(BQ) Part 1 book Succinct pediatrics - Evaluation and management for infectious diseases and dermatologic disorders has contents: Osteomyelitis and septic arthritis, anaerobic infections, cat scratch disease, group a streptococcal infections, listeria monocytogenes infections, meningococcal disease,... and other contents.
Editors Leonard G Feld, MD, PhD, MMM, FAAP, and John D Mahan, MD, FAAP Confidently evaluate evidence-based information to make timely and accurate diagnoses and treatment decisions Continuing with this volume, Succinct Pediatrics is an ongoing series covering the entire scope of pediatric medicine Each volume includes short chapters with key features and invaluable tables and algorithms, allowing health care professionals the opportunity to deliver the highest quality of care The second volume features 58 topics with key points and detailed therapies in infectious diseases and dermatologic disorders The book starts with an overview of the core knowledge needed for medical decision-making Also, evidence-based levels of decision support are provided throughout the book to provide insight into diagnostic tests and treatment modalities yy Influenza yy Cytomegalovirus yy Lyme disease yy Acne yy Plus much more… Parvovirus Fungal infections Rashes Pruritus For other pediatric resources, visit the American Academy of Pediatrics at ISBN 978-1-61002-076-3 90000> 781610 020763 Leonard G Feld, MD, PhD, MMM, FAAP John D Mahan, MD, FAAP Topics include Succinct Pediatrics Evaluation and Management for Infectious Diseases and Dermatologic Disorders Evaluation and Management for Infectious Diseases and Dermatologic Disorders Succinct Pediatrics AAP Succinct Pediatrics Book Evaluation and Management for Infectious Diseases and Dermatologic Disorders Leonard G Feld, MD, PhD, MMM, FAAP John D Mahan, MD, FAAP Succinct Pediatrics Evaluation and Management for Infectious Diseases and Dermatologic Disorders Editors Leonard G Feld, MD, PhD, MMM, FAAP John D Mahan, MD, FAAP Associate Editor Mary Anne Jackson, MD, FPIDS, FISSA, FAAP 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM American Academy of Pediatrics Publishing Staff Mark Grimes, Director, Department of Publishing Chris Wiberg, Senior Editor, Professional/Clinical Publishing Alain Park, Senior Product Development Editor Carrie Peters, Editor, Professional/Clinical Publishing Theresa Wiener, Production Manager, Clinical and Professional Publications Linda Diamond, Manager, Art Direction and Production Amanda Helmholz, Editorial Specialist Mary Lou White, Senior Vice President, Membership Engagement and Marketing & Sales Linda Smessaert, Brand Manager, Clinical and Professional Publications 141 Northwest Point Blvd Elk Grove Village, IL 60007-1019 Telephone: 847/434-4000 Facsimile: 847/434-8000 www.aap.org The recommendations in this publication not indicate an exclusive course of treatment or serve as a standard of care Variations, taking into account individual circumstances, may be appropriate Brand names are furnished for identification purposes only No endorsement of the manufacturers or products mentioned is implied Every effort has been made to ensure that the drug selection and dosages set forth in this text are in accordance with the current recommendations and practice at the time of publication It is the responsibility of the health care professional to check the package insert of each drug for any change in indications and dosages and for added warnings and precautions This publication has been developed by the American Academy of Pediatrics The authors, editors, and contributors are expert authorities in the field of pediatrics No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication The publishers have made every effort to trace the copyright holders for borrowed material If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity Every effort is made to keep Succinct Pediatrics: Evaluation and Management for Infectious Diseases and Dermatologic Disorders consistent with the most recent advice and information available from the American Academy of Pediatrics Special discounts are available for bulk purchases of this publication E-mail our Special Sales Department at aapsales@aap.org for more information © 2017 American Academy of Pediatrics All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher (locate title at http://ebooks.aappublications.org and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780 or e-mail permissions@aap.org) Printed in the United States of America 