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Pets Pets and Daycare Infections in the Pediatric

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Pets Pets and Daycare Infections in the Pediatric Powered By Docstoc
					      Pets and Daycare
Infections in the Pediatric Population
              Heather Becker, MD
               Assistant Attending
             St. Barnabas Hospital
        Pediatric Emergency Department
                       Salmonellosis
• 3% of households in US have at least one reptile

• 70,000 people in US get salmonellosis from reptiles (turtles, lizards,
  snakes) each year

• 1975 FDA banned commercial distribution of small turtles (<4 in.
  long) – est. 100,000 cases/yr of salmonellosis were prevented

• But reptile pets remained popular: 1991-2001 est. households with a
  reptile pet increased from 850,000 to 1.7 million

• Number of pet turtles in US: 950,000 (1996) up to 2 million (2006)

• CDC reported in 2006-07: nontyphoidal human Salmonella
  infections est. 1.4 million annually; with approx 15,000
  hospitalizations and 400 deaths per year
                     Salmonellosis
                      case report
Florida (2/20/07): 3 week old female with 1 day of poor
   feeding and lethargy presented to ED; transferred to
   tertiary-care pediatric hospital where she was found
   febrile and in septic shock; despite antibiotic treatment pt
   died on 3/1/07

CSF and Blood cxs: + Salmonella

Florida DOH determined that family friend had bought a
   turtle (1.25 in long) at a flea market in Nov 2006; was
   given to family as a pet in Jan 2007; fecal sample from
   turtle yielded exact same isolate as found in infant’s cxs
              Salmonellosis
                outbreak
In 2007-08:
2 girls swimming with pet turtle in backyard
  pool became ill (one hospitalized with kidney
  failure)
investigation revealed girls had same strain
  of Salmonella that was eventually traced
  to a total of 107 cases in 34 states (1/3 of
  these cases needed hospitalization)
                           Salmonella
                                   (non-Typhi)


• Animals are the principal reservoir
    – Including reptiles, poultry, livestock
    – Often transmitted through foods of animal origin or drinking water or
      other foods contaminated by the animal, animal product or an infected
      human
    – PETS include: turtles, iguanas, lizards, snakes
• Range of clinical manifestations:
    –   Gastroenteritis
    –   Bacteremia
    –   Focal Infections (i.e. meningitis, osteomyelitis)
    –   Asymptomatic Carriage
• Incubation for gastroenteritis: 6 to 48 hrs
• Can culture stool, blood, urine or fluid from foci of infection
• Antibiotics not indicated in gastroenteritis unless patient is at an
  increased risk of invasive disease
               Salmonellosis
• Attack rate highest in kids younger than 4 years
  of age
• Best way to prevent – proper hand hygiene,
  prohibition of sale of pet turtles and restricting
  sale of other reptiles
• Do not keep reptiles or wash cages near areas
  where food is prepared or where others bathe
  (unless cleaned with bleach afterwards)
• Kids do not need to be kept out of school unless
  symptomatic
                 Salmonella
Human Salmonellosis Associated with
 Animal-Derived Pet Treats --- United
 States and Canada, 2005
     During 2004--2005, contact with Salmonella-
 contaminated pet treats of beef and seafood origin
 resulted in nine culture-confirmed human Salmonella
 Thompson infections …. Public health practitioners
 should consider pet treats a potential source for
 Salmonella transmission.
                            From: MMWR Weekly; 6/30/2006 / 55(25); 702-705.
                                    Dogs
• Can be reservoirs for
  diarrheal illnesses:
       Campylobacter
       Cryptosporidium
       Salmonella
• Also Dogs and their
  environment can be
  source of parasitic
  infections:
   – Hookworms, Tapeworms,
     Roundworms
   – Giardia (will discuss with daycare)
• Also rare infections:
      Leptospira
               Campylobacter
• Mostly from GI tract of birds, farm animals and PETS
• Get infection from ingestion of contaminated food, water
  or unpasteurized milk; or from contact with feces of
  infected animals or people
• Sxs: Diarrhea, abdominal pain, malaise, fever
• Stools can have visible or occult blood
• Most get mild infection; up to 20% can relapse or have a
  prolonged or severe illness
• Incubation 1-7 days
• Can culture from feces or blood
• Rx: erythromycin, azithromycin (5-7 days)
• Kids in diapers should stay out of child care until
  diarrhea is gone
                Cryptosporidium
• Cryptosporidium parvum – spore-forming protozoan;
  oocytes are infectious (excreted in feces)
• Waterborne outbreaks most common
• Oocyte is resistant to chlorine!
• Frequent, nonbloody, watery diarrhea; children
  commonly get fever and vomiting too
• Can be asymptomatic
• Dangerous for immunosuppressed pts
• Incubation 7 days (range 2-14); usually self-limited, lasts
  1-20 days
• Oocytes continue to be shed in stool for 1-2 weeks after
  symptoms stop
• Routine Lab O&P tests – will not detect it! Have to tell
  lab to specifically look for the oocyte using special
  methods
Cryptosporidium ova in stool
              Hookworm
        Cutaneous Larva Migrans
• Ancylostoma caninum and braziliense
• Infective larvae enter through skin and advance to cause
  a “creeping eruption”
• Intensely itchy serpiginous tracks or bullae
• Usually affects children, gardeners, sunbathers
• Most prevalent in Southeast US
• Usually self-limited infection (lasts weeks to months)
• Can use oral albendazole or ivermectin or topical
  thiabendazole
• Rarely: can develop Löeffler syndrome or eosinophilic
  enteritis
              Toxocariasis
         Visceral Larva Migrans
• Toxacara canis and T. Cati
• Usually in children age 1-4 who have h/o pica
• From ingesting soil containing eggs of the
  parasite; beware of sandboxes!
• Marked by fever, leukocytosis, eosinophilia,
  hypergammaglobulinemia and hepatomegaly
• Liver biopsy with larvae is diagnostic but rarely
  found; so negative bx won’t exclude diagnosis
• Rx: Albendazole or mebendazole
• Need to treat puppies and kittens with
  antihelminitics at 2,4,6 and 8 wks of age
                    Dipylidium
                        (Tapeworm)

