AUTHOR INFORMATION	Section 1 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Author: Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota School of Medicine

Mark R Schleiss, MD, is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, International Society for Antiviral Research, Minnesota Medical Association, Pediatric Infectious Disease Society, and Society for Pediatric Research

Editor(s): David Jaimovich, MD, Section Chief, Division of Critical Care, Hope Children's Hospital, Assistant Professor Pediatrics, Assistant Professor, Department of Pediatrics, University of Illinois at Chicago; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota School of Medicine; Robert W Tolan, Jr, MD, Chief of Allergy, Immunology and Infectious Diseases, The Children's Hospital at St Peter's University Hospital, Clinical Associate Professor of Pediatrics, Drexel University College of Medicine; and Russell W Steele, MD, Professor and Vice Chairman, Department of Pediatrics, Head, Division of Infectious Diseases, Louisiana State University Health Sciences Center

Disclosure

	INTRODUCTION	Section 2 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Background: Although the type of infectious diseases caused by Haemophilus influenzae has changed considerably in recent years because of the widespread and routine immunization of children against type b organisms, H influenzae remains a significant pathogen.

First isolated in 1892 by Robert Pfeiffer from the sputum of patients with pandemic influenza infection, H influenzae was thought to be the infectious agent responsible for flu. In 1920, the organism was named Haemophilus influenzae (from the Greek haemophilus, meaning "blood-loving") to reflect the fastidious growth requirement of the organism, as well as its apparent association with influenza. In 1933, the discovery of the viral etiology of influenza eventually refuted this erroneous association. Nevertheless, subsequent findings revealed that H influenzae was responsible for a wide spectrum of clinical diseases.

In the 1930s, Margaret Pittman defined 2 major categories of H influenzae: the unencapsulated strains and the encapsulated strains. The unencapsulated strains were chiefly responsible for infections at mucosal surfaces, including otitis media, conjunctivitis, bronchitis, and sinusitis. In contrast, 1 of the 6 antigenically distinct encapsulated strains, strain type b, was associated with invasive diseases (eg, septicemia, meningitis, cellulitis, septic arthritis, epiglottitis, pneumonia).

Prior to the availability of an effective vaccine, H influenzae type b (Hib) was the most common cause of pediatric bacterial meningitis in the United States.

Pathophysiology:

Pathogenesis

A major virulence factor of H influenzae is its polysaccharide capsule, which plays a central role in molecular pathogenesis and the immune response. Six antigenically and biochemically distinct capsular polysaccharide subtypes (a-f) have been identified (see Lab Studies). Although, historically, type b encapsulated stains have been of primary clinical and immunologic importance because of their association with invasive infection, including meningitis, the other encapsulated strains also can cause invasive disease.

The type b capsular polysaccharide is well characterized at the molecular level. It is composed of repeating heteropolymers of ribosyl and ribitol phosphate. Rapid diagnostic latex agglutination tests are available for the identification of this polyribosyl ribitol phosphate (PRP) after its release in infected patients. This polysaccharide structure is unique to type; the other capsular Haemophilus serotypes are composed of hexose rather than pentose sugars.

Another important component of the H influenzae cell wall that contributes to pathogenesis is lipopolysaccharide (LPS). Although chemically different from the LPS of the Enterobacteriaceae, the biological activity of Hib LPS appears to be similar to that of other gram-negative endotoxins. Finally, a number of outer membrane proteins have recently been identified as important components of pathogenesis and immunity. Pili (or fimbriae), fibrils, and a protein called Hia mediate adherence of HiB to cells of the human respiratory tract. The multiple adhesins target specific cells of the airway and provide redundancy for adherence to respiratory tissues. H influenzae encodes 3 distinct immunoglobulin A (IgA) proteases that may be involved as virulence factors by interfering with host mucosal defenses.

Since the entire genome of a laboratory strain of H influenzae was sequenced recently, additional insights into its molecular mechanisms of pathogenesis undoubtedly will be gained in the near future.