9-371/1216 10 MA0815 ISBN: 978-1-61002-076-3 eBook: 978-1-61002-077-0 Library of Congress Control Number: 2016936023 Disclosures: Dr Chatterjee indicated a consulting, clinical trials, and speakers’ bureau relationship with Merck; a clinical trials relationship with GlaxoSmithKline; a speakers’ bureau, advisory board relationship with Pfizer; an advisory board and clinical trials relationship with Astra Zeneca; and a speakers’ bureau relationship with Sanofi Pasteur Dr Kaplan indicated a consulting relationship with Pfizer Dr Newland indicated an educational grant relationship with Pfizer All other contributors disclosed no relevant financial relationships 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM Contributors Amina Ahmed, MD, FAAP Department of Pediatrics Division of Pediatric Infectious Disease Levine Children’s Hospital at Carolinas Medical Center Charlotte, North Carolina Krow Ampofo, MB, ChB, FPIDS, FIDSA, FAAP Department of Pediatrics Division of Pediatric Infectious Diseases University of Utah School of Medicine Salt Lake City, UT Charalampos Antachopoulos, MD 3rd Department of Pediatrics Aristotle University, Hippokration Hospital Thessaloniki, Greece Paul M Arguin, MD Domestic Malaria Unit Chief Center for Global Health Centers for Disease Control and Prevention Atlanta, GA Jeffrey R Avner, MD, FAAP Chief, Division of Pediatric Emergency Medicine Professor of Clinical Pediatrics Children’s Hospital at Montefiore Albert Einstein College of Medicine Bronx, NY Henry Bernstein, DO, MHCM, FAAP Hofstra Northwell School of Medicine Steven and Alexandra Cohen Children’s Medical Center of New York Department of Pediatrics, Division of General Pediatrics New Hyde Park, NY Joseph A Bocchini Jr, MD, FAAP Department of Pediatrics Louisiana State University Health Sciences Center Shreveport, LA Kristina Bryant, MD, FAAP Department of Pediatrics Division of Pediatric Infectious Diseases University of Louisville Louisville, KY 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM iv Succinct Pediatrics Craig N Burkhart, MD Associate Professor Department of Dermatology University of North Carolina at Chapel Hill Chapel Hill, NC Jeana Bush, MD, FAAP Levine Children’s Hospital Carolinas Medical Center Charlotte, NC Kristi Canty, MD, FAAP, FAAD Department of Pediatrics Division of Dermatology Children’s Mercy Kansas City University of Missouri-Kansas City School of Medicine Kansas City, MO Cynthia Marie Carver DeKlotz, MD Assistant Professor, Dermatology Georgetown University School of Medicine MedStar Washington Hospital Center/Georgetown University Hospital Washington, DC Shelley Cathcart, MD Pediatric Dermatologist Blue Ridge Dermatology Associates Raleigh, North Carolina Archana Chatterjee, MD, PhD, FAAP Professor and Chair, Department of Pediatrics Senior Associate Dean for Faculty Development University of South Dakota Sanford School of Medicine Sioux Falls, SD Andrea T Cruz, MD, MPH, FAAP Department of Pediatrics Sections of Infectious Diseases and Emergency Medicine Baylor College of Medicine Houston, TX Rachel Dawkins, MD, FAAP Assistant Professor of Pediatrics, Johns Hopkins School of Medicine Medical Director, Pediatric and Adolescent Medicine Clinic Johns Hopkins All Children’s Hospital St Petersburg, FL 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM Contributors v James Christopher Day, MD, FAAP Department of Pediatrics Division of Infectious Diseases Children’s Mercy Hospitals and Clinics Kansas City, MO Penelope H Dennehy, MD, FAAP Director, Division of Pediatric Infectious Diseases Hasbro Children’s Hospital Professor and Vice Chair for Academic Affairs Department of Pediatrics The Alpert Medical School of Brown University Providence, RI B Keith English, MD, FAAP Professor and Chair Department of Pediatrics and Human Development College of Human Medicine Michigan State University Janet A Englund, MD Professor, Department of Pediatrics Seattle Children’s Hospital University of Washington Seattle, WA Claudia Espinosa, MD, MSc, FAAP Department of Pediatrics Division of Pediatric Infectious Diseases University of Louisville Louisville, KY Lori Falcone, DO, FAAP Priority Care Pediatrics Kansas City, MO Sheila Fallon Friedlander, MD, FAAP Professor of Clinical Dermatology and Pediatrics UC San Diego Medical Center Director, Pediatric Dermatology Fellowship Training Program Rady Children’s Hospital San Diego, CA Marc Foca, MD Associate Professor of Pediatrics Division of Infectious Diseases Department of Pediatrics Children’s Hospital of