Haemophilus Influenzae Infections Treatment & Management

  • Author: Vidya R Devarajan, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 10, 2012
 

Medical Care

  • Antibiotics and supportive care
    • These are the mainstays of treatment.
    • Initially, invasive and serious H influenzae type b (Hib) infections are best treated with an intravenous third-generation cephalosporin until antibiotic sensitivities become available. In Malawi, Africa, intramuscular ceftriaxone was compared with intravenous ceftriaxone and was not found to increase the mortality rate. This may be important in developing countries where the intravenous route may not be possible.[10]
    • The site of infection and the clinical response determine the length of antibiotic treatment.
  • Meningitis
    • Administer parenteral antibiotics (eg, ceftriaxone, ceftazidime, cefotaxime, ampicillin-sulbactam, fluoroquinolones, azithromycin) to patients with uncomplicated meningitis for 7-14 days. Cefotaxime and ceftriaxone are the initial drugs of choice for suspected Hib meningitis.
    • Once the susceptibilities are known, adjust antibiotics accordingly.
    • Do not use ampicillin empirically, since as many as 50% of the isolates are resistant, usually because of plasmid-mediated beta-lactamase production.
    • Cefuroxime is also not recommended because delayed sterilization is more common.
    • Chloramphenicol produces adequate bactericidal blood and CSF levels but is now used infrequently because it requires monitoring of drug levels and can result in dose-dependent (though reversible) bone marrow toxicity (particularly in neonates and patients with liver disease) or an idiosyncratic aplastic anemia.
    • Dexamethasone is an important adjunctive treatment in patients with meningitis who are older than 2 months because it has been shown to decrease the inflammatory response and the rate of hearing loss[11] and other neurological complications.[12]
      • The 2004 Infectious Disease Society of America (IDSA) guidelines recommend that dexamethasone 0.15 mg/kg/d q6h for 2-4 days be administered to children (but not adults) with H influenzae meningitis. When steroids are used, they must be administered either prior to or along with antibiotics, as dexamethasone administered after antimicrobials is unlikely to be beneficial.[13]
      • In January 2007, a systematic review of randomized controlled trials involving adjuvant corticosteroids therapy in acute bacterial meningitis found a significant benefit in children from developed countries but no beneficial or harmful effects in children in developing countries. This meta-analysis also found that dexamethasone administered to adults with community-acquired meningitis (including that caused by H influenzae) decreased the risk of mortality and neurologic sequelae. Based on data from 18 randomized controlled trials, the authors concluded that all adults and children with acute bacterial meningitis in developed countries who have good access to medical care should receive adjuvant corticosteroids. The authors also found no significant increase in adverse effects due to corticosteroids. The recommended dose for dexamethasone in adults and children is 0.6 mg/kg/d for 4 days.[11]
      • A randomized prospective study in 1994 found that, in treatment for bacterial meningitis, a 2-day course of dexamethasone provided effectiveness similar to that of a 4-day course.[14] However, most studies recommend a 4-day dexamethasone course.
      • In November 2007, a prospective randomized double-blind placebo-controlled trial studied adjuvant glycerol and dexamethasone in children with bacterial meningitis. All patients were given ceftriaxone and randomized to receive intravenous dexamethasone, oral glycerol, both agents, or neither agent. In addition, a subgroup of patients with Hib meningitis was studied. Findings showed that glycerol, an inexpensive osmotic diuretic that can be administered orally, reduced the incidence of neurologic sequelae and death. Dexamethasone prevented profound hearing loss when the timing of dexamethasone and ceftriaxone administration was not taken into account. Few adverse effects were found with either adjuvant medication. Additional studies need to be performed to evaluate the impact of glycerol in bacterial meningitis.[15]
      • In 2007, a Vietnamese study evaluated the benefit of dexamethasone in adults and adolescents with confirmed or suspected bacterial meningitis. Overall, initial findings showed that dexamethasone did not decrease the mortality rate at 1 month or the incidence of mortality or disability at 6 months. However, when the results were compared with culture-proven disease, dexamethasone was found to confer a significant benefit in terms of both mortality and disability in patients with confirmed bacterial meningitis. Among the patients studied, only 7 had H influenzae meningitis, and 6 of these were in the placebo group.[16]
      • In a 2007 study in Malawi, Africa, dexamethasone was given to adults with bacterial meningitis but was not found to reduce mortality or morbidity. However, 90% of the study patients had HIV infection. Of the 465 patients studied in this group, only 3 had H influenzae meningitis.[10]
    • Treatment of H influenzae meningitis also includes ongoing supportive care and management of complications such as shock, inappropriate secretion of antidiuretic hormone syndrome, seizures, subdural empyema, and secondary foci of infection.