Age-related susceptibility and immune response

In pioneering experiments in the 1930s, Fothergill and Wright demonstrated that blood obtained from children aged 3 months to 3 years lacked bactericidal activity against type b strains, whereas the blood of neonates, older children, and adults was bactericidal. Eventually, this effect was shown to be dependent upon the presence of a specific antibody against the type b capsule. In 1942, Alexander proposed that the polyribosyl ribitol capsular polysaccharide was intrinsically antiphagocytic and that efficient ingestion by phagocytes was facilitated by opsonization with type-specific antibodies.

Subsequent evidence has demonstrated that antibody to PRP protects individuals against invasive disease. It activates complement, is opsonophagocytic, and protects animals from experimental challenge. Indeed, passive transfer of type b antiserum was shown to be effective in the treatment of Hib disease in the preantibiotic era. Ultimately, the most compelling evidence for the protective properties of anticapsular antibody is the observation that purified PRP vaccines confer protection. Induction of the antibody to the type b capsular polysaccharide is the means by which all Hib vaccines result in protection.

The age-dependent susceptibility to infections is correlated with the age-dependent nature of the immune response to Hib capsular polysaccharide. When infants are at maximal risk of infection (ie, at the nadir of protective transplacental immunity), their serum anti-PRP antibody levels are low or absent. Even after they recover from illness, their antibody levels are low and their immune responses are poor. As a consequence, second or third episodes of invasive Hib disease are described, and a previous episode of invasive infection does not obviate Hib immunization. Infants' failure to make serum anti-PRP antibodies is typical of the natural delay in the development of their immune response to polysaccharide antigens.

PRP stimulates B cells, but it does not adequately activate macrophages and appropriate helper T cells. Therefore, it is considered to be a T-cell–independent antigen. Characteristics of T-cell–independent antigens include the following: immune responses to them are limited, particularly in young infants; no booster response occurs with repeated antigenic stimulation; and the antibodies have low affinity to the antigen and mostly consist of immunoglobulin M (IgM). The development of an HiB vaccine that was more immunogenic and protective in young infants required the conversion of PRP from a T-cell–independent antigen to a T-cell–dependent antigen; the principles of carrier-hapten linkage were used to accomplish this.

The role of other host immune responses in limiting H influenzae disease is poorly understood. PRP-specific IgA antibodies have been described. This finding suggests a possible role for secretory antibodies that can block H influenzae attachment to the respiratory tract mucosa, but the clinical relevance of this proposed mechanism remains to be demonstrated. Complement also appears to be involved in the host defense against H influenzae. Both encapsulated and unencapsulated strains of H influenzae activate the classical and alternative complement pathways in vitro. The clinical correlates of this observation are the results suggesting that individuals with C2, C3, and C4b deficiencies are more susceptible to invasive Hib disease.

Antimicrobial resistance

Another clinically important aspect of the molecular microbiology of H influenzae is the identification of the genes responsible for its antimicrobial resistance. Resistance to ampicillin has become extremely common; 5-50% of isolates in various parts of the world are resistant. The mechanism of resistance typically is due to the presence of a plasmid-encoded enzyme, beta-lactamase. Plasmid-encoded resistance to chloramphenicol, tetracycline, and sulfonamides can exist independently; in some countries, multiple resistance determinants reside on the same plasmid. Chromosomally mediated antibiotic resistance, due to the accumulation of point mutations, most commonly involves amoxicillin. This resistance is low level and can coexist with plasmid-mediated resistance. Trimethoprim resistance most commonly is due to mutations in chromosomal dihydrofolate reductase. Susceptibility testing should be performed with all isolates identified in invasive infections.

Transmission and infection

Humans are the only natural host for H influenzae. Therefore, maintenance of the organism in the human population depends on person-to-person transmission, which efficiently occurs via respiratory droplet spread. Although both nontypeable strains and Hib easily are spread via person-to-person transmission, Hib strains have historically been associated with invasive disease in children. Before effective vaccines were available, nasopharyngeal acquisition of Hib occurred in most children aged 5 years or younger. Although nasopharyngeal Hib colonization may not produce symptoms, breakthrough bacteremia with subsequent focal infection was common at one time, and it was a major public health problem in children in the United States.