New York Presbyterian New York, NY 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM vi Succinct Pediatrics Anne A Gershon, MD, FAAP Professor of Pediatrics Division of Infectious Disease Columbia University College of Physicians and Surgeons New York, NY Joan E Giovanni, MD, FAAP Department of Pediatrics Division of Emergency and Urgent Care Services Children’s Mercy Hospitals and Clinics Kansas City, MO Andreas H Groll, MD Infectious Disease Research Program Centre for Bone Marrow Transplantation Department of Pediatric Hematology/Oncology University Children’s Hospital Münster Münster, Germany Benjamin R Hanisch, MD Department of Pediatric Infectious Diseases University of Minnesota Minneapolis, MN Jason B Harris, MD, MPH, FIDSA Division of Infectious Diseases Massachusetts General Hospital Department of Pediatrics Harvard Medical School Jo-Ann S Harris, MD, FAAP Consultant, Pediatric Infectious Diseases Hospital Epidemiologist Stormont-Vail HealthCare Adjunct Professor of Pediatrics University of Kansas Topeka, KS Christopher Harrison, MD, FAAP, FPIDS, FIDSA Department of Pediatrics Director of Pediatric Infectious Diseases Laboratory Division of Infectious Diseases Children’s Mercy Hospital of Kansas City Professor of Pediatrics University of Missouri at Kansas City School of Medicine 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM Contributors vii Kimberly A Horii, MD, FAAP, FAAD Department of Pediatrics Division of Dermatology Children’s Mercy Hospitals and Clinics Associate Professor of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City, MO Sadaf Hussain, MD Fellow, Pediatric Dermatology The Children’s Hospital of Philadelphia Philadelphia, PA Christelle M Ilboudo, MD, FAAP Assistant Professor of Pediatrics Division of Infectious Diseases Department of Child Health University of Missouri Health System Jodi Jackson, MD, FAAP Division of Neonatology The Children’s Mercy Hospitals and Clinics, Kansas City Associate Professor of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City, MO Mary Anne Jackson, MD, FPIDS, FISSA, FAAP Director, Division of Infectious Diseases Associate Chair of Community and Regional Pediatric Collaboration Children’s Mercy, Kansas City Professor of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City, MO Chandy C John, MD, MS, FAAP Department of Pediatrics Director, Ryan White Center for Pediatric Infectious Disease and Global Health Indiana University School of Medicine Indianapolis, MN Sheldon L Kaplan, MD, FAAP Department of Pediatrics Section of Infectious Disease Baylor College of Medicine Texas Children’s Hospital Houston, TX 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM viii Succinct Pediatrics J Michael Klatte, MD, FAAP Assistant Professor of Pediatrics Baystate Medical Center Tufts University School of Medicine Springfield, MA Martin B Kleiman, MD Professor of Pediatrics Emeritus University of Indiana Riley Hospital for Children Indianapolis, IN Keren Z Landman, MD Atlanta, GA Sarah S Long, MD, FAAP Professor of Pediatrics Drexel University College of Medicine Department of Pediatrics, Section of Infectious Diseases (Chief) St Christopher’s Hospital for Children Philadelphia, PA Morgan Maier, PA-C Division of Dermatology Seattle Children’s Hospital Seattle, WA Keith J Mann, MD, MEd, FAAP Department of Pediatrics Division of General Pediatrics Chief Medical Quality and Safety Officer Associate Chair of Quality Improvement Children’s Mercy Hospitals and Clinics Professor of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City, MO Gary S Marshall, MD, FAAP Division of Pediatric Infectious Diseases University of Louisville School of Medicine Louisville, KY Kimberly C Martin, DO, MPH, FAAP Assistant Professor of Pediatrics Division of Pediatric Infectious Diseases University of Oklahoma School of Community Medicine Tulsa, OK 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM Contributors ix J Chase McNeil, MD, FAAP Department of Pediatrics Section of Infectious Disease Baylor College of Medicine Houston, TX Shirley Molitor-Kirsch, RN, MSN, CPNP-AC Infectious Diseases/International Travel Medicine Children’s Mercy Hospital & Clinics Kansas City, MO Dean S Morrell, MD Professor of Dermatology Director of Pediatric and Adolescent Dermatology University of North Carolina at Chapel Hill Department of Dermatology Chapel Hill, NC Angela L Myers MD, MPH, FAAP Associate Professor of Pediatrics Division of Infectious Diseases Director, Pediatric Infectious Diseases Fellowship Program