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Infectious disease Flashcards

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1
Q

Name 4 infectious disease emergencies in the returned traveler

A

Malaria
Typhoid fever
Meningococcemia
Viral hemorrhagic fevers

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2
Q

What investigations do you order in fever in a returned traveler?

A

CBC with differential
Liver function tests
Blood culture
Malarial smears x3(thick and thin)

Other tests, to be done more selectively:
Serology (EBV, CMV, hepatitis viruses, HIV, dengue, brucellosis, strongyloidiasis…)
CXR
TB skin test
Urine C/S
Stools for C/S, O/P

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3
Q

What are the 5 species of malaria affecting humans

A 
P. faciparum
P. vivax
P. ovale
P. malariae
P. knowlesi
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4
Q

What is the incubation period of P.falciprum and P. vivax?

A

P. falciprum-within 2 months

P.vivax-Can be many months

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5
Q

What are the clinical and laboratory criteria for severe malaria in children?

A 
Clinical:
•Prostration (unable to walk/sit up)
•Impaired consciousness/coma
•Respiratory distress
•Multiple convulsions (>2 in 24 hrs)
•Shock (SBP< 50mmHg)
•Respiratory failure/pulmonary edema/ARDS
•Abnormal bleeding/DIC
•Jaundice (total bili>45μmol/L)
•Haemoglobinuria(macroscopic)

Laboratory:

Hyperparasitemia(>2% in non-immune, >5% in semi-immune)**
Severe anemia (hematocrit<15%; Hgb≤50g/L)
Hypoglycemia (<2.2 mmol/L)
Acidosis (art pH < 7.25 or bicarb< 15 mmol/L)
Renal impairment (Cr > upper limit of normal)
Hyperlactatemia(> 5mmol/L)

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6
Q

How do you diagnose malaria?

A

3 thick and thin smears

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7
Q

How do you treat malaria?

A

Mild disease, able to tolerate oral
-Malarone x three days

Severe disease

  • IV Artesunate
  • Quinine is alternative, but not as effective, more toxic, requires cardiac and serum glucose monitoring
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8
Q

How does typhoid typically present?

A

Fever without localizing signs

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9
Q

What is the sensitivity of blood cultures for typhoid?

A

50%

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10
Q

How effective is the typhoid vaccine?

A

50-70% effective

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11
Q

How do you treat typhoid?

A

IV ceftriaxone

Cipro resistance is common

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12
Q

What are some considerations for care of children new to Canada?

A
  • Catch up vaccines
  • Hearing
  • Vision
  • Psychosocial:
  • -History of persecution, physical and emotional deprivation, cultural dislocation, family breakup etc.
  • Cultural and social transition
  • School-related issues
  • Health care coverage issues
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13
Q

What areas should you focus on physical exam of immigrant child?

A
  • Growth and development
  • Signs of undiagnosed chronic illness
  • Signs of congenital infections
  • Vision and hearing screen
  • Dentition
  • BCGscar
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14
Q

What is a reasonable preliminary infectous disease workup in an immigrant child?

A 
CBCand differential
Liver and renal function tests
Serology for HBV, HCV, HIV, syphilis
TB skin test
Chest x-ray
Stool O&amp;P
Urinalysis
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15
Q

What is the definition of classic FUO?

A
  • Fever of more than 2 to 3 weeks duration

- Diagnosis uncertain despite appropriate investigations after at least 3 outpatient visits or ≥ 3 days in hospital

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16
Q

What is the differential diagnosis of FUO?

A

Infectious causes

Rheumatologic/vasculitic causes

Malignancy

Other:
Granulomatousdiseases (IBD, Sarcoidosisetc.)
Hypersensitivity syndromes (drug fever etc.)
Familial (FMF, familial dysautonomiaetc.)
Thalamic dysfunction
Factitious fever
Munchausen syndrome by proxy

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17
Q

What is the infectious disease differential for FUO-localized and systemic?

A 
Localized
•Endocarditis
•Abscesses
•Dental infection
•Sinusitis
•Mastoiditis
•Osteomyelitis
•Pyelonephritis
•Pneumonia
•Sepsis

Systemic
•Viral: EBV, CMV, hepatitis viruses, HIV

  • Bacterial: Tuberculosis, brucellosis, yersiniosis, salmonella, cat scratch disease, leptospirosis, tularemia, Lyme disease, chronic meningococcemia
  • Rickettsia/chlamydia: Q fever, RMSF, tick typhus, psittacosis
  • Fungal: Histoplasmosis, blastomycosis
  • Parasitic: Malaria, toxoplasmosis, visceral larva migrans, amebiasis
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18
Q

What are first step investigations for FUO?

A

CBCwith differential, liver enzymes

ESR/CRP, ANA/RF

Blood cultures

Monospot, EBV, CMVserology

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19
Q

What are some second tier investigations for FUO?

A

Malaria smears

Tuberculin skin test

Echocardiogram

Imaging (radiographs, radionuclide scans, ultrasound, CT etc.)

Bone marrow aspirate

HIV and other serologies

Investigations for rheumatologic, neoplasticdiseases

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20
Q

What causes of FUO can be associated with pica?

A

Toxocariaisis

Toxoplasmosis

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21
Q

What two tests would you do in fever in a returning traveler from Nigeria?

A 
Malaria smears (thick and thin)
Blood culture (S. typhi, N. meningitidis)
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22
Q

Name 4 vaccine preventable illnesses from Africa

A 
Typhoid fever
Meningococcal disease
Hepatitis A and B
Yellow fever
Rabies
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23
Q

What are the two most common differentials for an isolated tender axillary lymph node?

A

Bartonella

Bacterial adenitis

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24
Q

What is parinaud oculoglandular

syndrome?