The molecular determinants responsible for the nasopharyngeal colonization and subsequent bacteremic invasiveness of H influenzae remain poorly understood. Invasive disease requires the spread of bacteria from the upper respiratory tract to the bloodstream and, subsequently, to other body sites. The organism first must colonize the respiratory mucosal epithelium, and several bacterial surface proteins appear to play an important role in the attachment process. The organism then invades the nasal mucosa. The exact mode of entry of the organism into the blood vessel is unknown; it may enter via the lymphatics. The size of the bacterial inoculum and the intercurrent presence of a viral respiratory tract infection potentiate the risk of invasive disease.

It has been suggested that H influenzae can invade and enter respiratory epithelial cells by means of transcytosis. Strains that are able to resist lysis by the complement system (ie, those with a capsule) or opsonophagocytosis (due to the lack of a natural antibody) then can replicate in the bloodstream, causing invasive disease. As organisms divide, bacteremia increases steadily over hours. When bacteremia occurs, its magnitude and duration are determined by the dynamics of bacterial proliferation and clearance by anti-PRP antibodies and phagocytes. When the bacterial concentration exceeds 104 organisms per milliliter, metastatic seeding occurs, especially to the meninges via the choroid plexus. Although the meninges are involved in more than half of recognized cases of invasive Hib disease, other potential metastatic sites include the lungs, joint synovium, pleura, peritoneum, and pericardium.

Noninvasive or mucosal infections are much more common than invasive disease, particularly in the postvaccine era. These generally are due to nontypeable strains of H influenzae, and bacteremia seldom is present. Therefore, these infections are presumed to represent extensions of H influenzae from the respiratory mucosa to contiguous body sites. Noninvasive infections include otitis media, sinusitis, bronchitis, and pneumonia. Local extension of nontypeable H influenzae can occur via the eustachian tubes, bronchi, or sinus passages. Disease is more likely if normal clearance mechanisms or immune function is impaired, for example, after viral infection, sinus obstruction, or eustachian tube dysfunction.

Risk factors and epidemiology

Chronic illnesses associated with an increased risk of invasive Hib disease include sickle-cell disease, asplenia, agammaglobulinemia, Hodgkin disease, and complement deficiencies. Risk is also increased in those who attend daycare and in those who have young siblings, a crowded household, a lower socioeconomic status, or exposure to cigarette smoke. Breastfeeding confers some protection against disease.

The epidemiology of invasive Hib disease has changed dramatically in recent years because of the widespread use of conjugate vaccines. In 1987, the first Hib vaccine (purified PRP) was licensed in the United States for use in children aged 18 months and older. Over the next few years, the incidence of invasive disease dramatically decreased in older children. However, because Hib meningitis was a greater problem in infants younger than 1 year, the most significant decline was not observed until late 1990, when protein-PRP conjugate vaccines were approved for use in infants aged 2 months or older. In populations with high rates of vaccination, the incidence of Hib disease has decreased by more than 95%.

The protective effectiveness of these vaccines exceeded initial expectations. This result was attributed to their direct effect on nasopharyngeal carriage, which ultimately decreased the environmental burden of Hib and protected even unimmunized children because of the effect of herd immunity. The conjugate vaccines are so effective in preventing Hib infection that the finding of invasive disease in a fully immunized child should suggest the possibility of an underlying immunodeficiency and prompt further diagnostic evaluation.

An important epidemiologic aspect of Hib disease is the risk that it poses to contacts of the affected person. Although the direct contagiousness of invasive Hib infection is limited, household contacts have a significant risk of secondary disease, particularly in the 30 days after their exposure to the index patient. This risk is related to droplet spread under conditions of continuous household exposure. Colonization rates of more than 70% have been noted after exposure in closed populations, such as those in families or daycare centers. This is the rationale for chemoprophylaxis after exposure to invasive Hib disease.

Another less common but recently recognized route of exposure is the vertical transmission of H influenzae via the maternal birth canal. In recent years, this phenomenon has been evidenced by an increase in cases of neonatal bacteremia and meningitis caused by nontypeable strains acquired from the mother's genital tract. These strains are genetically distinct from those that colonize the upper respiratory tract.

