
 Main long-term concern after pyelonephritis.
 May contribute to:
o Hypertension
o Proteinuria
o Reduced renal function
 Most scars are not clinically significant.
 Significant bilateral scarring can matter.
 Risk factors:
o Fever >72 hours before antibiotics
o Recurrent febrile UTIs
o Non-E. coli pathogens
o High-grade VUR, especially grades 4–5
o Delayed treatment
 Early antibiotics reduce renal damage risk.
 Ideally start within 48 hours of fever onset.

Etiology
 90% caused by aerobic intestinal bacteria.
 Most common:
o E. coli, about 70–90%
 Others:
o Klebsiella
 oProteus
oEnterobacter
oPseudomonas aeruginosa
oEnterococcus
oStaphylococcus saprophyticus
oRarely Staphylococcus aureus
 Pseudomonas more common in:
o Recurrent UTIs
o Urinary tract anomalies
o Urinary catheters/foreign bodies
o Previous urinary tract surgery

Clinical Features
Neonates

 Fever or hypothermia
 Sepsis-like presentation
 Poor feeding
 Irritability
 Failure to thrive
 Prolonged jaundice
 Recurrent vomiting

Infants and Young Children

 Fever without source

 Vomiting
 Abdominal pain
 Irritability
 Poor feeding

Older Children

 Dysuria
 Frequency
 Urgency
 Flank pain
 Chills
 Abdominal pain
 New daytime wetting
 New nighttime wetting

Important History
  Previous UTIs
 Antenatal urinary tract abnormalities
 Family history of UTI or urinary tract anomalies
 Constipation
 Weak urinary stream
 Holding behaviors
 Hygiene habits

When to Suspect UTI

 Any neonate up to 1 month with fever
 Infants 1–3 months with fever, especially without clear source
 Fever ≥39°C for ≥48 hours without source in:
o Girls under 2 years
o Uncircumcised boys under 1 year
o Circumcised boys under 6 months
 Any age with:
o Urinary symptoms
o Fever without source plus previous UTI
o Fever without source plus known urinary tract malformation
o Prolonged fever without source
 If clear source of fever:
o Routine UTI testing usually unnecessary
 Exceptions:
o Sepsis-like illness
o Known urinary anomaly
o Previous UTI
o Atypical course

Diagnosis
 Based on:
o Compatible clinical symptoms
o Abnormal urinalysis
o Positive urine culture
 Do not start antibiotics before sending urine culture.

Urinalysis
 Useful screening findings:
o Leukocyte esterase
o Nitrites
o Pyuria on microscopy
o Bacteria on microscopy
  Blood/protein are not reliable markers.
 Leukocytes:
o May appear in non-urinary illness
o May be absent in some UTIs, including Pseudomonas, Klebsiella, Enterococcus
 Nitrites:
o Require urine to remain in bladder long enough
o Often falsely negative in infants
o Negative with gram-positive pathogens
 Normal UA:
o High negative predictive value after age 2 months
 Still send urine culture despite normal UA if:
o Infant under 2 months
o Under 8 days according to newer American guidance cited in the document
o High clinical suspicion
o Sepsis-like presentation

Urine Collection
 Toilet-trained:
o Clean-catch midstream after careful cleaning
 Infants/non-toilet trained:
o Catheterized urine
o Suprapubic aspiration
 Young circumcised male infants:
o Clean-catch may sometimes be obtained after cleaning and stimulation
 Bag urine:
o Screening urinalysis only
o Not diagnostic culture
o False-positive culture rates very high
o Negative bag culture may be informative

Culture Thresholds
 Suprapubic aspiration:
o 1,000 CFU/mL
 Catheterized urine:
o 10,000–50,000 CFU/mL
 Clean-catch midstream:
o 100,000 CFU/mL
 Growth of two pathogens:
o Usually contamination
o May be meaningful in recurrent UTIs

Antibiotic Principles
  Start quickly when clinical/lab suspicion exists.
 Preferably within 48 hours from fever onset.
 Always send urine culture first.
 Narrow after culture by:
o Pathogen
o Susceptibility
o Clinical response