Children’s Mercy Hospital, Kansas City University of Missouri-Kansas City School of Medicine Kansas City, MO Kari Neemann, MD, FAAP Assistant Professor, Adult and Pediatric Infectious Diseases University of Nebraska Medical Center Omaha, NE Brandon D Newell, MD, FAAP Department of Pediatrics, Division of Dermatology Children’s Mercy Hospitals and Clinics Associate Professor of Pediatrics—University of Missouri-Kansas City Kansas City, MO Jason G Newland, MD, MEd, FAAP Associate Professor of Pediatrics Division of Infectious Diseases Washington University in St Louis School of Medicine St Louis, MO Ross E Newman, DO, MPHE, FAAP Department of Pediatrics Division of General Pediatrics Children’s Mercy Hospitals and Clinics Assistant Professor of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City, MO 00a-FM-Succinct_i-xxii.indd 11/9/16 9:24 AM 258 Succinct Pediatrics One strategy for the timing of chest radiographs in children with intrathoracic TB disease is to obtain imaging before starting therapy, after months (when anti-TB medications are generally stopped, to be sure that there is not substantial radiographic worsening), and at the end of therapy, to establish a new radiographic baseline for the child If a child’s 2-month chest radiographic findings are normal, there is no need to repeat a chest radiograph at the end of therapy unless the child changes clinically If the end-of-therapy chest radiographic findings remain abnormal, it would be reasonable to see the child again in to 12 months to repeat the radiograph to see if its findings have normalized If they have, the child needs no further evaluation and should be instructed that if she were to have a chest radiograph in the future showing anomalies, that would be a change from her post-TB treatment imaging Sequelae following TB disease are common in children with TB meningitis Most of these children have motor or cognitive dysfunction The extent of this dysfunction may not be evident until the child reaches school All children with TB meningitis should have audiologic evaluation prior to hospital discharge and should be referred for additional developmental resources, such as Early Childhood Intervention Suggested Reading American Thoracic Society, Centers for Disease Control and Prevention, Infectious Diseases Society of America Targeted tuberculin testing and treatment of latent tuberculosis infection Am J Resp Crit Care Med 2000;161(4 Pt 2):S221–S247 American Thoracic Society, Centers for Disease Control and Prevention, Infectious Diseases Society of America Treatment of tuberculosis MMWR Recomm Rep 2003;52(RR-11):1–77 Centers for Disease Control and Prevention Trends in tuberculosis—United States, 2011 MMWR Morb Mortal Wkly Rep 2012;61(11):181–185 Cruz AT, Starke JR Pediatric tuberculosis Pediatr Rev 2010;31(1):13–25 Froehlich H, Ackerson LM, Morozumi PA; Pediatric Tuberculosis Study Group of Kaiser Permanente, Northern California Targeted testing of children for tuberculosis: validation of a risk assessment questionnaire Pediatrics 2001;107(4):e54 Gie R Diagnostic Atlas of Intrathoracic Tuberculosis in Children: A Guide for Low-Income Countries International Union Against Tuberculosis and Lung Disease; 2003 Machingaze S, Wiysonge CS, Gonzalez-Angulo Y, et al The utility of an interferon gamma release assay for diagnosis of latent tuberculosis infection and disease in children: a systematic review and meta-analysis Pediatr Infect Dis J 2011;30(8):694–700 Mazurek GH, Jereb J, Vernon A, LoBue P, Goldberg S, Castro K; IGRA Expert Committee, Centers for Disease Control and Prevention Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection—United States, 2010 MMWR Recomm Rep 2010;59(RR-5):1–25 24-Ch24-Succinct_249-266.indd 258 11/14/16 3:13 PM Chapter 24 • Tuberculosis and Nontuberculous Mycobacterial Infections 259 Nontuberculous Mycobacterial Infections Overview Nontuberculous mycobacterial organisms are mycobacterial species other than M tuberculosis complex and Mycobacterium leprae Nontuberculous mycobacteria lack person-to-person transmission, but are environmentally ubiquitous They can cause cutaneous disease at the site of skin trauma and cervical lymphadenopathy in otherwise healthy children Nontuberculous mycobacterial species cause more invasive disease (ie, pulmonary, skeletal, bacteremia) in certain immunocompromised children The rapidly growing species (including Mycobacterium fortuitum, Mycobacterium abscessus, and Mycobacterium chelonae) may grow within a week Rapid growth may be