IC11 Infection Prevention in Travelers & SAP Flashcards
To get A for CA2 (70 cards)
1
Q
Information necessary for a risk assessment during pre travel consultations (11)
A
- past medical history
- immunisation history
- prior travel experience
- itinerary
- timing
- type of accommodation
- traveler’s risk tolerance
- financial challenges
- reason for travel
- travel style
- activities done during travel
2
Q
Describe Herd Immunity
A
Herd Immunity refers to when enough of the population is immunised against a certain disease to contain the spread of the disease, and most community members are protected, including the unimmunised individuals.
3
Q
List the vaccines included in national childhood immunisation schedule (11)
A
- BCG
- Influenza
- TDAP
- MMR
- Varicella
- Polio
- PCV
- Hep B
- Rotarix (recommended)
- HPV
- Hib
4
Q
List the vaccines included in national adult immunisation schedule (7)
A
- TDAP
- Varicella
- MMR
- HepB
- HPV
- PCV
- Influenza
5
Q
Malaria signs and symptoms (7)
A
- Fever
- Chills
- Sweats
- Headaches
- Body aches and weakness
- GI (NVD & abdominal pain)
- Cough
6
Q
Which species of plasmodium is resistant to chloroquine
A
P falciparum
7
Q
Name 3 Precautions for the use of live-attenuated vaccines (there are a total of 5 precautions)
A
1) Avoid in pregnant women
2) Usually not given in infancy (<1 year old)
3) Avoid in severely immunocompromised patients (Hematologic or solid organ malignancies, Immunosuppressive meds, chemotherapy, HIV with CD4 < 200)
4) Two live viral vaccines (IM/SC) can be given on the same day but if not on the same day, second vaccine has to be administered 28 days (1 month) after the first
5) Spaced 3‐10 months apart from administration of antibody containing products e.g. immunoglobulins, blood transfusion
8
Q
Risk factors of malaria (7)
A
- Between dusk and dawn
- Low altitude
- Hotter season/region
- At the end or soon after rainy season
- Africa South of Sahara and parts of Oceania eg Papua New Guinea
- Tropical and subtropical areas
- African children
9
Q
Mode of transmission of malaria
A
Primarily through bites of infected female Anopheles mosquitoes. Transfusion of contaminated blood products, organ transplantation, vertical transmission (mother to foetus)
10
Q
Strategies for prevention of malaria (5)
A
Awareness - of risk, possibility of delayed onset and main symptoms
Bite prevention - stay away from mosquitoes, especially between dusk and dawn. Use chemical or physical repellents
Chemoprophylaxis - adhere closely to antimalarial preventive medications when prescribed
Diagnosis - early recognition and seek treatment
Environments - keep off mosquito breeding places, such as swamps or marshy areas, especially in late evenings and at night
11
Q
Describe the life cycle of Plasmodium
A
1) Human liver (Exo-erythrocytic cycle)
Paracites grow and multiply first in the liver cells
2) Human blood (Erythrocytic cycle)
Parasites grow and multiply in RBCs and undergo differentiation into sexual stages (gametocytes)
3) Mosquito (Sporogenic cycle)
When certain forms of blood stage parasites (gametocytes, which occur in male and female forms) are ingested during blood feeding by a female Anopheles mosquito, they mate, grow and multiply in the gut of the mosquito and get released into the human again when the mosquito takes another blood meal.
12
Q
Atovaquone + proguanil (malarone) benefits (5)
A
- Good for last minute travellers because the drug is started 1-2days before travelling to an area where malaria transmission occurs
- Some people prefer to take a daily medicine
- Good choice for shorter trips because you only have to take the medicine for 7days after travelling rather than 4weeks
- Very well tolerated medicine - SE uncommon
- Pediatric tablets are available and may be more convenient
13
Q
At which stage of the Plasmodium life cycle will signs and symptoms of Malaria appear?