A
  • Caused by Bartonella

- Submandibular/preauricular lymphadenopathy and ipsilateral unilateral granulomatous conjunctivitis

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25
What is the most common cause of afebrile chronic lymphadenopathy with no TB/CSD risk factors?
Atypical mycobacterium
26
What is the differential for acute bilateral cervical LAD?
``` Respiratory viruses Enteroviruses Adenovirus, EBV CMV ```
27
What is the differential for acute unilateral cervical LAD?
S. aureus | S. pyogenes (80%)
28
What is the infectious differential for chronic bilateral cervical LAD?
HIV EBV CMV Toxoplasmosis
29
What is the infectious differential for chronic unilateral cervical LAD?
``` Non-tuberculous mycobacteria M. tuberculosis Bartonella henselae Tularemia, Plague (Y. pestis) ```
30
Name 6 clinical presentations associated with cat scratch disease
Lymphadenitis (axillary most common) Perinaud oculoglandular syndrome Hepatosplenic bartonellosis (granulomatous disease) Neuro-retinitis Encephalopathy Fever of unknown origin
31
How do you treat cat scratch disease?
Observation is reasonable Azithromycin for lymphadenitis (to shorten duration of sx) Doxycycline + rifampin for neuroretinitis/CNS disease
32
What is a mnemonic to remember TORCH infections?
``` C Chicken pox H Hepatitis B, C, E E Enterovirus A AIDS P Parvovirus B19 ``` ``` T Toxoplasmosis O Other (TB, WNV) R Rubella C CMV H HSV E Every other STD S Syphilis ```
33
What % of patients with congenital CMV are asymptomatic at birth?
2/3 of those with sequelae are asymptomatic at birth
34
Name 7 clinical features of congenital CMV
``` IUGR Hepatosplenomegaly Thrombocytopenia*** Microcephaly Periventricular calcifications*** SNHL*** Chorioretinitis ``` ``` Others: Strabismus Optic atrophy Microphthalmia Seizures Hyperbilirubinemia Elevated ALT ```
35
Name 3 long term sequelae of asymptomatic CMV
Sensorineural hearing loss (7% to 15%)-can be delayed onset Mental retardation, learning disabilities (3.5%) Chorioretinitis (2.5%)
36
Name 3 indications for treatment in congenital CMV
- CNS involvement - SNHL - Chorioretinitis - Case-by-case for “mildly symptomatic” neonates
37
How do you treat congenital CMV?
Valganciclovir 16 mg/kg/dose bid for 6 months IV ganciclovir for hospitalized, severely affected newborns
38
List 2 toxicities do you need to monitor for when treating CMV
Neutropenia Nephrotoxicity Close monitoring of CBC (neutrophil count) & creatinine Consider interruption of therapy if ANC < 0.5 Consider GCSF if neutropenia is persistent
39
Name 5 features of congenital syphilis
IUGR Snuffles (persistent nasal d/c)*** Maculopapular rashes (involving palms & soles)*** Bony changes (Osteitis/perichondritis)*** Pseudoparalysis due to bon pain*** Chorioretinitis Aseptic meningitis ``` Others: Prematurity, IUGR, FTT Maculopapular rash followed by desquamation, blistering and crusting Condyloma lata Hepatosplenomegaly Lymphadenopathy Coomb’s negative hemolytic anemia Thrombocytopenia Pseudoparalysis Osteochondritis Diaphyseal periostitis Deminiralization/destruction of proximal tibia metaphysis, osteitis Hydrocephalus Cranial nerve palsies Glaucoma, uveitis ```
40
Name 7 late onset manifestations of congenital syphilis
``` GDD SNHL Saddle nose Hutchinson's teeth Gummas Saber shins Optic atrophy ``` ``` Others: GDD, hydrocephalus, cranial nerve palsies, seizures, juvenile paresis Eye Interstitial keratitis, healed chorioretinitis, corneal scarring, glaucoma, optic atrophy ``` Ears Sensorineural hearing loss Face Saddle nose, frontal bossing, protuberant mandible, high arch palate Teeth Hutchinson’s teeth, mulberry molars Skin Ragades (linear scars), gummas MSK Saber shins, clutton joints, Higoumenakis’ sign
41
How do you interpret the following maternal syphilis serologies: 1) CLIA+ TPPA+ RPR+ (titre >1:16) 2) CLIA+ TPPA+ RPR+ (titre <1:8) 3) CLIA+ TPPA+ RPR- 4) CLIA- TPPA- RPR+ 5) CLIA+ TPPA- RPR-
1) Active syphilis, cross reactivity 2) Previously treated syphilis, cross reactivity 3) Late latent syphilis, treated syphilis or early primary syphilis, cross reactivity 4) False positive RPR 5) False positive CLIA
42
When do you do a FULL evaluation for congenital syphilis in an infant AND treat (Name 6 indications) ?
Infant has signs and symptoms of congenital syphilis Mother not treated or treatment not adequately documented Mother treated with non-penicillin regimen Mother treated within 30 days of child’s birth Less than 4-fold drop in mothers non-treponemal titer or not assessed or documented Mother had relapse or re-infection after treatment Infant RPR 4 fold higher than maternal RPR Infant symptomatic
43
What is a full evaluation for congenital syphilis?
CBC, LFTs Syphilis serology (Treponemal and non-treponemal) Skeletal survey-long bones CSF (WBC count, protein, treponemal and non-treponemal tests)-if positive need to repeat 6 months after tx!
44
In a mother who was treated for syphilis and has no indications for the full work up, what test do you do?
1) Infant RPR If Infant RPR nonreactive OR Infant RPR ≤ mothers and asymptomatic, no further investigations required for now 2) Baseline and monthly assessment for signs or symptoms x 3 mos 3) Serology at 0, 3, 6, 18 months
45
In a mom with syphilis, name 4 criteria that need to be fulfilled for you to NOT do a full work up and treat her baby?
1) Mom appropriately treated during pregnancy (penicillin ONLY!) 2) >4 fold drop in maternal titres during pregnancy 3) Infant RPR non-reactive OR less than mom's RPR titre 4) Infant is asymptomatic!
46
How do you treat congenital syphilis?
IV Penicillin G x 10-14 days
47
What is the classic triad of congenital toxoplasmosis?
Hydrocephalus/macrocephaly*** Cerebral calcifications*** Chorioretinitis
48
What percentage of toxoplasmosis is symptomatic at birth?
15% (similar to CMV)
49
During what trimester(s) is symptomatic congenital toxo acquired?
1st and 2nd
50
During what trimester is asymptomatic congenital toxo acquired?
3rd
51
What is the prognosis for congenital toxo that is asymptomatic at birth?
Untreated majority will go on to develop disease (unlike CMV)
52
What is the most common manifestation of congenital toxo that is asymptomatic at birth?
Chorioretinitis
53
How do you diagnose congenital toxoplasmosis (name 3 tests)?
Serology (IgG, IgM, IgA) in serum of infant PCR on CSF, blood and/or urine Placental pathology
54
What two findings will you see on CSF in congenital toxo?
Lymphocytic pleocytosis | Elevated CSF protein (often very high)
55
How do you treat confirmed congenital toxo?
