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infections Flashcards

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1
Q

what is the role of ART

A

Suppress viral replication
Control immune activation
Preserve existing immunity and permitting recovery of lost or dysfunctional immunity.

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2
Q

What is the impact of ART in children

A

Preserves and restores their immunity
Improves growth
Decreased risk for death/ prolong life expectancy
Preserve neurocognitive decline
Reduces infectious disease risk
Preserve vaccine induced responses
Reversal of organ-specific progression to AIDS

The sooner ART is strted the better the outcome

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3
Q

What tests should you do or conditions to exclude before initiating HRT

A

Full clinical assessment: history & examination
* Review all medication and be aware of potential drug interactions
* Nutritional assessment
* Neurodevelopmental screen
* WHO clinical stage of HIV infection
* Screen for TB
* In older children, screen for mental issues including active depression
* Screen for pregnancy (adolescents)
* Symptom screen for sexually transmitted infections (adolescents)
* Confirm HIV test results
* CD4 cell count and percentage
* Hb, if low do FBC and treat accordingly
* Creatinine and eGFR if tenofovir to be used
* Adolescents: Cryptococcal antigen test if CD4 <100 cells/µL; cervical
cancer screen if female; HBsAg

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4
Q

What renel function tests are done for pregnant women before initiating HRT

A

Absolute creatinine level
<85 umol/l

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5
Q

What renal tests should be done for adults and adolescents over 16 years before initiating ART

A

eGFR using MDRD equation
>50

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6
Q

What renal function tests should be done for adolescents at the ages 10-16 before initiating ART

A

eGFR using Counahan Barratt formula
>80

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7
Q

What are the indications for ART

A

All people living with HIV (PLHIV) are eligible for ART regardless of age, CD4 count and clinical stage. For all PLHIV
without contra-indications, ART should be started within 7 days

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8
Q

What are the medical indications to defer ART (Contraindications to ART)

A
  1. TB symptoms
    -Drug susceptible TB (Less than 50 cd4 cells initiate ART within 2 weeks, if more than 50 initiate in 8weeks).
    -Children <5 years, If CD4 count ≤200 cells/µL or <15% - initiate ART within 2 wks of
    starting TB treatment
    If CD4 count >200 cells/µL or >15% - initiate ART 2 – 8 wks of starting TB treatment
    -Drug Resistant TB (Initiate ART after 2 weeks of TB treatment, when pt symptoms improving)
  2. Cryptococcal meningitis
  3. Clinical features of liver disease
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9
Q

What are the prefered 1st line regimens for preterm neonates and neonates <2.3 kg

A

Seek expert advice

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10
Q

what is the preferred 1st line HIV regimens for Birth (≥2.0 kg) – <4 weeks (<3.0 kg)

A

AZT (zidovudine) + 3TC (lamivudine) + NVP (nevarapine)

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11
Q

What is the preferred 1st line HIV tx ≥4 weeks (≥3 kg) – <10 years (<30 kg)

A

ABC (abacavir) + 3TC (lamivudine) + DTG (dolutegravir)

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12
Q

What is the preferred 1st line HIV treatment for children ≥10 years & ≥30 kg

A

TDC (Tenofovir) + 3TC (lamivudine)+ DTG (dolutegravir) (TLD)

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13
Q

What drug interactions occur with Zidovudine

A
  1. Rifampicine decreases the effect of dolutegravir, so increase the dose to 50mg 12hrly
  2. Polyvalent cations (Mg, Fe, Ca, Al, Zn eg Antiacids, sulfate, multivitamin and nutritional supplements) decrease the effect of dolutegravir.
    Soln: Ca and Iron decreases DTG if taken together on an empty stomach, to prevent this, take ca and DTG taken together with food but calcium and iron should be taken 4 hours apart.
    Mg and aluminium containing antiacids decrease DTG regardless of food intake, should be taken min 2hours or 6hours before DTG.
  3. Anticonvulsants: Carbamezapine, Phenobarbatal, Phenytoin decrease DTG concentration
    Avoid and use alternatives: Valproate, Lamotrigine, Levetiracetam, topiramate. Valproate contraindicated in pregnancy
    Double dose of DTG to 50mg 12hrly if alternative anticonvulsant cant be used.
  4. Metformin: DTG increases the effects of metformin
    Max dose 500mg 12hourly
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14
Q

WHen do you monitor fofr TDF-induced nephrotoxocity

A

creatinine at months 3 and 10, thereafter repeate every 12 months

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15
Q

When to monitor for Anaemia and neutropaenia

A

If on AZR, do Fbc and wcc at month 1 and 3, thereafter repeat if clinically indicated

