OI SEMINAR IN PEDIATRICS(PCP, Toxoplasmosis, and Candidiasis(Thrush).pptx

It is seminar presentation on OI, but only common in pediatrics PCP, Toxoplasmosis, and Candidiasis (Thrush).

1. MIZAN TEPI UNIVERSITY COLLEGE OF MEDICINE & HEALTH SCIENCE SCHOOL OF PHARMACY DEPARTMENT OF CLINICAL PHARMACY   SEMINAR ON MANAGEMENT OF OI IN PEDIATRIC SUBMITED BY GROUP-5, PRESENT BY   SUBMITED TO: ASS. PROFESSOR HABTAMU ACHO 8/5/2024 BY GROUP-1

2. SEMINAR on OI IN PEDIATRICS 8/5/2024 BY GROUP-1

3. outline Objective Introduction Epidemiology Risk factors Etiology Pathophysiology Clinical Presentation Diagnosis Treatment monitoring  & Evaluation   8/5/2024 BY GROUP-1

4. Introduction Definition According to theWHO, OIs are infections that occur more frequently or are more severe in individuals with weakened immune systems compared to those with healthy immune systems. These infections take advantage of the body's compromised defenses, often seen in childrens, people living with HIV/AIDS and CA. 8/5/2024 BY GROUP-1

5. Introduction... The common causative agents of the opportunistic infections in are bacteria, fungi, viruses and protozoa . The main systems of the body affected are the nervous system, gastro-intestinal system, respiratory system and the skin . The level of immunity determines the occurrence and type of opportunistic infections. 8/5/2024 BY GROUP-1

6. Introduction... Among the common OIs in children are Pneumocystis pneumonia (PCP), toxoplasmosis, and candidiasis. 8/5/2024 BY GROUP-1

7. Introduction... Types of OIs Pneumocystis carnii pneumonia (PCP) It is caused by the fungus Pneumocystis jirovecii, but does not respond to antifungal treatment. It primarily affects children with compromised immune systems, such as those with HIV/AIDS or undergoing immunosuppressive therapy. 8/5/2024 BY GROUP-1

8. Introduction... It commonly occurs when patients have significant immune suppression (CD4<200cells/mm3 or CD4 percentage < 14%). PCP presents with symptoms like fever, cough, and difficulty breathing. Early diagnosis and treatment with antibiotics such as trimethoprim-sulfamethoxazole, and alternative pentamidine are crucial for improving outcomes. 8/5/2024 BY GROUP-1

9. Introduction... Toxoplasmosis It is an infection caused by the parasite Toxoplasma gondii. It can be acquired congenitally or through exposure to contaminated food, water, or cat feces. In children, toxoplasmosis can lead to severe complications, including encephalitis, chorioretinitis, and systemic illness. 8/5/2024 BY GROUP-1

10. Introduction... Preventive measures and prompt treatment with medications like Trimethoprim/sulfamethoxazole, and alternative pyrimethamine and sulfadiazine are essential to manage this infection effectively. 8/5/2024 BY GROUP-1

11. Introduction... Candidiasis (Thrush) It is a fungal infection caused by Candida species. It can manifest as oral thrush, or systemic infection in immunocompromised children. 8/5/2024 BY GROUP-1

12. Introduction... Candidiasis is commonly seen in children with prolonged antibiotic use, steroid or those receiving chemotherapy. Antifungal treatments, such as Nystatin and alternative miconazole used to treat candidiasis and prevent its complications. 8/5/2024 BY GROUP-1

13. Epidemiology/PCP A study published in 2022 reported that the incidence of PCP in non-HIV-infected pediatric patients was approximately 1.2 cases per 100,000 children per year. This includes children with malignancies, organ transplants, and primary immunodeficiencies. [Journal of Pediatric Infectious Diseases in 2022] The mortality rate for PCP in immunocompromised children remains high, ranging from 20% to 40%. [a review article in the Pediatric Pulmonology journal] 8/5/2024 BY GROUP-1