Pyrimethamine + sulfadiazine + leucovorin x12 months Steroids for eye disease and possibly hydrocephalus VP shunt for hydrocephalus
56
What toxicity do you need to monitor for when treating congenital toxo?
Neutropenia
57
What are the clinical features of congenital VZV?
``` Microcephaly Cicatricial scars*** Limb hypoplasia*** Microphthalmia GERD ```
58
What are the potential sequelae of VZV infection during pregnancy on infants in a) first/second trimester b) third trimester c) perinatal
a) Congenital varicella syndrome b) Herpes zoster in infancy/childhood c) disseminated neonatal varicella
59
How do you manage VZV exposure during pregnancy?
If history of chicken pox/immunized-->do nothing If no definitive history of chicken pox-->stat varicella serology If IgG negative-VZIG within 96 hours of exposure If manifestations of chicken pox-acyclovir
60
What is a significant VZV exposure in pregnancy?
Household exposure Face-to-face contact for ≥ 5 minutes Indoor contact for ≥ 15 minutes
61
Name 7 clinical features of congenital rubella?
``` IUGR Blueberry muffin rash Hepatosplenomegaly Cataract*** Bony lucencies***(can be confused with syphilis) Cardiac anomalies (PDA)*** SNHL ``` Others: Hemolytic anemia Thrombocytopenia
62
At what point in pregnancy are you most at risk of congenital rubella syndrome?
First trimester After 16 weeks congenital anomalies are uncommon
63
Name 5 long term features of congenital rubella syndrome
``` Sensorineural hearing loss Cataract Chorioretinitis Microphthalmia PDA Peripheral pulmonary stenosis Pulmonary valvular stenosis VSD Myocarditis Global developmental delay Language defects Behavioral disorders Seizures ```
64
What tests should you do if a pregnant woman is exposed to parvovirus?
1) Parvovirus serology 2) If IgM+, weekly ultrasounds x 12 weeks to look for hydrops 3) If negative, repeat in 2-3 weeks. If IgM- and IgG +, reassure (infection was >60 days ago and hydrous develops 4-6 weeks after infection)
65
What are the clinical features of parvovirus infection?
``` Papular-purpuric glove and sock syndrome Arthropathy Transient aplastic crisis Pure RBC aplasia (HIV, transplant) HLH Myocarditis Encephalitis ```
66
Name two risk factors for parvovirus infection?
Young school aged children in home Occupational (teachers of 5-7 year old children, health care workers)
67
Name 2 potential sequelae of parvovirus infection during pregnancy?
Fetal loss Non-immune hydrops fetalis
68
When during pregnancy is the risk of fetal loss highest in parvovirus infection?
First trimester
69
What type of virus is Zika?
Flavivirus
70
How is Zika transmitted
Mosquito | Sexual
71
What are the clinical manifestations of Zika?
Asymptomatic infection (75-80%) Clinical illness typified by fever, maculopapular rash, conjunctivitis and myalgia
72
When during pregnancy is the highest risk period for Zika?
First & early second trimester
73
How do you make an antenatal diagnosis of Zika?
Fetal US | Amniotic fluid PCR
74
How do you make a postnatal diagnosis of Zika?
Zika IgM, dengue IgG and IgM If either positive PRNT CSF Zika IgM PCR on placenta, umbilical cord tissue, serum, urine and CSF
75
What are the clinical features of congenital Zika?
Severe microcephaly with partially collapsed skull Thin cerebral cortices Subcortical calcifications Macular scarring Contractures
76
Which congenital infections are associated with brain calcifications?
CMV-periventricular Toxo-parenchymal HIV-basal ganglia Rarer: HSV-parenchymal LCMV-parenchymal Zika-subcortical
77
Which congenital infections are associated with microcephaly?
CMV, HSV, Rubella, TOXO, syphilis, VZV
78
Which congenital infections are associated with macrocephaly?
TOXO, LCMV, syphilis
79
Which congenital infections are associated with chorioretinitis?
CMV, TOXO, syphilis, rubella
80
Which congenital infections are associated with SNHL?
CMV, Rubella, syphilis, TOXO
81
Which congenital infections are associated with microopthalmia?
VZV
82
Which congenital infections are associated with cataracts?
Rubella (syphilis)
83
Which congenital infections are associated with pseudoparalysis?
Syphilis
84
Which congenital infections are associated with optic atrophy?
CMV
85
Which congenital infections are associated with hydrops?
Parvovirus B19, syphilis, CMV, TOXO
86
Which congenital infections are associated with HSM?
CMV, HSV, rubella, syphilis, TOXO
87
Which congenital infections are associated with hemolytic anemia?
Syphilis
88
Which congenital infections are associated with blueberry muffin rash?
Rubella, CMV
89
Which congenital infections are associated with cytopenias?
CMV, TOXO, HSV, syphilis, rubella
90
Which congenital infections are associated with liver failure?
Enteroviruses, TOXO, HSV
91
What are the typical manifestations of early onset (<7 days) GBS?
Pneumonia, septicemia, meningitis
92
What are the typical manifestations of late onset (>7 days) GBS?
Meningitis, osteomyelitis, soft tissue infections, sepsis
93
What are indications for intrapartum antibiotics?
1) GBS positive 2) Unknown GBS status AND any of the following: - Previous infant with GBS disease - GBS bacteriuria during current pregnancy - Delivery at < 37 weeks gestation - Membranes ruptured ≥ 18 hours - Intrapartum fever (>38.0oC)
94
What are the only two antibiotics that are considered adequate IAP?
Penicillin | Ampicillin
95
What antibiotics can be used for IAP in a mom who is penicillin allergic?
Mild allergy-cefazolin | Severe allergy-clinda
96
What are the low risk criteria for febrile infants 29-90 days old?
Previously healthy term infant Non-toxic clinical appearance No focal infection (except otitis media) Peripheral leukocyte count 5.0 – 15.0 x109/L Absolute band count ≤ 1.5 x109/L Urine: ≤ 10 WBC per high field (x40) Stool (if diarrhea): ≤ 5 WBC per high field (x40)
97
If any of the low risk criteria are NOT met for a febrile infant 29-90 days old, what should you do?
FSWU - If CSF abnormal: amp+cefotax+vancomycin - If CSF normal-amp+cefotax
98
What are the most common bacterial pathogens for 0-28 d infants with fever without source ?
Most common: GBS, E. coli Less common Listeria, S. aureus, GAS, Klebsiella pneumoniae
99
What are the most common bacterial pathogens for 29-90 d infants with fever without source ?
Most common: GBS, E. coli Less common: S pneumoniae, Neisseria meningitidis, Listeria, S. aureus, GAS
100
What are the most common bacterial pathogens for 3-36m infants with fever without source ?
Most common: S pneumoniae Less common: S. aureus, GAS, Neisseria meningitidis
101
What is empiric antibiotic therapy for rule out sepsis 0-28 days 29-90 days 3-36 months