• Most common tapeworm of cats and dogs in US –
  Dipylidium caninum
• Animals get it from swallowing a flea infected with larva
  while grooming self
• Become adult tapeworm in gut of pet – and proglottids
  (containing eggs) are released into stool – they are size
  of grain of rice and can be seen around anus of animal
  or on freshly passed stool
• Children can be infected in same way (swallowing flea
  from pet) – but is thankfully rare
• Rx: praziquantel
• Flea control very important for pets
                 Leptospirosis
• Leptospira (spirochete) excreted in animal urine,
  amniotic fluid, or placenta
• Are viable in soil or water for weeks to months
• Humans are infected thru contact of mucosal surfaces or
  broken skin with contaminated soil, water or animal
  tissues
• Causes a generalized vasculitis
• 90% have a self-limited illness
• Very non-specific symptoms (fever, chills, HA, N/V,
  rash), often get non-purulent conjunctivitis (30-40%) and
  myalgias of lower legs and lower back (80%)
• Incubation 5-14 days
• Rx: IV Pen G
   – Can get a Jarisch-Herxheimer reaction
                      Cats
• Like dogs can be
  source of:
  Salmonella
  Campylobacter
  Cryptosporidia
  Tapeworm
  Hookworm
  Roundworm
  Giardia
• + Other important
  infections to consider
             Bartonella henselae
            (Cat-scratch disease)
• Most infections in pts aged < 20 yrs
• More than 90% have had contact with a cat (usually a
  kitten)
• Starts with skin papule at site of scratch, followed by a
  regional lymphadenopathy (at the nodes that drain the
  site of inoculation) by 1-2 weeks
• Incubation: 7-12 days for primary lesion; 5-50 days for
  lymphadenopathy
• Can have fever and mild systemic symptoms
• Typically skin over node is tender, warm, red and
  indurated
• Self-limited infection
Cat-scratch Disease
                    Toxoplasmosis
• Toxoplasma gondii – more than 60 million people in US carry the
  parasite – but immune system prevents them from having symptoms

• If acquired after birth usually asymptomatic; congenitally acquired
  can lead to mental retardation, learning disabilities, seizures,
  deafness, chorioretinitis and visual impairment, death

• Cats are definitive host (parasite replicates in sm. Intestine)

• Cats get it from feeding on mice or undercooked meats of animals
  that are infected

• Cats (especially kittens) excrete oocyst in stool

• Human usually become infected by raw or undercooked meat of
  intermediate hosts (sheep, pigs, cows) or from accidental ingestion
  of oocysts from soil, contaminated foods or KITTY LITTER!
               “Pocket Pets”
• Including rats, mice, gerbils, hamsters, guinea
  pigs, ferrets, rabbits
             Salmonella again…