14. Epidemiology/toxoplasmosis In the European Union/European Economic Area the incidence of congenital toxoplasmosis was reported to be 5.08 cases per 100,000 live births in 2020. France had the highest number of reported cases due to active screening programs. [European Centre for Disease Prevention and Control (ECDC) report] Immunocompromised children, such as those undergoing chemotherapy or with primary immunodeficiencies, are at increased risk of severe toxoplasmosis. [Journal of Clinical Microbiology] 8/5/2024 BY GROUP-1

15. Epidemiology/Candidiasis(Thrush) A 2023 study found that the incidence of oropharyngeal candidiasis in hospitalized children was 15 cases per 1,000 admissions. This includes children with chronic illnesses, those on prolonged antibiotic or corticosteroid therapy, and those with diabetes. [Journal of Pediatric Infectious Diseases,2023] In a cohort of immunocompromised children, the prevalence of candidiasis was found to be 25%. [Journal of Pediatric Hematology/Oncology] 8/5/2024 BY GROUP-1

16. Risk factors/PCP HIV infection with CD4 cell count below 200 cells/µL. Immunosuppression due to chronic corticosteroid therapy, organ transplantation, or hematologic malignancies. Previous PCP infection. Other immunocompromised states, such as autoimmune diseases. 8/5/2024 BY GROUP-1

17. Risk factors/Toxoplasmosis HIV infection with CD4 cell count below 100 cells/µL. Consumption of undercooked meat containing Toxoplasma cysts. Exposure to cat feces, containing Toxoplasma oocysts. Organ transplantation from an infected donor. 8/5/2024 BY GROUP-1

18. Risk factors/Candidiasis(Thursh) Immunosuppression due to HIV/AIDS, chemotherapy, or prolonged use of corticosteroid use. Diabetes mellitus with elivated bllod sugar. prolonged use of Broad-spectrum antibiotic, which disrupts normal flora. poor oral hygine prematurity infants, with low birth weight 8/5/2024 BY GROUP-1

19. Etiology/PCP it’s primarily caused by the fungal organism pneumocystis jirovecii (formerly known as p. carinii). 8/5/2024 BY GROUP-1

20. Etiology/Toxoplasmosis It’s caused by, toxoplasma gondi. 8/5/2024 BY GROUP-1

21. Etiology/ Candidiasis(Thrash) its primarily Caused by over growth of candida albicans. 8/5/2024 BY GROUP-1

22. Pathophysiology/ (PCP) Pt. with immunocompromised (with Therapy & disease) CD4 count <200 c/Ul Inhalation of fungal spores/ reactivation of latent infection Fungus attaches to alveolar walls. Triggers an inflammatory response. Alveolar walls thicken and foamy exudate accumulates. Impaired gas exchange/Hypoxia/Resp.Failure 8/5/2024 BY GROUP-1

23. Pathophysiology/ Toxoplasmagondi Ingestion of contaminated food or water(containing oocyst) Parasite forms tissue cysts. usually asymptomatic or mild ( In immunocompetent individuals ) cysts reactivate (in immunocompromised individuals) Severe complications like encephalitis, chorioretinitis, systemic disease. 8/5/2024 BY GROUP-1

24. Pathophysiology/Candidiasis(Thrash) Overgrowth candidiasis in mucosal surfaces. Yeast adheres to epithelial cells. Forms biofilms and invades tissues. Causes inflammation and white plaques. 8/5/2024 BY GROUP-1

25. Clinical presentation The clinical presentation of OI infectionsdepends on the type, severity, duration, and cause of the infection, as well as the presence of other comorbidities. 8/5/2024 BY GROUP-1

26. Onset: Gradual, over several weeks. Symptoms: Progressive dyspnea, Dry cough, low grade Fever, Fatigue Signs: Hypoxemia, Tachypnea, Bilateral diffuse interstitial infiltrates on chest X-ray Clinical presentation... 8/5/2024 BY GROUP-1 PCP Onset: Variable, often asymptomatic in immunocompetent individuals. Symptoms: Flu-like symptoms, Swollen lymph nodes In severe cases confusion, seizures, and other neurological symptoms Signs: Retinochoroiditis, Encephalitis. Toxoplasmosis Onset: Rapid, within days. Symptoms: Fever, White patches on the tongue, Redness or soreness, Difficulty swallowing, Cracking and redness at the corners of the mouth (angular cheilitis) Signs: White, creamy lesions that can be wiped off, leaving a red, raw, and sometimes bleeding surface underneath Candidiasis (Thrash)