0-28 days Sepsis- Ampicillin + gentamicin or cefotaxime Meningitis- Ampicillin + cefotaxime 29-90 days Sepsis-Ampicillin + cefotaxime Meningitis-Ampicillin + cefotaxime + vancomycin 3-36 months Sepsis AND meningitis-Ceftriaxone + vancomycin
102
What are the three clinical presentations of neonatal HSV?
Mucocutaneous (Skin, eye, mouth) (45%) Enchephalitis (30%) Disseminated
103
When does mucocutaneous neonatal HSV usually present?
Day 10-12 of life
104
Does clinically silent CNS infection occur with mucocutaneous HSV?
Yes | Dissemination can occur without treatment
105
When does neonatal HSV encephalitis present?
Day 16-19 of life
106
How does neonatal HSV encephalitis typically present?
Fever ↓LOC Seizures Skin lesions in 2/3 of cases
107
When does disseminated neonatal HSV typically present?
Day 10-12 of life
108
What are the clinical features of disseminated neonatal HSV?
Sepsis-like presentation Multi-organ involvement-elevated LFTs (in 100s) 2/3 have concurrent encephalitis
109
What investigations should you do for suspected neonatal HSV?
Culture/PCR of vesicle fluid, nasopharynx, eyes, urine, stool, blood, CSF Do LP even if clinically well (e.g. isolated mucocutaneousdisease)
110
How do you treat neonatal HSV and for how long?
IV acyclovir 60 mg/kg/day Isolated mucocutaneous disease: 2 weeks Disseminated, CNS disease: 3 weeks, then oral acyclovir x 6 months for CNS disease
111
Name 5 factors determining transmission risk in HSV?
Type of maternal infection & maternal serostatus: First episode primary (57%); first episode non-primary (25%); recurrent (<3%) NOTE: First episode primary=Mother has no serum Abs at onset of first episode First episode non-primary=Mother has a new infection with one HSV type in the presence of Abs to the other type Membrane rupture >6 hours Fetal scalp monitor HSV-1 vs. HSV-2 (31.3% vs. 2.7%) C/section reduces risk (1.2% vs. 7.7%)
112
What percentage of whomem who deliver an HSV-infected child have no history of genital herpes?
60-80%
113
How do you manage asymptomatic infant of mother with active lesions at delivery? A. First episode; born vaginally or by C/section after membrane rupture B. First episode; C/section prior to membrane rupture C. Recurrent episodes
A. First episode; born vaginally or by C/section after membrane rupture - Empiric acyclovir recommended - If swabs positive –full workup and treatment - If swabs negative, complete 10 days of IV acyclovir B. First episode; C/section prior to membrane rupture - Empiric acyclovir not recommended - If swabs positive –full workup and treatment C. Recurrent episodes - Empiric acyclovir not recommended - If swabs positive –full workup and treatment
114
What bacteria cause AOM?
Streptococcus pneumoniae(25% to 40%) Non-typeable Haemophilus influenzae (10% to 30%) Moraxella catarrhalis(5% to 15%) Other less commonly seen pathogens include group A streptococcus, S. aureus(3% to 5%) Viruses-20%
115
What antibiotics are first line for AOM?
Amoxicillin 75-90 mg/kg/day divided BID Amoxicillin 45-60 mg/kg/day divided TID
116
What antibiotics are first line for AOM with mild amoxicillin allergy?
Cefprozil30 mg/kg/day divided BID Cefuroxime30 mg/kg/day divided BID Ceftriaxone 50 mg/kg IM/IV x 3 doses
117
What antibiotics are first line for AOM with severe amoxicillin allergy?
Azithromycin Clarithromycin Clindamycin Levofloxacin in select circumstances
118
What antibiotics do you use for treatment failure?
Amoxicillin-clavulanate45-60 mg/kg/day divided TID (≤35 kg) or 500 mg TID (>35 kg) x 10 days -For betalactamase producing Hib Ceftriaxone 50 mg/kg/day for 3 doses
119
For how long do you treat AOM?
5 days for children ≥2 years 10 days for 6 months-2 years OR perf TM OR recurrent AOM
120
When can you employ watchful waiting in AOM (children >6 months)?
1) Non-severe illness - Mild-moderate TM bulge - Mildly ill, alert, mild otalgia, low grade fever (<39.0oC) - Responding to antipyretics 2) No underlying conditions of concern (Immunodeficiency, chronic cardiac or pulmonary disease, anatomic abnormalities of head/neck, history of complicated otitis media, down syndrome) 3) Parents capable of recognizing signs of worsening disease and can readily access medical care
121
What bacteria cause acute pneumonia?
``` Most common: Streptococcus pneumoniae Staphylococcus aureus GAS Non-typeable Haemophilus influenzae ``` ``` Less common: Mycoplasma pneumoniae Chlamydophila pneumoniae Psittacosis (C. psittaci) Coxiellaburnetii(Q fever) Legionella pneumophila ```
122
What is empiric antibiotic therapy for uncomplicated community acquired pneumonia?
Well-amoxicillin/ampicillin Respiratory failure/shock-ceftriaxone +/- vanco Rapidly progressive multilobar disease or pneumatoceles-ceftriaxone + vanco (for possible MRSA)
123
What is the rationale for upgrading from ampicillin to cefriaxone for unwell children with community acquired pneumonia?
Ceftriaxone offers better coverage against β-lactamase+ H. influenzae and possibly for S. pneumoniae with high level resistance to penicillin
124
What bacteria typically causes meningitis? A. <1 month B. 1-3 months C. >3 months
A. <1 month GBS, GNB (E. Coli), Listeria B. 1-3 months Mix of A+C C. >3 months S. pneumo***, neisseria***, non-typeable Hib
125
How do you treat suspected bacterial meningitis? A. <1 month B. 1-3 months C. >3 months
A. Amp +cefotax B. Amp+cefotax+vanco C. Cefotax+vanco Duration - S pneumoniae : 10 to 14 days - Hib: 7 to 10 days - N meningitidis: 5-7 days. - GBS meningitis: 14 to 21 days
126
Should you give dexamethasone for bacterial meningitis, and if so when?
YES. Reduces mortality and hearing loss due to HIB and possibly S. pneumoniae Dexamethasone 0.6 mg/kg/day in 4 divided doses Should be administered before or within 30 minutes of antibiotics
127
When do you consider repeat LP at 24-36 hours in bacterial meningitis (name 4 indications)
Failure to improve clinically Immunocompromised host S. pneumoniae resistant to penicillin/cephalosporins Meningitis due to gram negative bacilli
128
What are the most common bacteria causing purpura fulminans?
N. meningitidis S. aureus S. pneumoniae GAS
129
What antibiotics do you use for purpura fulminans?
Ceftriaxone + vancomycin
130
What are the most common bacteria causing toxic shock syndrome?
S. pyogenes, S. aureus
131
How do you treat TSS?
Cloxacillin (or cefazolin)+ clinda If TSS due to group A strep-Penicillin + clindamycin±IVIGfor
132
What are physical exam findings associated with endocarditis?
Osler nodes Splinter hemorrhage Janeway lesions
133