Cystitis Treatment
 Afebrile lower UTI/cystitis:
o Oral therapy
 Empiric options:
o TMP-SMX
o Nitrofurantoin
o Cephalexin
 Duration:
o 3–5 days
 Fosfomycin:
o Second-line for resistant cystitis
o Usually single dose in appropriate older children/adolescents
 Nitrofurantoin:
o Only for cystitis
o Not pyelonephritis because poor renal tissue levels

Pyelonephritis / Febrile UTI Treatment

 Resistance to oral agents in Israel is not negligible.
 Preferred oral empiric options if stable:
o Amoxicillin-clavulanate
o Cefuroxime
 Oral treatment may be started in community in infants over 3 months if:
o Not severe
o No significant underlying disease
o No dehydration
o No repeated vomiting
o Reliable adherence/follow-up
 IV/IM preferred:
o Gentamicin
 IV/IM alternatives:
o Ceftriaxone
o Cefotaxime
 Duration for uncomplicated pyelonephritis with good response:
o 7–10 days
 Expected response:
 o Within 72 hours
 Persistent fever beyond 72 hours, especially with poor clinical/lab improvement:
o Reassess for:
 Wrong diagnosis
 Resistant pathogen
 Renal abscess
 Acute focal bacterial nephritis/nephronia
 Obstruction
 Other complications
o Consider renal ultrasound

When to Use IV Antibiotics

 Toxic appearance
 Age under 3 months
 Significant underlying disease
 Immunosuppression
 Repeated vomiting
 Unable to take oral medication
 Dehydration
 Unreliable adherence
 No suitable oral antibiotic
 Previous resistant urinary pathogen
 Failure of oral antibiotics
 Borderline cases:
o Once-daily IM/IV gentamicin or ceftriaxone for 24–48 hours with close follow-up

Switching IV to Oral
 Consider when:
o Clinical improvement
o Afebrile for at least 24 hours
o Blood culture negative
o Urine pathogen and susceptibility available
o Suitable oral antibiotic exists
o Reliable follow-up
 Pseudomonas UTI:
o Oral ciprofloxacin if susceptible and no better option
o Explain to parents

UTI Antibiotic Doses

Oral
  Amoxicillin:
o 50 mg/kg/day divided 3 times daily
o Max 1500 mg/day
o Only definitive therapy if susceptible
 Amoxicillin-clavulanate:
o 40 mg/kg/day divided twice daily
o Max 1750 mg/day
 TMP-SMX:
o TMP component 8 mg/kg/day divided twice daily
o Max TMP 320 mg/day
o Avoid before age 2 months
 Cephalexin:
o 50–100 mg/kg/day divided 3 times daily
o Max 4000 mg/day
 Cefuroxime:
o 30 mg/kg/day divided twice daily
o Max 1000 mg/day
 Nitrofurantoin:
o 5–7 mg/kg/day divided 4 times daily
o Max 400 mg/day
o Cystitis only
o Avoid in:
 Pyelonephritis
 Age under 1 month
 G6PD deficiency
 Significant renal dysfunction
 Fosfomycin:
o Usually age >12 years
o 3 g single dose
o Limited data under 12
 Ciprofloxacin:
o 30 mg/kg/day divided twice daily
o Max 1000 mg/day
o Only if no suitable alternative

IV

 Ceftriaxone:
o 50 mg/kg/day once daily
o Max 2000 mg/day
 Gentamicin:
o 5 mg/kg/day once daily
o Monitor levels in reduced renal function or prolonged therapy

Repeat Urine Culture

  If clinical response is good:
o No repeat urine culture needed during or after treatment

Imaging After UTI

Renal and Urinary Tract Ultrasound

 Recommended after:
o First pyelonephritis/febrile UTI
o Two cystitis episodes
 In toilet-trained children, include:
o Bladder emptying
o Post-void residual
 If ultrasound during infection shows:
o Bladder wall thickening
o Voiding abnormality
 Repeat after infection resolves.