27. Diagnosis General diagnosis of OI is based on  the: Medical history Physical examination Laboratory tests Imaging studies 8/5/2024 BY GROUP-1

28. Diagnosis/ PCP Symptom Assessment A healthcare provider will start by asking about symptoms, which may include: Due to non-specific presentation, PCP should always be considered in those patients with evidence of moderate to severe immunosuppression who come up with Non-productive cough, Fever, progressive dyspnea or fatigue. 8/5/2024 BY GROUP-1

29. Diagnosis... Lab DX If needed, a lab test such as: Culture: definitive diagnosis of PCP. Induced sputum sample using special stains like Giemsa or methylamine silver stains can be performed, but these tests are not routinely done in Ethiopia. 8/5/2024 BY GROUP-1

30. Diagnosis... Imaging DX If needed, an imaging such as: Chest X-ray: presumptive diagnosis of PCP is based on clinical judgment and typical chest X-ray findings revealing a perihilar interstitial infiltration with tendency to spread outwards. Note that the chest X-ray can be normal in 20% of patients. 8/5/2024 BY GROUP-1

31. Diagnosis... Other DX pulse-oximeter NG aspirate Oronchoscopy with broncho alveolar lavage Open lung biopsy 8/5/2024 BY GROUP-1

32. Diagnosis/Toxoplasmosis Lab DX Serologic test, PCR, CBC With Diffrential Imaging DX Neuro-imaging (CT scan or MRI of the brain) 8/5/2024 BY GROUP-1

33. Diagnosis/Candidiasis(Thrash) Sign & Symptom Assessment It is frequently made on clinical grounds (signs and symptoms of infection) LAB DX fungal cultures, potassium hydroxide smear may be done. Imaging DX When facilities are available upper GI endoscopy with or without biopsy or contrast imaging. 8/5/2024 BY GROUP-1

34. Treatment 8/5/2024 BY GROUP-1

35. Goal of treatment The treatment of PCP aims is: To prevent respiratory failure To suppress multiplication of the organism To decreas the risk of complocations To shorten hospital stay 8/5/2024 BY GROUP-1

36. Goal of treatment The treatment of TOXOPLASMOSIS aims is To alleviate sign and symptom To eliminate/reduce the parasite load To Prevent or minimize neurologic sequelae To prevent the complications 8/5/2024 BY GROUP-1

37. Goal of treatment The treatment of CANDIDIASIS(Thrash) aims is To Aleviate symptoms and improve feeding Decrease the risk of complication To identify the underline cause 8/5/2024 BY GROUP-1

38. Non-pharmacological Treatment 8/5/2024 BY GROUP-1

39. PCP Oxygen therapy should be given. Approppriate fluid Management Appropriate Nutritional Support 8/5/2024 BY GROUP-1

40. Toxoplasmosis nutritional support rest and recovery stress management 8/5/2024 BY GROUP-1

41. Candidiasis(Thrash) support feeding(if admited use NG tube feeding, especially in severe case) Oral Hygine Dietary Adjustment 8/5/2024 BY GROUP-1

42. Pharmacological treatment 8/5/2024 BY GROUP-1

43. For PCP First line: Trimethoprim + Sulphamethoxazole for 3 weeks. Trimethoprim+Sulphamethoxazole, 15-20mg/kg/day based on the trimethoprim component and administered in three or four divided doses for 21 days. 8/5/2024 BY GROUP-1

44. For PCP Alternative: Clindamycin, 30mg/kg/day P.O., Q6-8 Hrs for 3 weeks PLUS Primaquine, 0.3 mg base/kg/QD P.O for 3 weeks. OR Clindamycin, 30mg/kg/day P.O., Q6-8 Hrs plus Dapsone 2mg/kg po QD for 3 weeks. 8/5/2024 BY GROUP-1