How do you treat skin abscesses after incision and drainage? A. <1 month B. 1-3 months C. >3 months without fever/cellulitis D. >3 months with cellulitis, no other systemic features E. Systemic features
A. <1 month IV antibiotics (with vanco) PO clindamycin for well babies with no fever, abscesses <1 cm B. 1-3 months TMP-SMX C. >3 months without fever/cellulitis No antibiotics UNLESS does not improve after I+D, culture grows anything other than S. aureus D. >3 months with cellulitis, no other systemic features TMP-SMX (MRSA coverage) and cephalexin E. Systemic features IV antibiotics
134
What are the typical bacteria causing impetigo?
S. aureus, Group A streptococcus
135
What empiric antibiotics do you use for impetigo?
PO: Cloxacillin, Cephalexin | topical mupirocin
136
What are the typical bacteria causing cellulitis?
S. aureus, Group A streptococcus
137
What empiric antibiotics do you use for cellulitis?
IV: Cloxacillin, Cefazolin PO: Cloxacillin, Cephalexin
138
What are the typical bacteria causing pyomyositis?
S. aureus, streptococci
139
What empiric antibiotics do you use for pyomyositis?
IV: Cefazolin, Cloxacillin
140
What are the typical bacteria causing necrotizing fasciitis?
Group A streptococcus, S. aureus
141
What empiric antibiotics do you use for necrotizing fasciitis?
IV: Cloxacillin(or Cefazolin) + clindamycin ±vancomycin Penicillin +clindamycin if you suspect GAS (e.g. in chicken pox)
142
What complication of chickenpox would you suspect in a child who develops refusal to weight bear, significant pain, indurated area, bluish hue?
Necrotizing fasciitis | Suspect GAS as underlying cause
143
List 4 management steps in suspected necrotizing fasciitis?
CBC & blood culture Urgent surgical consult IV antibiotics IVIG Imaging should not delay surgical intervention
144
Name 5 complications of chickenpox
General - Pneumonia - Hepatitis, pancreatitis, nephritis, orchitis - Thrombocytopenia Bacterial infections -Cellulitis, soft tissue abscess, necrotizing fasciitis Neurologic - Cerebellar ataxia - Encephalitis - Reye syndrome - Stroke - Zoster (including Ramsay Hunt syndrome)
145
What are some complications of enterovirus?
``` Meningitis Encephalitis Acute flaccid paralysis Myocarditis Hepatitis ```
146
What are some complications of EBV?
``` Upper airway obstruction (adenopathy) Splenic rupture Encephalitis X-linked lymphoproliferative diseas ITP ```
147
What are some complications of influenza?
Otitis media Secondary bacterial pneumonia Myositis, Encephalopathy/encephalitis Reye syndrome
148
What are some complications of measles?
Otitis media Secondary bacterial pneumonia Encephalitis SSPE
149
What are some complications of mumps?
``` Meningitis Encephalitis Orchitis/oophoritis Arthritis Pancreatitis ```
150
What are some complications of parvovirus?
Papular-purpuric gloves and socks syndrome Transient aplastic crisis Chronic bone marrow failure Polyarthropathy syndrome
151
What are three options for obtaining a sterile specimen for diagnosis of UTI?
Catheterization Suprapubic aspiration Clean catch
152
What are antibiotic options for empiric treatment of UTI >2 months?
Majority can be managed with oral antibiotics Cephalosporin, amoxicillin-clavulanate, TMPSMX
153
What are indications for IV antibiotics in UTI?
Toxic appearance <1 month 2-3 months controversial Unable to retain oral intake (including medications) Immunocompromisedhost (selectively)
154
What investigations should be done after first febrile UTI?
Renal and bladder ultrasound for children < 2 years of age VCUG selectively
155
What are indications for VCUG
Ultrasound evidence of hydronephrosis, renal scarring or other findings suggestive of high grade vesicoureteralreflux or obstructive uropathy 2nd febrile UTI
156
What are indications for prophylactic antibiotics for UTI?
Grade 4 or 5 VUR
157
What antibiotics should you use for prophylaxis for UTI?
TMP SMX Nitrofurantoin If child has UTI due to organism resistant to these –consider stopping prophylaxis
158
What are the most common organisms for dog/cat bite?
Pasteurellamultocida, Streptococci spp., S. aureus, anaerobes, others
159
What is the best empiric therapy for dog/cat bites?
PO amoxicillin-clavulanate IV cloxacillin+ penicillin If not improving, surgical debridement
160
What are the most common organisms for human bite?
Streptococci, S. aureus, anaerobes, nontypable Haemophilus influenzae, Eikenella corrodens
161
What is the best empiric therapy for human bite?
PO amoxicillin-clavulanate | IV cloxacillin+ Penicillin
162
What are the most common organisms for puncture wound of foot WITH sneakers?
Pseudomonas
163
What is the best empiric therapy for puncture wound of foot WITH sneakers?
Piperacillinor ciprofloxacin ±gentamicin
164
What are the most common organisms for puncture wood of foot WITHOUT sneakers?
S. aureus
165
What is the best empiric therapy for puncture wood of foot WITHOUT sneakers?
PO cloxacillinor cephalexin | IV cloxacillinor cefazolin
166
Name 5 organisms that can cause severe invasive disease in patients with asplenia
``` S. pneumo (majority of sepsis) HIB Neisseria meningitidis Capnocytophaga canimorsus (dog saliva) Salmonella (reptiles, food, water) Malaria Babesiosis ```
167
What are three categories of preventive interventions for children post-splenectomy?
Immunizations Antibiotic prophylaxis Education around fevers
168
What immunizations do asplenic children need?
1) Prevnar13 & 23-valent polysaccharide vaccine 2) Quadrivalent meningococcal vaccine & 4CMenB 3) H. Influenzaetype b 4) Influenza vaccine, annually 5) S. typhivaccine pre-travel Household contacts need routine vaccines & annual influenza vaccine
169
What do you use for antibiotic prophylaxis in asplenic patients?
Birth –3 months: amoxicillin-clavulanate (higher risk of E Coli) ≥3 months: Penicillin (amoxicillin alternative)
170
When are asplenic patients at highest risk of sepsis?
- Younger children - First year after splenectomy - Congenital asplenia/functional asplenia>traumatic asplenia
171
What ticks transmit lyme disease (borrelia burgdorferi)?
Ixodes scapularis Ixodes pacificus
172
What are the 3 clinical stages of lyme disease and what are the associated manifestations?
Early localized disease - Erythema migrans (MOST COMMON)*** - Systemic symptoms (fever, myalgia, headache, arthralgia, neck stiffness) Early disseminated disease - Multiple EM lesions - Meningitis - Facial nerve palsy (THIRD MOST COMMON)*** - Carditis with heart block Late disease - Pauciarticular arthritis (SECOND MOST COMMON)*** - Peripheral neuropathy - CNS manifestations
173
How do you diagnose lyme disease?