the first laboratory indication that an acid-fast-positive organism is not M tuberculosis Most other NTM species, including one of the most commonly isolated NTM species, Mycobacterium avium complex (MAC), take several weeks before growth is evident Just as children with HIV are more commonly affected by TB, certain comorbidities predispose to NTM disease Interferon and interleukin receptor mutations increase risk for disseminated disease Cystic fibrosis predisposes children to NTM pulmonary disease Untreated, advanced HIV infection predisposes to disseminated NTM (primarily MAC) disease Causes and Differential Diagnosis Mycobacterium fortuitum, M chelonae, and M abscessus represent species called “rapid growers,” which grow sufficiently for diagnosis after just to days, in contrast to typical TB and other species of NTM, which take several weeks to grow The differential diagnosis of NTM lymphadenitis includes other bacterial causes of lymphadenitis (eg, streptococci, staphylococci, bartonellosis), viral infections (eg, Epstein-Barr virus, cytomegalovirus), M tuberculosis, and malignancy One study compared children with TB and NTM lymphadenopathy, finding that children with NTM were younger (often preschool aged), born in countries with low TB prevalence, and had normal chest radiographic findings Pulmonary NTM occurs in already-diseased lungs Consequently, the differential diagnosis is broad and includes Stenotrophomonas and Pseudomonas aeruginosa in cystic fibrosis patients Nodular or reticulonodular lung disease may be confused with fungal pneumonitis or Pneumocystis jiroveci For children with cystic fibrosis, a tree-in-bud or cavitary appearance on CT is suggestive of NTM infection Plain radiographs may demonstrate worsening bronchiectasis, which can be caused by both progression of cystic fibrosis and other lung pathogens 24-Ch24-Succinct_249-266.indd 259 11/14/16 3:13 PM 260 Succinct Pediatrics Cutaneous NTM disease can have a similar appearance to nocardiosis and sporotrichosis In the immunocompromised patient, the disseminated nodular skin lesions seen with NTM can mimic cutaneous findings for disseminated cryptococcal disease, histoplasmosis, or aspergillosis Disseminated NTM infection also mimics the symptomatology and radiographic manifestations of disseminated fungal disease Clinical Manifestations The most commonly encountered NTM scenarios in US children are the otherwise healthy preschool-aged child with NTM lymphadenitis and the cystic fibrosis patient with NTM pulmonary disease Nontuberculous mycobacterial lymphadenitis is the most common clinical manifestation of pediatric NTM disease Children have slowly enlarging non-tender cervical nodes; lymphadenopathy is frequently unilateral The nodes may become adherent to underlying soft tissues, the overlying skin, or both, which results in examination findings of fixed or apparently matted nodes With time, the overlying skin often develops a violaceous discoloration Pulmonary NTM usually occurs in children with underlying lung pathology Nontuberculous mycobacterial disease in patients with cystic fibrosis increases in frequency at adolescence, when routine bacterial lung flora often changes Symptoms include worsening of existing pulmonary symptoms (cough, bronchodilator-refractory wheezing), deterioration of pulmonary function testing, or nonspecific constitutional symptoms (fatigue, weight loss) Fever is seen in some patients The nonspecific nature of symptoms, occurring at a time when many adolescents with cystic fibrosis have other reasons for pulmonary decompensation, makes the diagnosis of NTM disease more challenging Patients can have NTM in their sputum as colonizing organisms, not causing pathologic changes in the lungs Consequently, the American Thoracic Society (ATS) has identified clinical, radiographic, and microbiologic parameters to differentiate colonization from infection (Table 24-3) Radiographic changes may include worsening bronchiectasis, mucus plugging, and pulmonary nodules; however, these findings are nonspecific Skin and soft-tissue infections are seen most commonly with Mycobacterium marinum The classic history is development of an indolent verrucousappearing skin lesion, occasionally with adjacent tenosynovitis, after a child has had physical contact with a fish tank or waterborne animal Superficial (folliculitis) and deeper soft-tissue infections (pyomyositis, osteomyelitis after penetrating injuries) have been described Disseminated disease has become much less common