A bimodal seasonal disease pattern has been described; one peak occurs in autumn between September and December, and a second occurs in spring between March and May. Historically, invasive HiB infection has been uncommon in adults (apparently because of the gradual development of protective antibodies over time in the context of asymptomatic nasopharyngeal colonization), but Hib occasionally can cause invasive infection in adults. Remarkably, in the postvaccine era, Hib meningitis is more common in adults than in children. The effect of routine childhood Hib immunization on the epidemiologic characteristics of adult infections, if any, remains to be seen.

Frequency:

• In the US: Nontypeable strains colonize the upper respiratory tract in as many as three fourths of healthy adults. Hib strains colonize the nasopharynx of 3-5% of children; the effectiveness of vaccines is related, in part, to their ability to dramatically diminish the prevalence of nasopharyngeal colonization.
  
  In the prevaccine era, invasive Hib disease had a characteristic and striking age-related prevalence; approximately 85% of cases occurred in children younger than 5 years. The peak prevalence of the most serious form of invasive disease, meningitis, occurred in infants aged 6-12 months. Hib epiglottitis was, in contrast, predominantly a disease of older children, with more than 80% of the infections occurring in children older than 2 years.

  In the prevaccine era, approximately 20,000 instances of invasive Hib disease occurred annually in the United States, affecting approximately 1 child in every 200 younger than 5 years. Certain high-risk groups, including Navajo and Alaskan Native Americans, had an even higher incidence of disease.

• Internationally: Hib continues to be a major cause of sepsis and meningitis in the developing world, where resources for widespread immunization programs are not available. In addition, a nonserotypeable H influenzae biogroup III (which is identical to the Haemophilus aegyptius group) has been shown to be the cause of a disease called Brazilian purpuric fever (BPF), recently discovered in children in southern Brazil.

Mortality/Morbidity: Even with prompt diagnosis and supportive care, the mortality rate of Hib meningitis is approximately 5%. Long-term sequelae occur in 15-30% of survivors and include sensorineural hearing loss, language disorders, mental retardation, and developmental disorders. In epiglottis, the mortality rate of 5-10% invariably is related to poor early airway control.

Age: In the prevaccine era, invasive Hib disease had a characteristic and striking age-related prevalence; approximately 85% of the cases occurred in children younger than 5 years. Hib was the most common cause of pediatric bacterial meningitis, which had a peak prevalence in infants aged 6-12 months. More than 80% of cases of Hib epiglottitis occurred in children older than 2 years. Hib was the leading cause of septic arthritis in children younger than 2 years. Currently, epiglottitis occurs primarily in older children (aged 2-7 y). The vast majority of cases of cellulitis occur in children aged 2 years or younger.

	CLINICAL	Section 3 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

History: The history is targeted to identifying the specific H influenzae disease syndromes, which include the following:

• Meningitis

• Prior to Hib vaccines, meningitis was the most common and serious manifestation of invasive disease.

• Disease is insidious in onset, with a preceding nonspecific febrile illness. No specific etiologic clues are present. The signs and symptoms can be nonspecific.

• Young infants may present with irritability, lethargy, anorexia, or vomiting. Only older children are likely to present with the classic findings of headache, photophobia, and meningismus. Therefore, the absence of meningismus is not a helpful finding for excluding meningitis in a young child.

• Epiglottitis

• Acute upper airway obstruction caused by Hib infection of the epiglottis and supraglottic tissues is perhaps the most dramatic and rapidly progressive form of disease caused by H influenzae.

• Epiglottitis occurs primarily in older children (aged 2-7 y), and it usually has an abrupt onset with high fever, dysphagia, drooling, and toxicity.

• Occasional cases of Hib epiglottitis in older children still occur in children who were never fully immunized.

• Hib is also an important cause of epiglottitis in adult patients.

• Septic arthritis and osteomyelitis: In the prevaccine era, Hib was the leading cause of septic arthritis in children younger than 2 years.

• Cellulitis

• Hib cellulitis usually involves the face, head, or neck.

• Most cases occur in children aged 2 years or younger.

• Occult bacteremia: In the prevaccine era, Hib was the second leading cause of occult bacteremia after Streptococcus pneumoniae.

• Pneumonia: Hib pneumonia caused as many as one third of the documented cases of bacterial pneumonia in the prevaccine era.