For erythema migrans: - DO NOT NEED SEROLOGIES - Will often be negative in early LD For all other clinical manifestations: 1) Screening ELISA 2) Confirmatory immunoblot for IgM and IgG NOTE: ELISA and IgM IB high likelihood of false positive if pretest probability low
174
When can IgM and IgG be detected in Lyme disease?
IgM can be detected within 2 weeks of infection IgG rise usually 4-6 after infection
175
What are oral and IV treatment options for Lyme disease?
Oral: Doxycycline for children ≥8 years of age Amoxicillin for children <8 years of age Cefuroxime IV: Ceftriaxone Penicillin G
176
How do you remove a tick?
Carefully grasp tick with fine point tweezers as close to your skin as possible Pull straight out, gently but firmly Don't squeeze Clean the bite area and your hands with soap and water Don't put anything on the tick, or try to burn the tick off
177
What should you do with the tick?
Send to PHL for identification
178
Do you use chemoprophylaxis is in children with a tick bite?
Yes, if >8 years old | Single dose of doxycycline in high-risk exposure (high endemic region, exudes tick)
179
When is the peak incidence of West Nile Virus?
Late summer & fall
180
What are the 3 clinical presentations of WNV?
Asymptomatic infection (~80%) West Nile fever (~ 20%) West Nile neurologic disease (≤1%)
181
What are the neurologic symptoms associated with WNV?
Aseptic meningitis Encephalitis Acute flaccid paralysis (poliomyelitis like)
182
What are 5 strategies to avoid WNV?
Avoid outdoors during times of high mosquito activity (dawn and dusk) Mosquito repellents (DEET, icaridin) Long clothing, hat, closed shoes Screens on windows/doors Fine mesh netting for cribs, strollers Limit mosquito breeding by minimizing containers or other objects with standing water (toys, pots etc)
183
What are the different levels of severity in C. difficile?
1) Mild - <4 abnormal stools/day 2) Moderate - ≥4 abnormal stools/day 3) Severe - Evidence of systemic toxicity (eg, high grade fevers, rigors) 4) Severe complicated - Evidence of systemic toxicity and severe colitis, including hypotension, shock, peritonitis, ileus or megacolon
184
How do you treat the following types of C. difficile? 1) Mild 2) First episode mild/moderat, no change with antibiotic stoppage 3) First episode severe 4) First episode severe complicated 5) First recurrence 6) Second recurrence
1) Mild - Discontinue precipitating antibiotic - Follow-up 2) First episode mild/moderate, no change with antibiotic stoppage - PO metronidazole x 10-14 days 3) First episode severe - po vancomycin x 10-14 days 4) First episode severe complicated - po vancomycin +IV metronidazole x 10-14 days 5) First recurrence - Same as above 6) Second recurrence - vancomycin in tapered or pulsed regimen
185
List 4 steps for infection control for C. difficile
1) Hand hygiene 2) Identifying and cleaning environmental sources - Sporicidal agents (chlorine-based, other) - NOTE: alcohol does not kill spores 3) Contact precautions for duration of symptoms (until 48 hours diarrhea free) 4) Private rooms or cohorting
186
Who should be screened for STIs?
Females -All who are sexually active or victims of sexual assault Males In presence of risk factors: -Sexual contact with STI -Previous STI -New sexual partner or >2 partners within past year -Injection drug use or substance abuse -Unsafe sexual practices (e.g. unprotected sex) -Anonymous sexual partnering -Sex worker, survival sex, street involved, homelessness -Time in detention facility -Sexual assault or abuse
187
What tests should be done for an STI screen?
First catch urine NAAT chlamydia and gonorrhea | HIV, HepB, syphilis serology
188
How do you treat uncomplicated gonorrhea in children >9 years?
Ceftriaxone 250 mg IM OR Cefixime 800 mg po SD PLUS Azithromycin1 g SD
189
How do you treat uncomplicated gonorrhea in children <9 years?
Ceftriaxone 50 mg/kg IM OR Cefixime 8mg/kg BID po x2 doses PLUS Azithromycin 20 mg/kg SD
190
What are the next steps in management of a child born to a mother with untreated gonorrhea?
Well: Conjunctival cultures IM Ceftriaxone Unwell: Conjunctival, blood and CSF cultures
191
What are the next steps in management of a child born to a mother with untreated chlamydia?
Routine culture, treatment not recommended Observe for conjunctivitis, pneumonia
192
Differential diagnosis for genital lesions
HSV Cysts or abscesses of the Bartholin glands Chancroid(Haemophilus ducreyi) Bechet disease Trauma Genital warts Molluscum contageosum Syphilis, lymphogranuloma venereum, granuloma inguinale(usually painless)
193
What is the definition of TB exposure?
Asymptomatic, negative TST, normal CXR
194
What is the definition of TB infection?
Asymptomatic,normal CXR, but positive TST
195
What is the definition of TB disease?
Signs and symptoms or radiographic manifestations are apparent
196
What is the definition of a positive TST?
0-4 mm •Child under 5 years of age ANDhigh risk of TB infection ≥5mm •HIV infection (well) •Close contact with active contagious case (past 2 years) •Presence of fibronodulardisease on CXR(healed TB) •Organ transplant •TNF-αinhibitors •Other immunosuppressive medications (e.g. corticosteroids –equivalent of ≥15 mg/day for ≥1 month) •End stage renal disease ≥10mm •All others
197
Name 4 reasons for reactive tuberculin skin test
Mycobacterium tuberculosis infection Non-tuberculous mycobacteria infection BCG in past Incorrect technique (measurement)
198
Name 8 reasons for false negative TST
``` Incorrect technique Active TB disease Immunodeficiency states Corticosteroids Young age Malnutrition Viral infections (measles, varicella, influenza) Live attenuated vaccines (measles) ```
199
What are the advantages of Interferon γ release assays in the diagnosis of TB?
-More specific for M. tuberculosis than TST (Doesn’t cross react with BCG and most non-tuberculous mycobacteria) -Does not require follow-up visit in 48-72 hours
200
What clinical situation are interferon gamma tests most useful?
Diagnosis of LTBI in BCG recipients
201
What are the disadvantages of Interferon γ release assays in the diagnosis of TB?
- Cross reacts with some NTMB species - Cannot distinguish LTBI from active TB - Sensitivity ↓by temporary anergy of acute illness - Reduced sensitivity in immune compromised individuals (including HIV)
202
What are risk factors for development of TB disease?
Infants and post-pubertal adolescents Recently infected (past 2 years) Immunodeficiency states (PID, HIV, malignancy, organ transplant, immunosuppressive meds, malnutrition)
203
How do you diagnose pulmonary TB?