in the antiretroviral era Bacteremia (including catheter-related bacteremia) and other disseminated forms (eg, meningitis, osteomyelitis) are now most common in solid organ and bone marrow transplant recipients and patients with specific immunologic 24-Ch24-Succinct_249-266.indd 260 11/14/16 3:13 PM Chapter 24 • Tuberculosis and Nontuberculous Mycobacterial Infections 261 Table 24-3 American Thoracic Society Criteria for the Diagnosis of Nontuberculous Mycobacterial Pulmonary Disease (Both clinical and microbiologic categories must be fulfilled.) Category Criteria Clinical Pulmonary symptoms, chest radiographic findings (nodules or cavities), or CT findings (multiple nodules and multifocal bronchiectasis) and Exclusion of other diagnoses Microbiologic Positive cultures from >1 expectorated sputum samples or Positive culture from at least bronchial wash/lavage or Transbronchial biopsy or other lung biopsy showing histopathologic features consistent with mycobacterial infection and that are culture positive for NTM or Transbronchial biopsy or other lung biopsy showing histopathologic features consistent with mycobacterial infection and sputum or bronchial wash/lavage specimen that is culture positive for NTM Abbreviations: CT, computed tomography; NTM, nontuberculous mycobacteria deficits Constitutional symptoms such as fever and weight loss predominate, and examination may demonstrate hepatosplenomegaly, diffuse nodular skin rash, and disseminated lymphadenopathy Evaluation The optimal diagnostic technique and treatment for NTM cervical lymphadenitis is complete excision of the lymph node In most cases, tissue should be sent for AFB stain, culture, and histopathology; in addition, routine aerobic and fungal cultures should be sent Histopathology in NTM lymphadenitis is more likely to demonstrate microabscesses, positive AFB stain, and necrotizing granulomas, and less likely to demonstrate caseating granulomas than in TB lymphadenitis Incision and drainage of lymph nodes with suspected NTM is not recommended, because this increases the risk of development of a chronically draining sinus tract Several NTM species can cause large areas of induration in response to the tuberculin skin test One would expect the tuberculin skin test result to be positive and the IGRA result to be negative in most cases of NTM lymphadenitis, whereas positive tuberculin skin test and IGRA results would be more consistent with M tuberculosis The diagnosis of NTM pulmonary disease is much more difficult than the diagnosis of NTM infection in ordinarily sterile sites Nontuberculous mycobacterial species can colonize healthy or diseased tissue, and they can also cause disease To facilitate diagnosis, the ATS has developed criteria to differentiate colonization from NTM pulmonary disease (Table 24-3) 24-Ch24-Succinct_249-266.indd 261 11/14/16 3:13 PM 262 Succinct Pediatrics Table 24-4 Potential Adverse Effects and Drug Interactions for Medications Used to Treat Nontuberculous Mycobacteria Disease Drug Interactions Medication Adverse Effects Notes Macrolides (azithromycin, clarithromycin) GI distress; prolongation of QT interval Rare The only drug susceptibilities that correlate with in vivo results are for macrolides; they form the backbone of therapy for NTM disease RIF Hepatotoxicity; idiosyncratic bone marrow suppression Common Important to warn parents and patients about orange discoloration to urine and (less commonly) secretions EMB Optic neuritis and redgreen color discrimination difficulties Rare As children metabolize the drug more rapidly than adults, toxicity is very rare EMB can be used even in the preverbal child in whom visual screening may be difficult Ototoxicity; nephrotoxicity Aminoglycosides (amikacin, kanamycin, tobramycin) Rare Toxicity is cumulative; serial evaluation of hearing and renal function is needed TMP/SMX Rash; hypersensitivity reactions; idiosyncratic bone marrow suppression Rare IV formulation contains a substantial fluid volume Fluoroquinolones (ciprofloxacin, levofloxacin) Prolongation of QT interval; Rare tendon damage; exacerbated muscle weakness in myasthenia gravis patients Particularly useful for Mycobacterium fortuitum Cephalosporins Bone marrow suppression; (cefoxitin) interstitial nephritis Rare Adverse effects depend on cumulative dose Carbapenems (imipenem, meropenem) Bone marrow suppression; interstitial nephritis; lower seizure threshold Rare Levels of antiepileptics may need to be increased Tetracyclines Tooth discoloration in children