• Pericarditis

• Neonatal disease

• In recent years, H influenzae has been increasingly recognized as a cause of bacteremia and meningitis in neonates. Neonatal infections are usually caused by nontypeable H influenzae, which can be cultured with samples from the maternal genital tract, the presumed source of the infection.

• The disease involves early-onset sepsis; more than 80% of cases occur in 1-day-old neonates.

• Maternal-to-fetal transmission probably occurs in utero because the infection is associated with prematurity, low birth weight, and maternal complications such as premature rupture of membranes and chorioamnionitis.

• Brazilian purpuric fever

• A nonserotypeable H influenzae biogroup III (identical to the H aegyptius group) organism has been demonstrated to be the cause of a disease called Brazilian purpuric fever (BPF) recently discovered in children in southern Brazil.

• After an antecedent episode of purulent conjunctivitis, children with BPF become bacteremic and present with fever, shock, and purpura fulminans.

• The disease may mimic meningococcemia, but this has not been reported in the United States.

• Nontypeable H influenzae disease
  • Underlying medical conditions, such as prematurity, cerebrospinal fluid (CSF) leak, congenital heart disease, and immunoglobulin deficiency, may predispose an individual to invasive disease caused by the nontypeable strains of H influenzae.

  • Immunization with conjugate Hib vaccines does not confer protection against the nontypeable strains. Therefore, nontypeable H influenzae remains a major cause of otitis media in children. (Other common causes of acute otitis media in children are S pneumoniae and Moraxella catarrhalis.) Hib is an unusual cause of acute otitis media, particularly in the era of conjugate vaccines.

  • Occasionally, the encapsulated non-Hib strains of H influenzae are implicated as causes of invasive disease.

  • Recent findings from a series of H influenzae type F meningitis cases suggest that these organisms conceivably could emerge as important causes of invasive disease in children in the post-Hib vaccine era, although this trend has not yet become widespread.

Physical: Physical examination findings depend on the clinical syndrome. Because influenza is a bacteremic infection, comprehensive physical examination and complete evaluation are mandatory, with a focus on excluding meningeal, lung, and pericardial involvement.

At physical examination, findings may include the following:

• Meningitis

• Approximately 30% of children have seizures at some point in the course of Hib meningitis.

• Like patients with meningococcal disease, children with Hib bacteremia can have a petechial rash.

• Patients can also have a secondary site of infection, such as septic arthritis or facial cellulitis.

• Shock is present in approximately 20% of patients.

• Anemia is common; it is caused by a combination of accelerated red blood cell destruction and diminished erythropoiesis.

• Complications of Hib meningitis include subdural effusion or empyema, ischemic or hemorrhagic cortical infarction, cerebritis, ventriculitis, intracerebral abscess, and hydrocephalus.

• Epiglottitis

• Typically, a child with Hib epiglottitis drools because of an inability to swallow the oropharyngeal secretions, and progressive respiratory distress develops over a period of hours, with tachypnea, stridor, cyanosis, and retractions.

• The patient may sit forward with his or her chin extended, in the so-called tripod position, to maintain an open airway. Few conditions produce such a striking constellation of symptoms and findings.

• Lateral neck radiography can be helpful if the clinical presentation is subtle (see Imaging Studies), but diagnostic studies should not delay direct inspection of the epiglottis in the operating room and insertion of an endotracheal tube. The mortality rate of 5-10% is invariably related to poor early airway control.

• Septic arthritis and osteomyelitis

• These usually affect the large joints, particularly knees, ankles, hips, and elbows.

• Contiguous osteomyelitis may be present, but isolated osteomyelitis without an adjacent septic joint is uncommon.

• Characteristically, preceding nonspecific illness is present; this is followed by pain, swelling, and erythema of the involved joint.

• Clinical signs in children with a septic hip may be less prominent than in those with other affected joints. Findings may be limited to a decreased range of motion in the joint or referred pain from the hip.

• A strong association exists between septic arthritis and meningitis; lumbar puncture is necessary.

• Cellulitis

• Buccal cellulitis occurs almost exclusively in infants aged 1 year or younger. In infants, the onset of illness includes fever and a raised, warm, tender, and indurated area that develops a violaceous hue.