TST/IGRA (does not distinguish between latent and active disease) CXR Gastric aspirates (3x early morning, before feeding or ambulation) Microbiology-acid fast staining, culture, DNA probes, PCR
204
What are three different ways pulmonary TB can appear on chest imaging?
Hilar adenopathy Ghon complex Miliary TB
205
How do you treat LTBI?
INH x 9 months
206
How do you treat active TB?
INH, RIF, PYR, ETH (4 drugs) x 2 months | INH + RIF to complete course
207
What supplement should you give for all children with TB disease?
Vitamin D
208
What are the side effects of INH?
``` Hepatotoxicity Peripheral neuropathy (interferes withpyridoximemetabolism) ```
209
What are the side effects of rifampin?
``` Hepatotoxicity Hypersensitivity reactions Memory impairment Drug interaction Body fluids turn orange ```
210
What are the side effects of pyrazinamide?
Hepatotoxicity | Increased uric acid levels
211
What are the side effects of ethambutol?
Optic neuropathy (decreased acuity, decreased visual fields, color blindness)
212
What are the infectious risks associated with blood transfusions?
HIV 1 in 8-12 million Hepatitis C virus 1 in 5-7 million Hepatitis B virus 1 in 1.1-1.7 million HTLV-1/2 1 in 1-1.3 million
213
What is the leading cause of HIV infection in women?
Heterosexual transmission
214
In a mother with HIV, what two things do we test for in the infant and when?
PCR(birth, 1, 2 months) | Serology (18 months)
215
What is the likelihood of vaginal transmission if mom on ART and received IV zidovudine during labour?
<2% 25% if no interventions
216
Name 5 medical interventions to prevent vertical HIV transmission
1) Triple ART starting in 2ndtrimester (or earlier) 2) IV zidovudine during labor 3) Zidovudine to infant x 6 weeks (or combination ART if mother's VL elevated) 4) Elective Cesarean section if VL>1000 copies/mL 5) Avoidance of breast feeding
217
What are the initial management steps in an HIV-exposed infant after birth?
Assess risk of HIV transmission (maternal viral load, CD4 count, ART, mode of delivery) Assess for potentially associated conditions (syphilis, HepB/C) Clean well prior to administration of vitamin K CBC, HIV DNA PCR, viral culture, CD4count Zidovudine2 mg/kg qid for 6 weeks-start within 8 hours of birth!
218
When should you give cotrimoxazole prophylaxis in an HIV exposed infant?
Mom has suboptimal virologic control
219
How can you finalize HIV negative status in exposed infant?
Exclusion of HIV requires 2 separate negative PCR tests taken at 1 month of age or later
220
How can you finalize diagnosis of HIV infection in exposed infant?
HIV infection confirmed by positive PCRx2 prior to 18 months or reactive serology after 18 months
221
What are the two most common laboratory abnormalities with AZT?
Macrocytic anemia | Elevated lactate
222
Name 8 AIDS-defining conditions in chidlren
PJP pneumonia Lymphoid interstitial pneumonitis Recurrent bacterial infections HIV wasting syndrome HIV encephalopathy Candida esophagitis CMV disease Mycobacterium avium intracellulare infection
223
Name 11 clinical manifestations of HIV infection in children
Category A (“mild”) symptoms - Lymphadenopathy, hepatosplenomegaly, parotitis - Dermatitis - Recurrent or persistent sinusitis, otitismedia Category B (“moderate”) symptoms - Bacterial meningitis, pneumonia, sepsis - Oropharyngeal candidiasis(non-neonatal) - Recurrent or chronic diarrhea - Cardiomyopathy - Nephropathy - Complicated chicken pox - CMV disease (early onset) - Persistent fever (>1 month)
224
Well controlled children with HIV are almost immunologically normal. Name two ways they are not.
Increased risk of pneumococcal disease Vaccine responses not as good as healthy children
225
What immunizations should be given to children with HIV?
All routine childhood vaccines Annual influenza vaccine Polysaccharide pneumococcal vaccine (after Prevnar) Meningococcal vaccine (Menactra)
226
What vaccines are contraindicated in HIV?
MMR if severe immune compromise VZV vaccine if CD4percentage < 25% BCG & oral polio vaccine contraindicated in developed countries
227
What is the risk of transmission with needle stick injury for the following viruses if positive source? Hep B Hep C HIV
HepB 2-40% HepC 3-10% HIV 0.2-0.5%
228
What factors affect HIV transmission following needlestick injury?
``` Community prevalence Needle size Hollow bore Visible blood Depth of penetration Elapsed time ``` ``` HIV infected source: Disease stage Viral load CD4count Antiretroviral therapy ```
229
What tests do you do for needlestick injury and how often?
HBsAg, HBsAb, HBcAb HIV serology HCV serology 0, 6 weeks, 3 months, 6 months
230
What is the schedule for HepB vaccination in needlestick injury?
0, 1, 6 months
231
What do you do if a patient is fully vaccinated for HepB and get a needlestick injury?
1) HBsAb & HBsAg (STAT) 2) If HBsAb (+) or HBsAg (+)-no treatment, refer to GI if Ag + 3) If HBsAb (−) & HBsAg (−)-HBIg and vaccine
232
What do you do if a patient is not fully vaccinated for HepB and gets a needlestick injury?
1) HBsAb & HBsAg (STAT) Administer HBIG & first dose of vaccine 2) D/C vaccine if HBsAg+ or HBsAb+
233
List 5 management priorities in daycare bite wounds
1) Local wound care (allow to bleed freely***, soap and water) 2) Tetanus immunization if needed 3) Prophylactic antibiotics if moderate/severe tissue damage, deep puncture, more than superficial injury to face/hand/foot/genitalia 4) HIV post-exposure prophylaxis if one kid is HIV infected and there is exchange of blood
234
What to do when unknown HepB status child bites another unknown HepB status child AND there is break in skin?
Vaccinate both | No testing
235
What to do when HBV carrier child bites a non-immune child AND there is break in skin?
For bitten child: HBIg HB vaccine Follow up testing (HepB serology at 6 months)
236
What to do when a non-immune child bites HBV carrier AND there is break in skin?
For biting child: HBIg HB vaccine Follow up testing (HepB serology at 6 months)
237
What to do when unknown HepB status child bites non-immune child AND there is break in skin?
For bitten child: | HB vaccine
238
What to do when non-immune child bites child with unknown HepB status AND there is break in skin?
For biting child: | HB vaccine
239
What is a general contraindication to any vaccine?
Prior history of anaphylaxis to vaccine or vaccine component (egg allergy is ok-can be observed in office after vaccine administration)
240
What is a contraindication to live vaccines?
Severe immune deficiency
241
What are contraindications to influenza vaccine?