Referral to Pediatric Nephrology / Urology

 Recommended after:
o Two pyelonephritis episodes
o Abnormal renal ultrasound
o Recurrent UTIs with BBD resistant to behavioral treatment
o Abnormal renal function
 Abnormal renal function:
o Pediatric nephrology referral required

DMSA

 Used for:
o Renal scars
o Renal dysplasia
o Differential renal function
 Timing:
o 4–6 months after infection resolution
 Consider after:
o Recurrent febrile UTIs
o Suspected scars/dysplasia on ultrasound

VCUG

 Used to diagnose:
o VUR
o Bladder anatomy
 o Urethral anatomy
o Voiding function
 Decision is case-by-case by nephrology/urology.
 Usually performed:
o At least 2–3 weeks after febrile UTI resolution
 VCUG remains preferred if reflux surgery is being considered.

Antibiotic Prophylaxis
 Routine prophylaxis is controversial.
 Evidence mixed for preventing recurrent UTI.
 Clear prevention of renal scarring not proven.
 Consider with nephrology/urology input in:
o At least two proven pyelonephritis episodes
o Significant neonatal hydronephrosis/hydroureteronephrosis, SFU 3–4
o Suspected urinary obstruction
o Recurrent UTI with BBD until BBD treated
 Preferred agents:
o Nitrofurantoin
o TMP-SMX
 Cephalexin:
o Can be used if alternatives unsuitable, especially small infants
o May promote resistant bowel flora
o Prefer shorter periods
 Prophylaxis dosing:
o About one-third treatment dose
o Once nightly

Bladder-Bowel Dysfunction, BBD

 Major risk factor for recurrent UTIs.
 Symptoms:
o Holding urine
o Infrequent voiding
o Urgency
o Frequency
o Daytime wetting
o Nighttime wetting
o Hesitancy
o Urinary retention
o Constipation
o Fecal soiling
 Common in children with:
o Recurrent UTIs
o VUR
  BBD may:
o Reduce spontaneous resolution of reflux
o Reduce success of endoscopic reflux correction

Evaluation of BBD
 Ask about:
o Urinary holding while playing/screens
o Voiding frequency
o Urgency
o Daytime accidents
o Nighttime wetting
o Crossing legs/holding maneuvers
o Stool frequency
o Stool consistency
o Painful defecation
o Fecal soiling
o School/kindergarten toilet avoidance
o Psychosocial or behavioral issues
 Physical exam:
o Abdomen for fecal masses
o Genital exam
o Boys: meatal stenosis
o Girls: labial adhesions
o Perianal exam if needed
 Additional tools:
o Voiding dysfunction questionnaire
o Bristol stool scale
o Voiding diary
o Renal/bladder ultrasound including post-void residual

Treatment of BBD
 Initial treatment is behavioral:
o Scheduled voiding every 2–3 hours
o Avoid holding urine
o Improve genital hygiene
o Encourage adequate water intake
o Treat constipation aggressively
 Constipation treatment:
o High-fiber diet
o Stool softeners such as polyethylene glycol
o Enemas if needed
o Aim for one soft stool daily
  If behavioral treatment fails:
o Refer to pediatric urology
o Consider pediatric gastroenterology if constipation significant
o Medication or surgical approaches only after specialist evaluation

Master Clinical Pearls Across All Topics

 Cultures should be taken before antibiotics whenever possible.
 Clinical reassessment at 48–72 hours is essential in treated infections.
 Failure to improve should trigger reconsideration of:
o Wrong diagnosis
o Resistant organism
o Abscess
o Complication
o Noninfectious mimic
 Fever in infants ≤3 months is high stakes.
 Urine testing is central in febrile infants because UTI is the most common SBI.
 Dehydration severity drives gastroenteritis management more than pathogen
identification.
 Most pneumonia under age 5 is viral.
 Suspected bacterial CAP in the community usually starts with amoxicillin, not
unnecessarily broad antibiotics.
 Fever + refusal to walk should always raise concern for osteomyelitis or septic arthritis.
 Bag urine culture is a trap wearing a lab coat.
 Normal WBC does not exclude serious infection.
 CRP trends are often more useful than single values for monitoring response.
 Imaging should be used when it changes management, not as a ritual sacrifice to
uncertainty.
 Reliable family follow-up is part of the treatment plan, not a decorative sentence at
discharge.