A
Erythrocytic cycle (Blood phase)
14
Q
Atovaquone + proguanil (malarone) limitations (4)
A
- Cannot be used by women who are pregnant or breastfeeding a child less than 5kg
- Cannot be taken by people with severe renal impairment
- Tends to be more expensive than some of the other options (especially for trips of long duration)
- Some people (including children) would rather not take a medicine every day
15
Q
SE of Atovaquone + proguanil (malarone) (3)
A
- GI (NVD, stomach pain)
- Headache
- Dizzy
16
Q
DDI of Atovaquone + proguanil (malarone)
(3)
A
- Rifampicin
- Metoclopramide
- Efavirenz
17
Q
What are the most prevalent species of Plasmodium
A
P. Falciparum and P. vivax
18
Q
CI of Atovaquone + proguanil (malarone)
(4)
A
- Hypersensitivity
- Renal impaired (CrCl <30ml/min)
- Pregnancy and lactation
- Infants under <5kg
19
Q
Dosing of Atovaquone + proguanil (malarone)
A
Adult dose: 1 adult tablet (Atovaquone 250mg + proguanil 100mg) OD, with food or milky drinks
Start 1-2days prior to trip, during trip and continue for 7days after return
20
Q
Which of the 4 Malaria drugs are able to affect the Liver phase of Malaria?
A
Malarone
21
Q
Dosing of chloroquine
A
Adult dose: 300mg chloroquine base (500mg salt) weekly in one dose, with or after meals. Start 1-2weeks before departure, during trip and continue 4weeks after return
22
Q
CI of chloroquine (3)
A
- Hypersensitivity
- P falciparum resistant
- Precaution: exacerbate psoriasis, seizure disorders, myasthenia gravis, auditory damage, liver impairment, G6PD
23
Q
ADR of chloroquine (3)
A
- GI (NV, stomach pain)
- Skin rash/itching
- QT prolonging (frequency undefined)
24
Q
DDI of chloroquine
A
Caution with QT prolonging strong CYP3A4i eg clarithromycin, voriconazole
25
What are the ADRs of Doxycycline?
GI discomfort, nausea, vomiting, Sunburn, vaginal candidiasis
26
Name the DDI(s) of Doxycycline
Reduced bioavailability with multivalent ions (adsorption; Fe, Mg, Ca)
27
Strengths of chloroquine (4)
- Some people would rather take medicine weekly
- Good choice for long trips because it is taken only weekly
- Some people are already taking hydroxychloroquine chronically for rheumatologic conditions. In those instances, they may not have to take an additional medicine
- Used for all trimesters of pregnancy
28
Contraindications for Doxycycline
Hypersensitivity, not for children < 8 years old, pregnant and breastfeeding
29
Weakness of chloroquine (5)
- Cannot be used in areas with chloroquine or mefloquine resistance
- May exacerbate psoriasis
- Some people would rather not take a weekly medication
- For trips of short duration, some people would rather not take medication for 4 weeks after travel
- Not good choice for last minute traveller because drug needs to be started 1-2weeks prior to travel
30
Dosing of mefloquine
Adult dose: 250mg weekly in 1 dose, after meals
Start at least 1 week (preferably 2-3weeks) before departure, during trip and continue for 4weeks after return
31
CI of mefloquine (5)
- Hypersensitivity
- Regions with resistance
- History of psychiatric (depression, generalised anxiety disorders, psychosis, schizophrenia)
- History of convulsive disorders
- History of cardiac conduction abnormalities
32
What are some of the considerations as to why you would use Doxycycline?
1) Some people prefer to take a daily medicine
2) Good for last minute travellers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
3) Tends to be the least expensive antimalarial
4) Some people are already taking doxycycline chronically for prevention of acne. In those instances, they do not have to take an additional medicine
5) Doxycycline also can prevent some additional infections (e.g., Rickettsiae and leptospirosis) and so it may be preferred by people planning to do lots of hiking, camping, and wading and swimming in fresh water
33
ADR of mefloquine (7)
- GI discomfort
- Dizzy
- Fatigue
- Headache
- Insomnia
- Vivid dreams
- Neuropsychiatric disorder
-
34
DDI of mefloquine
ketoconazole
35
Strength of mefloquine (3)
- Some people would rather take medicine weekly
- Good choice for long trips because it is taken only weekly
- Can be used during pregnancy
36
What are some of the reasons why you would NOT use Doxycycline?
1) Cannot be used by pregnant women and children <8 years old
2) Some people would rather not take a medicine every day
3) For trips of short duration, some people would rather not take medication for 4 weeks after travel
4) Women prone to getting vaginal yeast infections when taking antibiotics may prefer taking a different medicine
5) Persons planning on considerable sun exposure may want to avoid the increased risk of sun sensitivity
6) Some people are concerned about the potential of getting an upset stomach from doxycycline
37
Define surgical site infections (SSIs).