• The clinical presentation may mimic erysipelas.

• Periorbital (preseptal) cellulitis occurs in young children, and it often occurs in the context of contiguous sinus disease. It must be differentiated from the more serious orbital (postseptal) cellulitis, which can be a life-threatening complication of invasive Hib disease (or disease caused by other pathogens).

• Often a complication of disease in the paranasal sinuses, orbital cellulitis can lead to cranial sequelae, including cavernous sinus thrombosis. (Typically, hospital admission for intravenous antibiotics, imaging studies [CT scan, MRI], and consultations with an ophthalmologist and a neurosurgeon is required.)

• The clinical triad of chemosis, proptosis, and ophthalmoplegia should prompt consideration of the diagnosis of postseptal cellulitis.

• Hib cellulitis is a bacteremic disease, and meningitis must be excluded by means of lumbar puncture.

• Occult bacteremia

• Although most children with Hib bacteremia have a focus of infection, occasionally bacteremia can be the sole manifestation of disease in the febrile child. These children are usually younger than 2 years and have temperatures of 39°C or higher.

• An important distinction between Hib and pneumococcal bacteremia is that most episodes of untreated occult pneumococcal bacteremia resolve spontaneously without sequelae, whereas 30-50% of children with occult Hib bacteremia have focal infections, including meningitis. Hence, in any child with blood culture results positive for Hib, the possibility of meningitis must be seriously considered.

• Pneumonia

• Hib pneumonia is clinically indistinguishable from other bacterial pneumonias. It has a strong association with pleural effusion; therefore, radiography may be helpful (see Imaging Studies).

• The best diagnostic test is blood culture, which has positive findings in almost 90% of patients.

• Complications of Hib pneumonia include pleural empyema, pericarditis, and meningitis.

• Pericarditis

• The classic presentation of H influenzae pericarditis is that of a toxic-appearing child with fever, respiratory distress, and a clear chest on examination.

• Associated conditions include pneumonia and meningitis.

• Hib pericarditis may become clinically apparent when a child receives antibiotic therapy. It should be considered in the differential diagnosis in a child who has a persistent fever while receiving therapy for H influenzae meningitis.

• Although the diagnosis may be suggested after careful inspection of the cardiac silhouette and neck veins, echocardiography is the best test for establishing the diagnosis of pericardial effusion.

• Pericardiocentesis is the diagnostic procedure of choice.

• Other invasive infections

• Hib bacteremic disease is rarely associated with seeding of other body sites.

• Endophthalmitis, glossitis, uvulitis, thyroiditis, endocarditis, lung abscess, epididymitis, peritonitis, intraperitoneal abscesses, hepatobiliary disease, and brain abscesses have been reported.

• Nontypeable H influenzae disease

• Nontypeable strains of H influenzae frequently cause otitis media, sinusitis, conjunctivitis, and bronchitis. Conjunctivitis is usually bilateral and purulent and often occurs in association with acute otitis media (ie, conjunctivitis-otitis syndrome).

• Although these respiratory tract infections are common, they are rarely life threatening. In general, they are not associated with bacteremia.

• The finding of nontypeable H influenzae systemic infection should prompt immunologic investigation, even if the obvious risk factors are absent.

• CNS involvement: The CNS is a major target organ in invasive H influenzae disease.

• Cardiovascular involvement

• Children with invasive H influenzae disease often have septic shock.

• Cardiovascular instability may manifest as blood pressure instability.

• Myocardial dysfunction may occur, and pericarditis is a known and important complication.
• Respiratory involvement
  • Invasive H influenzae disease may cause pneumonia or upper airway obstruction secondary to epiglottitis.

  • Clinicians skilled at airway management should be available to coordinate the treatment of these children.

• Fluid and electrolyte disturbances: When meningitis is present, children may have disturbances in fluid and electrolyte homeostasis due to shock and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

	DIFFERENTIALS	Section 4 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Arthritis, Septic
Asplenia
Bacteremia
Bronchitis, Acute and Chronic
Epiglottitis
Fever in the Toddler
Meningitis, Bacterial
Otitis Media
Pericarditis, Bacterial
Pneumonia