    • Small, clinically insignificant subdural effusions are common.
    • In uncomplicated cases, a repeat lumbar puncture is unnecessary to ensure sterility of the CSF.
  • Cellulitis
    • In patients with Hib cellulitis, administer parenteral antibiotics until the patient shows defervescence and the cellulitis subsides. Then, administer appropriate oral antibiotics until the course of therapy, usually 7-10 days, is finished. Empiric therapy for preseptal cellulitis should cover not only Hib but also S pneumoniae, Staphylococcus aureus, and group A beta-hemolytic streptococci. Patients with orbital cellulitis require at least 14 days of parenteral therapy.
    • Surgical drainage may be needed for the underlying sinusitis or for orbital abscesses.
  • Epiglottitis
    • Maintenance of a patent airway via intubation or tracheostomy is the mainstay of treatment for epiglottitis.
    • Administer antimicrobial therapy parenterally once the airway is secured, and continue until the patient can receive oral fluids. The total duration of therapy is 7-10 days.
  • Arthritis
    • So far, no studies have accurately defined the appropriate length of therapy for septic arthritis. However, uncomplicated septic arthritis usually requires systemic antibiotics for at least 7 days.
    • If an appropriate clinical response is obtained, oral therapy for 2-3 weeks may follow. Therapy may continue beyond 3 weeks until the ESR begins to normalize. The ESR may lag behind successful clinical response for weeks; accordingly, the C-reactive protein test may be a more useful laboratory tool because its values tend to normalize more rapidly.
  • Bacteremia and other Hib infections
    • Bacteremia precedes essentially all invasive Hib infection.
    • Approximately 30-50% of children with occult Hib bacteremia (bacteremia without an identifiable cause) develop a focus of infection such as meningitis, cellulitis, or pneumonia. Therefore, reevaluate these children (including with lumbar punctures and chest radiography) for an infectious focus and obtain repeat blood cultures.
    • Administer parenteral antibiotics for at least 2-5 days and guide subsequent therapy based on the focus of infection. If no focus is identified, substitute oral antibiotics to complete 10 days of therapy. Patients with pericarditis, empyema, endocarditis, endophthalmitis, or osteomyelitis require an extended antibiotic treatment duration of 3-6 weeks.
  • Nonencapsulated H influenzae
    • These organisms can cause mucosal infections treatable with oral antibiotics. The first-line antibiotic for otitis media is amoxicillin (80-90 mg/kg/d for 7-10 d) because of its safety and low cost. If the organism produces beta-lactamase or if other treatment fails, treatment with amoxicillin-clavulanate is recommended. Penicillin-allergic individuals may be treated with erythromycin-sulfisoxazole or cefaclor. Cefaclor has weak activity against beta-lactamase–producing bacteria and causes a serum sickness–like illness in 2% of patients. Approximately 25-50% of NTHi strains produce beta-lactamase and, therefore, are resistant to amoxicillin and ampicillin.
    • Oral antibiotics with activity against beta-lactamase–producing H influenzae include trimethoprim-sulfamethoxazole, cefuroxime axetil, cefixime, clarithromycin, azithromycin, and fluoroquinolones. The duration of therapy is 10 days for otitis media and at least 14 days for sinusitis. Patients with conjunctivitis should receive topical antibiotics such as sulfacetamide and erythromycin.
    • Administer parenteral antibiotics to patients with invasive NTHi infection, which can be treated similarly to invasive Hib disease.
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Surgical Care

  • Patients with subdural and pleural empyema may require surgical drainage if orbital cellulitis is extensive.
  • Patients with pericarditis require systemic antibiotics and drainage via early pericardectomy or pericardiostomy rather than multiple pericardiocentesis.
  • Patients with septic arthritis of the hip require surgical drainage to avoid avascular necrosis of the femoral head. Repeated aspirations or surgical drain placement may be needed in other infected joints to reduce pressure.
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Consultations

  • Consult an ear, nose, and throat specialist and an anesthesiologist for help in securing difficult airways in all cases of suspected epiglottitis.
  • Consult a neurosurgeon for suppurative complications of nervous system involvement.
  • Consult an ophthalmologist for management of orbital cellulitis.
  • Consult an infectious disease specialist for assistance with complicated infections.
  • Consult an orthopedic surgeon for surgical drainage of a joint.
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Contributor Information and Disclosures
Author

Vidya R Devarajan, MD 

Disclosure: Nothing to disclose.

Specialty Editor Board

Wesley W Emmons, MD, FACP  Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE

Wesley W Emmons, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International AIDS Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Charles V Sanders, MD  Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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