Healthcare-associated infections (HAIs) occurring within 30 days after surgical operation or within 1 year if an implant was left in place and affecting the incision or deep tissue at the operation site.
These may be superficial or deep incisional infections, or infections involving organs or body spaces.
38
Weakness of mefloquine (7)
- Cannot be used in areas with mefloquine resistance
- Not a good choice for last minute travellers because drug needs to be started at least 2weeks prior to travel
- Some people would rather not take a weekly medication
- For trips of short duration, some people would rather not take medication for 4weeks after travel
- Cannot be used in patients with certain psychiatric conditions
- Cannot be used in patients with a seizure disorder
- Not recommended for persons with cardiac conduction abnormalities
39
Considerations for choosing antimalarial chemoprophylaxis (4)
- Travel itinerary
- Medical history (medications DDI, allergy, pregnancy)
- Travel date and duration
- Traveller's preference (dosing, cost)
40
Precaution of using insect repellent (7)
- Apply only to exposed skin or clothing, as directed on product labels. Do not apply to skin covered by clothing
- Never use on cuts, wounds or irritated skin
- When using sprays, do not spray directly on the face - spray on hands first and then apply to the face. Do not apply to eyes or mouth, and only sparingly around ears
- Wash hands after application to avoid accidental exposure to eyes or ingestion
- Children should not handle repellents. Instead, adults should apply it to their own hands first and then gently spread it on the child's exposed skin. Avoid applying directly to children’s hands. After returning indoors, wash children’s treated skin and clothing with soap and water or give child a bath
- Use just enough to cover exposed skin or clothing. Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, apply a bit more
- After returning indoors, wash repellent treated skin with soap and water or bathe. Wash treated clothing before wearing it again. This caution may vary with different products - be sure to check label
41
What are the barrier precautions to be taken to prevent bites?
1) Avoid exposure by staying indoors, especially dusk to dawn (mosquito is night biter)
2) Wear clothing that exposes as little skin as possible (avoid excessively thin clothing as well)
3) Wear light colored clothing
4) Sleep under a permethrin impregnated bed net
5) Sleep in a sealed, air-conditioned room, or screened windows with fan
42
Considerations for immunisation before travelling (6)
- Review routine vaccination
- Choice of vaccine
- Last minute travel
- Number of vaccines in a day
- Minimum intervals between vaccine
- Missed dose
43
List the characteristics of an optimal SAP.
1) Narrowest spectrum of antibiotic effective against pathogens most likely to contaminate surgical site
2) Given in appropriate dose and time that achieves highest tissue concentration upon skin incision
3) Administered for the shortest effective period to minimise ADR, development of resistance and costs
44
List the indications of SAP.
1) Clean surgery (where prosthesis or implant will be inserted OR when SSI poses catastrophic risk e.g. cardiothoracic surgery)
2) Clean-contaminated surgery
3) Contaminated (used as treatment, not prophylaxis)
45
Other advice for patients travelling to high risk malaria countries (5)
- Interventions used to prevent malaria can be very effective when used properly but not 100% effective
- If symptoms of malaria occur, traveller should seek immediate medical attention
- Malaria is always a serious disease and may be a deadly illness. Travellers who become ill with a fever or flu like illness either while travelling in malaria-risk area or after returning home (for up to 1year) should seek immediate medical attention and should tell the physician their travel history
- Travellers who are assessed at being at high risk of developing malaria while travelling should consider carrying a full treatment course of malaria medicines with them
- Exclusion from blood donation - 4months after return
46
Which 2 species of Plasmodium can remain dormant and how long can they remain dormant for?
P. ovale and P. vivax (up to 1 year)
47
List the considerations for timing of administration of antibiotics for SAP.
1) Start administration within 30-60min before surgical incision to achieve good conc. Infusion should be complete prior to incision.
2) For antibiotics requiring longer infusion time (e.g. FQs and vancomycin), administer at least 1-2h before incision.
48
List the considerations for choice of antibiotic for SAP.
1) Cover expected pathogen for operative site
2) Concentrate in high levels at site prior to incision
3) Narrowest spectrum preferred
4) Consider local resistance patterns
5) Consider ADRs such as increased C. difficile and MDR infections
49
List considerations for duration of antibiotic treatment for SAP.