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16
Q

when to monitor for dislipidemia

A

Total cholesterol and TGs at month 3, if above acceptable, do fasting cholesterol and TGs
If acceptable, obtain expert advice

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17
Q

When to monitor viral load and response to treatment after initiating ART

A

Routine monitoring at 3 and 10 months thereafter if virally suppressed, every 12 months

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18
Q

What is virally suppressed

A

<50 copies/mL = undetectable
(suppressed VL)

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19
Q

What could potentially cause a high VL in a pt on ART

A
  1. Adherence
  2. Bugs (infections)
  3. inCorrect ART dosage
  4. Drug Interactions
  5. rEsistence (if >2yrs on tx)
  6. poor absorption
  7. incorrect dosing
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20
Q

What are some of the factors that affect adherence to ART

A

– Inadequate counselling and education of caregivers
– Caregiver factors: non-disclosure to family, physical illness, depression, untreated affective disorders, substance abuse,
change of caregiver
– The more complex the antiretroviral regimen the less adherent:
number of tablets, frequency of administration, processing such
as crushing, mixing, dissolving & measuring.
– Side effects: patients may discontinue medication to avoid side effects

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21
Q

How to maintain good adherence to ART

A

(think of causes of poor adherence)

. Education / counselling
* Give patients feedback
* Support groups & treatment clubs
* Simplify medication
* Link medication to daily activities, educate caregivers about
consistency
* Manage side effects
* Provide tools: pill boxes, reminder calls

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22
Q

Which drugs are used for drug susceptible TB in SA and what effects do they have

Study These Flashcards
A

Isoniazid (high early bactericidal activity, kills actively dividing bacteria)
Rifampicin (major sterilizing agent)
Pyrazinamide (kills dormant or slow dividing bacilli)
Ethambutol (efficacy against actively replicating bacilli)
Ethionamide (high CSF penetration)

23
Q

Which TB treatment do you give to HIV negative children with minimal PTB

Study These Flashcards
A

Intensive phase: 2HRZ (Isoniazide, Rifampicin, Pyrazinamide)
Continuation phase: 4HR

24
Q

Which TB treatment do you give to HIV negative children with extensive PTB or severe forms of extrapulmonary TB