Outbreak of Multidrug-Resistant Salmonella
 Typhimurium Associated with Rodents
 Purchased at Retail Pet Stores --- United
 States, December 2003--October 2004
      …This report describes two of the first identified
 human cases associated with this outbreak, summarizes
 the multistate investigation of human S. Typhimurium
 infections associated with exposure to rodents (e.g.,
 hamsters, mice, and rats) purchased at pet stores…

                            From: MMWR Weekly; 5/6/2005 / 54(17); 429-433
    Lymphocytic Choriomeningitis
          Virus (LCMV)
• An arenavirus – passed to humans from rodents
  (primary host for virus)
• Humans infected by aerosol or ingestion of dust or food
  contaminated by the virus from urine, droppings, saliva
• Usually get from exposure to “house mice” not pets; but
  has been reported in pet hamsters
• Sxs are similar to “flu”: fever, stiff neck, malaise,
  anorexia, myalgias, retro-orbital HA, photophobia,
  nausea, vomiting -- occur 1–2 weeks after exposure.
• Usually complete recovery; can last 1-3 wks
• Pet rodents are infected from contact with wild rodents at
  a breeding facility, pet store or home
Daycare
                            Daycare
• Respiratory and diarrheal illnesses are at least twice as common in
  pre-schoolers who go to daycare then those who stay home

• On average: toddler will put hand or toy in mouth every 3 minutes

• Direct contact with nose secretions, eye secretions or saliva from
  other kids is common – increasing risk for viral (ie rhinovirus,
  adenovirus, RSV, paraflu) and bacterial (s. pneumo, non-typable
  H.flu, moraxella) infections

• Toilet trained children are often not supervised in restroom; staff
  who change diapers often not educated about importance of hand
  washing and cleaning surfaces

• Some of the pet-borne infections we already talked about are also
  spread in childcare facilities: Salmonella, Campylobacter,
  Cryptosporidium
                        Giardia
• Most common protozoan-caused diarrhea in North
  America
• G. lamblia cysts ingested from unwashed hands that
  were in contact with infected feces
• Outbreaks often human to human transmission, but can
  come from contaminated drinking water, pools, pets
• Contagious for as long as infected person excretes cysts
• Diarrhea is non-bloody, but voluminous and odiferous
• Usually self-limited but can last a long time
• Some otherwise healthy kids can get prolonged diarrhea
  that can cause weight loss of 10-15%, failure to thrive or
  stunting of growth for 2 years or more
                             Giardia
• Suspect in any child whose diarrhea lasts more than 5
  days; infection can persist for months
• Asymptomatic infection is very common (>20% of well
    children < 3 yrs who attend daycare harbor organism)
•   Very contagious b/c low inoculum necessary for infection
•   Incubation period: 1-4 wks
•   Diagnosis made by detecting antigen in stool
•   Asymptomatic kids need not be treated
•   Rx: Metronidazole (15mg/kg) x 10 days
•   Often co-infection of Cryptosporidium and Giardia –
    treated with Nitazoxanide x 3 days
                     Shigella
• Humans are natural host
• Spread fecal-oral
• Low inoculum (10-200
  orgs)
• Incubation 1-7 days
• Watery stools (but can be
  mucoid +/- blood)
• Mostly self-limited
• Amp, Bactrim for severe
  infection but there is
  resistance
                       Rotavirus
• Most common cause of severe
  diarrhea in kids under 2 yrs
• Fecal-oral spread
• Present in stool up to 21 days
  before diarrhea develops;
  incubation 2-4 days
• Can be spread by fomites
• Nonbloody diarrhea preceded
  by vomiting and fever
• Lasts 3-8 days
• Virtually all children are
  infected by 3 years of age
• Rotateq
                           Hepatitis A
• Fecal-oral spread; highest titers are in stool 1-2 wks before onset of
  illness

• Mild illness in infants and young kids, but substantial morbidity in
  adults

• Usually self-limited infection (fever, malaise, jaundice, nausea,
  anorexia)

• In older kids and adults symptoms can last several weeks

• 13-40% of reported Hepatitis A community outbreaks had some
  association to a daycare outbreak

• Children or staff with infection need to be excluded from childcare
  facility or school for at least 7 days after onset of illness

• Vaccine-preventable disease!
                Ringworm
              (Tinea infections)