1) Duration should not exceed 24h for most procedures (no benefit).
50
List some non-SAP strategies to reduce risk of SSIs.
1) Don't remove hair at site unless presence affects operation. Use clippers/depilatory agent in place of razors.
2) Control blood glucose during immediate postoperative period (<10mmol/L)
3) Maintain normothermia (>35.5) during perioperative period.
4) Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation.
5) Use alcohol-containing preoperative skin preparatory agents if no CI
6) Use impervious plastic wound protectors for GI and biliary tract surgeries
7) Use WHO checklist to ensure compliance with safe surgical practices
8) Perform surveillance for SSIs
9) Provide ongoing feedback of SSIs to surgical personnel and leadership
51
List considerations for antibiotic dosing and re-dosing in SAP.
Intra-operative re-dosing required when
- Duration of procedure > 2t1/2 of drug
- excessive intra-op blood loss (>1500mL)
- extensive burns
52
Which of the vaccines in NCIS are live attenuated?
MMR, Varicella
53
The only exceptions to the rule of simultaneous administration of vaccine are ____ and ____ in patients with _____. In these patients, there should be a _____ interval between the administration of the two vaccines
pneumococcal conjugate vaccine (PCV),
meningococcal conjugate vaccine,
functional or anatomical asplenia (absence of spleen).
4 week
54
__(number)__ live viral vaccines can be given on the same day but if not given on same day have to be given ____ apart.
2, 4 weeks (28 days)
55
Vaccines should be spaced _____ apart from administration of antibody containing products (e.g immunoglobulins, blood transfusion)
3-10 months
56
Suggest a dosing regimen for a patient who weighs more than 120kg who requires Cefazolin for Surgical Prophylaxis
3g q4h
57
Which is the only oral antibiotic that is used in SAP and what is the dose and redosing interval?
PO Ciprofloxacin 500mg, q8-12h
58
What is the only aminoglycoside used in SAP (according to CTeng's list) and what is the dosing like?
IV/IM Gentamicin 3-5mg/kg
59
What dose of cephalosporins would you give a regular patient (weigh < 120kg) in SAP? Suggest a suitable dosing interval
Both 2g
Cefazolin q4h
Ceftriaxone q12h
60
A patient is undergoing surgery that for whatever reason, has a high risk of C. difficile exposure. Which of the antibiotic(s) in CTeng's list are possible as SAP? Give a suitable dose and re-dosing interval
Vancomycin 15-20mg/kg q8-12h
Metronidazole 500mg q8-12h
61
Suggest a dose of clindamycin to be given as SAP for a surgery that will last 3 hours. Will redosing be required?
IV Clindamycin 600-900mg.
No redosing required (redosing is q4-6h)
62
Which 2 antibiotics (in CTeng's list) can be used if only aerobic gram negatives are to be covered for SAP? Suggest their dosing and re-dosing interval as well
IV Aztreonam 2g q4h
IV/IM Gentamicin 3-5mg/kg (dosing interval NA)
63
Which is the only penicillin drug that is included in CTeng's list and what is the dose and re-dosing interval?
Augmentin 1.2g q4h
64
Which of the SAP antibiotics need to be re-dosed frequently (more than 4 times in 24hrs)
Cefazolin, Aztreonam, Augmentin, Clindamycin (only one that is 4-6h)
65
Which of the SAP antibiotics can be dosed LESS frequently (less than 4 times in 24hrs)?
Ciprofloxacin, Metronidazole, Ceftriaxone, Vancomycin.
Idk where tf Gentamicin falls under but I shall assume its here.
66
A traveller is headed to a country which the CDC deems as Type A for malaria risk, what should be given for chemoprophylaxis?
Nothing. Chemoprophylaxis not required, just focus on bite prevention.
67
A traveller is headed to a country which the CDC deems as Type C for malaria risk, what can be given for chemoprophylaxis?
Malarone, Mefloquine (assuming no resistance), Doxycycline
68
A traveller is headed to a country where there is a risk of multi-drug resistant malaria, what can be given for chemoprophylaxis?
Doxycycline, Malarone
69
What added advantage does DEET 60% confer as an insect repellent?
No added advantage
70
Which of the following are acceptable insect repellants? MRQ.
a) DEET 30%
b) Picaridin 10%
c) Oil of lemon eucalyptus
d) IR3535
e) 2-undecanone
Everything except b).