Study These Flashcards
A

intensive phase: 2HRZE
Continuation phase: 4HR

25
What TB tx do you give to HIV infected children (with all forms of EPTB except TBM or miliary TB)
Intensive phase 2HRZE Continuation phase: 4-7 HR
26
What TB tx do you give to all children (with TBM and miliary TB
Intensive: 2HRZEt continuation: 4-7 HRZEth (NB Ethionimide has high CSF penetration)
27
what is multi-drug resistant TB
resistance to both INH and RIF with/without resistance to other anti-TB drugs
28
What is Extensive drug-resistent TB (XDR-TB)
resistance to rifampicin (and may also be resistant to isoniazid), and that is also resistant to at least one fluoroquinolone (levofloxacin or moxifloxacin) and at least one additional Group A drug, either BDQ or LZD
29
How to diagnose drug-resistant TB in paeds
1. Culture-unconfirmed TB with a drug-resistant TB contact – TB treatment regimen is based on the susceptibility of the isolate causing TB in the household/close contact 2* Rifampicin resistance identified by Xpert MTB/RIF Ultra 3* TB isolates cultured from children: – Hain line probe assay screening for INH & RIF resistance – If INH & RIF resistance detected on the LPA, DR-TB reflex testing will be don
30
Define Pre-extensively drug-resistant TB (pre-XDR-TB)
resistance to rifampicin (and may be resistant to isoniazid), and that is also resistant to fluoroquinolones
31
What is IRIS
unmasking of new TB disease Paradoxical worsening of established disease
32
Discuss the manifestations of IRIS
– Swinging fever – New/worsening lymphadenitis – New/worsening pulmonary infiltrates, respiratory failure – New/worsening pleuritis, pericarditis, ascites – Intracranial tuberculomas, TBM – Disseminated skin lesions – Hepatosplenomegaly, soft tissue abscesses
33
How do we treat IRIS
– Expectant – Glucocorticosteroids
34
How is BCG administered in SA
BCG is injected on the upper right arm at the insertion of the deltoid muscle. The dose is 0.05 ml administered with a special BCG syringe, at birth.
35
What are the contraindications of BCG
1. Children over 12 months of age not for BCG 2. Children with symptoms of HIV infection 3. HIV-exposed newborns who are well enough to be discharged should be given BCG 4. If HIV-exposed newborns are sick the birth PCR should be checked, and BCG administered if the PCR result is negative 5. If mother has TB and is on Anti TB drugs, child should be given TB preventive treatment and BCG only after TB treatment has been completed
36
What are the complications of BCG
Local BCG disease- papular eruption, ulceration 2. Regional BCG disease- Ipsilateral lymphadenitis, suppuration, fistulation 3. Distant/ disseminated BCG disease- lymphadenitis, pulmonary disease, BCG osteitis, dissemination 4. BCG Iris - 3months of starting ART 5. Erythema nodusum 6. Lupus vulgaris 7. Uveitis
37
Who should be given TB Preveventive tx
All adult, adolescent and child contacts in whom TB disease has been ruled out
38
what Preventive tx do you give to drug susceptible TB contact after TB exposure (NB HIV + and HIV neg)
HIV-negative children: Daily isoniazid plus rifampicin for 3 months using the NDoH dosing recommendations HIV-infected children: Daily isoniazid for 6 months
39
What TB preventive tx do you give to Isoniazid monoresistant TB contact
Rifampicin 10-15 mg/kg/day per os for 4 months
40
What TB preventive tx do you give to Rifampicin monoresistant TB contact
Isoniazid 10 mg/kg/day per os for 6 months
41
What TB preventive tx do you give to MDR-TB TB contact
▪ Isoniazid 15-20 mg/kg/day plus ethambutol 20-25 mg/kg/day plus levofloxacin 15-20 mg/kg/day per os for 6 months ▪ Levofloxacin 15-20 mg/kg/day per os for 6 months (likely to be recommended in the near future)
42
What TB preventive tx do you give to xDR-TB TB contact
▪ Isoniazid 15-20 mg/kg/day per os for 6 months ▪ Regular follow-up for two years ▪ Ensure household infection control practices are observed ▪ Children who develop active infection should be referred
43
How effective is TB preventive treatment
Provisional finding ex TB-CHAMP study: Levofloxacin preventive treatment reduced risk of MDR-TB by 56%
44
How to prevent meningitis
The general stuff: hygiene, tx infections otitis media, head injury etc Vaccines (bacterial) Pneumococcal vaccine for over 2months old Meningococcal vaccines for 11-12 years H.Influenza type b virus from 2months
45
Symptoms and signs of meningitis
Fever Vomiting Headache Photophobia Poor feeding Hugh pitched cry Lethargic Neck stiffness Bulging fontanelle in babies Purple-red splotchy rash Severe Convulsions Confusion Hallucinations Staggering or swaying when walking Loss of consciousness
46
Which organisms cause meningitis
Neonates Bacterial: Group B strep, Listeria, EColi In 1year or older Viruses: CMV, herpes simplex virus, enterovirus Bacteria: Neisseria meningitis, strep pneumonia, haemophilia influenza Fungal: cryptococcus TB Parasites: toxoplasmosis? Adults: strep pneumonia, Elderly: listeria In older Virus: Polio, enteroviruses
47
Complications of meningitis
Sepsis/shock Hearing loss Brain damage: intellectual disabilities Long term seizures Hydrocephalus Other short term: SIADH presenting as Hyponatremia, cerebral oedema, brain abscesses, secondary infections eg pneumonia, pericarditis
48
Treatment of meningitis according to the causative organism
Strep pneumonia: IV Penicillin or IV ceftriaxone, if resistant IV Vancomycin H. Influenza: IV ceftriaxone Nisseria meningitis: Ciprofloxacin oral single dose or ceftriaxone IM single dose, or IV Penicillin for 7d
49
What type of meningitis do you get petechia or purpura and hypothermia
Meningococcal
50
Contraindications to Lp
Infection at site Signs of raised ICP Bleeding disorders Congenital anomalies of lower spine (meningomyelocele) Extremely ill infant
51
Drug Tx for raised ICP
Mannitol 0.25-1.5 g/kg in children <12
52
What is the normal CSF glucose
2.5mmol/l, it is about 2/3 of serum glucose If lowered, consider bacterial meningitis
53
Treatment of TB meningitis
Rifampicin 20mg/kg PO as single dose Isoniazide 40mg/kg PO as single dose Pyrazinamide 40mg/kg PO single dose Ethionamide 20mg/kg PO as single dose Tx is a 6month regimen

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