• Spread by direct contact with infected
  humans, animals or fomites
• Unknown incubation period
• Treat topically with miconazole or
  clotrimazole BID; or ketoconazole,
  econazole daily
• Treat for at least 4 weeks (even though
  usually gone in 2 wks)
                     Pinworm
• Enterobius vermicularis
• Humans are only known natural host
• Asymptomatic or pruritus ani (sometimes pruritus vulvae)
• Tends to spread within families
• Can be a cause of nonspecific urethritis, vaginitis
• Female worm dies after depositing eggs on perianal
  skin; reinfection occurs by reingestion of eggs
• Incubation: from ingestion of egg until female gets to
  anus (1-2 months); eggs can stay infective for 2-3 weeks
• Worms can be seen in perianal area 2-3 hrs after child
  asleep
• Treat with mebendazole, pyrantel pamoate or
  albendazole – one dose, repeated 2 weeks later
                      Scabies
• Spread by direct contact with infected skin
• Transmission usually through prolonged, close, personal
  contact
• Very itchy eruption – caused by hypersensitivity reaction
  to the proteins of the parasite
• Adult female mites burrow into upper layers of epidermis
• Transmissible for as long as the patient remains infected
  and untreated
• Incubation 4-6 weeks if no previous exposure, 1-4 days if
  previous infestation
• Rx: permethrin 5% cream
                Pediculosis Capitis
                        (Head Lice)

• Spread by direct contact with infected hair (often from
  fomites)
• Usually itchy but can be asymptomatic
• Adult lice or nits (eggs) usually found behind ears and
  near nape of neck
• Incubation from egg to first hatch 6-10 days (adult lice
  that can lay eggs appear 2-3 weeks later)
• Exclude from daycare until day after treatment
  (permethrin 1%) – “no-nit” policy is not recommended
• Screen classmates and family members and treat if
  infested
            Cytomegalovirus
• Children with CMV infection are usually
  asymptomatic but excrete virus in urine and
  saliva intermittently for years
• Excretion rate in childcare centers – 70% for
  kids 1-3 years of age
• Risk is not to other kids but to pregnant childcare
  workers and mothers
• Annual seroconversion rate for adults who have
  children in daycare is 15%
• All you can do is wash your hands!
                   Case
• 18 month old female from an orthodox
  Jewish family presents to NYC hospital
  emergency department with new onset
  focal seizures

• No history of travel
                 Cysticercosis
• Taenia solium – pork tapeworm

• Taeniasis = intestinal tapeworm infection
  (usually only one worm present), acquired by
  eating undercooked pork that contains encysted
  larvae, often asymptomatic

• Cysticercosis = infection acquired by ingesting
  eggs

• Humans are definitive host so eggs found in
  human feces only
             Neurocysticercosis
• Cysts in brain: can cause seizures, behavioral
  disturbances, obstructive hydrocephalus
• Host reaction to degenerating cysts can cause
  meningitis symptoms
• Cysts in spinal column: gait disturbance, pain,
  transverse myelitis
• Can get ocular involvement and visual
  impairment
• Diagnosis: based on CT or MRI
• Treatment based on number and viability of
  cysticerci and where they are located
                         References
•   Behrman, RE, Klegman R, JensonHB. Nelson’s Textbook of Pediatrics.
    Philadelphia: WB Saunders Co.,2000.

•   Goodman RA, Osterholm MT, et al. Infectious Diseases and Child Day
    Care. Pediatrics 1984; 74; 134-139.

•   “Guidelines for Veterinarians: Prevention of Zoonotic Transmission of
    Ascarids and Hookworms of Dogs and Cats.” (2004) From www.cdc.gov

•   James C, Schneider J, et al. Turtle-Associated Salmonellosis in Humans –
    United States, 2006-2007. MMWR Weekly 2007; 56(26); 649-652.

•   Keating JP. Chronic Diarrhea. Pediatr. Rev. 2005;26;5-14.
                          References
•   Pickering, LK ed. Red Book: 2003 Report of the Committee on Infectious
    Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics;
    2003.

•   Reporter R, Sun B, et al. Reptile-Associated Salmonellosis --- Selected
    States, 1998-2002. MMWR Weekly 2003; 52(49);1206-1209.

•   Robinson J. Infectious Diseases in Schools and Child Care Facilities.
    Pediatr. Rev. 2001; 22; 39-46.

•   www.cdc.gov/healthypets

				
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