45. For PCP OR Pentamidine Isethionate, 4mg/kg I.V./I.M. QD for 2-3weeks. “It should be given to those who fail to tolerate the above regimen.” OR Dapsone 2mg/kg po QD for 3 weeks. PLUS Trimethoprim, 20mg/kg administered P.O., in divided doses QID for 3 weeks. 8/5/2024 BY GROUP-1

46. For PCP Adjuvant corticosteroids treatment : For severe PCP in children: prednisolone 2mg/kg per day for the first 7 - 10 days followed by a tapering regimen for the next 10 - 14 days. 8/5/2024 BY GROUP-1

47. For Toxoplasmosis First line 10mg trimethoprim + 50mg sulfamethoxazole (60mg)/kg/Dose po Q12 Hrs for 28 days followed by maintenance therapy at 50% reduced dosage for three months. 8/5/2024 BY GROUP-1

48. For Toxoplasmosis Alternative Sulfadiazine, 75mg/kg/Day, then 150mg/kg/day QID PO Q6 Hrs for 3-4 weeks or 3 weeks after resolution of lesion PLUS Pyrimethamine: loading dose of 200 mg once, followed by 50-75 mg/day for six weeks. PLUS Folinic acid (Leucovorin): 10-20 mg/d for six weeks. OR Pyrimethamine and Folinic Acid (Leucovorin)100-200mg/kg/day QID) PLUS Clindamycin 5-7.5mg/kg/dose PO/I.V. 8/5/2024 BY GROUP-1

49. For Toxoplasmosis Chronic maintenance treatment (Secondary prophylaxis): 10mg trimethoprim + 50mg sulfamethoxazole (60mg)/kg/Dose po Q12 Hrs Discontinuing chronic maintenance therapy if: successfully completed initial therapy, remain asymptomatic of signs and symptoms of TE, and CD4 count >200 cells/mm3 Reinitiate prophylaxis if CD4 count <200 cells/mm3 8/5/2024 BY GROUP-1

50. For Candidiasis(Thrash) First line: Fluconazole orally 3mg/k/day daily 1-2 Wks OR Itraconazole 200 mg PO daily 1-2 Wks 0R ketoconazole 3-6mg/kg/day BID 1-2 Wks 8/5/2024 BY GROUP-1

51. For Candidiasis(Thrash) Alternative: Posaconazole 100 mg PO BID on day one, then daily for 13 days. OR miconazole buccal tablets 50 mg PO daily For 1-2 Wks. OR nystatin 5 mL (100,000 units/mL)- swish and swallow four or five times daily 1-2 Wks. 8/5/2024 BY GROUP-1

52. Monitoring & Evaluation Assess respiratory symptoms(cough, sob,fever) Ascultation of the lung to detect abnormal brething sound continous monitoring using pulse-oximeter CBC initial and follow-up xray to asses the extent of lung involvement and response to treatment. neurological symptoms serological tests (IGg and IGm) inspection of oral cavity 8/5/2024 BY GROUP-1

53. References Book Source DiPiro’s Pharmacotherapy Handbook, 12 th Edition, By Terry L. Schwinghammer, PharmD, FCCP, FASHP, FAPhA, Joseph T. DiPiro, PharmD, FCCP, FAAAS,Vicki L. Ellingrod, PharmD, FCCP, FACNP, Cecily V. DiPiro, PharmD Standard treatment guide line for general hospital, 4th edition, 2021 Intenet Source www.Mediscape.com www.Drug.com Mobile App Source msad manual professional practical dignosis and management drug information mnagement system 8/5/2024 BY GROUP-1

54. Group Membrs NAME ID Daniel Birhanu HSS/062/10 Asteraye Belay HSS/036/10 Mubarek Habib HSS/138/10 Wondaferahu Wondimu HSS/195/10 Ermias Tadesse HSS/073/10 Yonas Endayehu HSS/187/10 8/5/2024 BY GROUP-1 NAME ID Adugenet Markos HSS/014/10 Hailu Bekuma HSS/095/10 Abeba Yikunom HSS/002/10 Tadele Bekele HSS/152/10 Amanuel Lemma HSS/021/10 Tsedeke Lara HSS/173/10 Matios T/mariam HSS//11910