-History of Guilain Barre within 6 weeks of influenza vaccine in past
242
What are contraindications to live attenuated influenza vaccine?
Immune compromising conditions Severe asthma (oral steroid; high dose inhaled steroids; active wheezing; medically attended wheezing in preceding 7 days) Chronic ASA therapy Pregnancy
243
What vaccines are contraindicated in patients with active TB?
MMR | VZV
244
What are contraindications for rotavirus vaccine?
Hypersensitivity History of intussusception Immunocompromisedinfants (especially SCID) >= 8 months of age
245
What is the period of infectiousness of meningococcal meningitis?
7 days prior to symptom onset until 24 hours after start of effective therapy
246
Do you give chemoprophylaxis for meningococcal meningitis to contacts that are immunized?
YES
247
During what time period of contact with an index case would you consider chemoprophylaxis for meningococcal meningitis?
Up to 10 days after last contact with index case
248
What are indications for chemoprophyalxis AND vaccination in close contacts for meningococcal meningitis?
Household contact Persons who share sleeping arrangement with index case Childcare and preschool contact Direct exposure to index secretions (kissing etc) HCW who have intensive unprotected exposure Seated next to index case during flight >8 hours
249
Name 3 options for chemoprophylaxis for meningococcal meningitis
Rifampin (5 mg/kg [max 600 mg] bid x2 days) Ceftriaxone single dose IM (adult -250 mg; 125 mg <12 years) Ciprofloxacin (adults 500 mg single dose)
250
What are the three types of meningococcal vaccines and what do they protect against?
Meningococcal C conjugate vaccine (Menjugate, Meningitec, NeisVac-C) -Serogroup C Quadrivalent conjugate vaccine (Menactra, Menveo) -Serogroup A, Y, W-135 Multicomponentmeningococcal B vaccine (4CMenB) -Serogroup B
251
What are the indications for MenC vaccine?
Administer at 12 months of age to healthy children Close contacts of known group C disease
252
What are the indications for quadrivalent meningoccal vaccine?
Menveo recommended for children < 2 years of age at increased risk of disease All adolescents should be offered a booster dose beginning at 12 years of age Close contact of serogroups A, Y, W-135
253
Who is at increased risk of invasive meningococcal disease?
Asplenia Primary antibody deficiencies Complement, properdinor factor D deficiency Acquired complement deficiency (Eculizumab) Travelers to areas where meningococcal risk is high (e.g. sub-SaharanAfrica, Saudi Arabia during Haj) Laboratory personnel with exposure to meningococcus The military
254
What are the indications for multicomponent meningococcal B vaccine (4CMenB)?
Recommended for children 2 months or older if: -Increased risk of invasive meningococcal disease (asplenia, complement deficiency, eculizumab therapy) -Close contacts of invasive group B disease case -Outbreak control
255
What are the indications for HPV vaccine?
All girls and boys 9-26 years of age and older regardless of sexual activity
256
What is Gardasil?
Recombinant vaccine for the prevention of cervical cancer and condylomata
257
Which HPV serotypes does Gardasil protect against?
Covers HPV types 6, 11, 16, 18
258
What does HPV 6, 11 cause?
90% of anogenital warts | Recurrent respiratory papillomatosis
259
What does HPV 16, 18 cause?
70% of squamous cell and adenocarcinomas 86% of adenocarcinomas of the cervix Cancers of penis, anus, vulva and vagina
260
What is the dosing regimen for Gardasil?
3 dose schedule-0, 2, 6 months
261
Who can get 2 dose schedule (0, 6 months) for Gardasil?
Otherwise healthy children 9-14 years of age
262
What pathogen accounts for most admissions for gastroenteritis and most gastroenteritis <2 years of age?
Rotavirus
263
How effective is the rotavirus vaccine?
Decreases incidence of gastroenteritis by 70-80% | Decreases severity by 85-95% (reduces admissions)
264
When should rotavirus vaccine be given?
Between 6-14 weeks of life | SHOULD NOT be given >8 months of age
265
Who should get the flu vaccine?
All children >6 months of age
266
In what groups of children in influenza vaccine particularly recommended?
Children 6-59 months of age Chronic respiratory, cardiac, renal, metabolic conditions Immune compromising conditions Hemoglobinopathies Children and adolescents on long-term with salicylates Children and adolescents with underlying neurological disorders Children who are household contacts of individuals at high risk All pregnant women, adults over 65 years, aboriginal peoples, chronic care facility residents People capable of transmitting influenza to those at risk
267
What form of the inactivated influenza vaccine is recommended for children?
Quadrivalent
268
What is the dose of inactivated influenza vaccine?
Two doses 0.5 mL 4 weeks apart in children 6 months to 9 years of age first year of receipt Single dose in all others
269
In what age group is live attenated influenza vaccine authorized?
>=2 years of age
270
How many after receiving antivirals can you get the live flu vaccine?
48 hours
271
If you get an antiviral within 2 weeks of getting the live flu vaccine, when should you give a second dose of vaccine?
48 hours after stopping antiviral
272
Who should get antibiotics for pertussis and what is the purpose?
Treatment of child indicated to reduce spread; wont impact duration of cough Household contacts should also get antibiotics
273
What are 4 nationwide strategies to reduce pertussis?
Universal vaccination of children Universal vaccination of teenagers and adults Invest in more immunogenic vaccines Post-exposure immunization Education of public
274
How long after IVIg do you need to wait before giving MMR or varicella vaccines?
Recommended interval depends on IVIG dose 300-400 mg/kg=8 months 1 g/kg=10 months 2 grams/kg=11 months***
275
Which vaccines have reduced efficacy after IVIg?
MMR and varicella | Not other live vaccines or inactivated vaccines
276
What are the indications for Hepatitis A prophylaxis with JUST vaccine?
All individuals within 2 weeks of exposure in those ≥6 months of age
277
What are the indications for Hep A prophylaxis with JUST immunoglobulin?
Infants <6 months | Vaccine contraindications
278
What are the indications for HepA prophylaxis with BOTH vaccine and Ig?
Immunocompromised
279
What should you do for a newborn born to mom with unknown HepB status?
- Send maternal HBsAgSTAT - If result available within 12 hours of birth can await result, if (+) give HBV vaccine and HBIG, if (-) no intervention
280
If mom HepBsAg positive, what time frame do you have to give HepB vaccine and Ig?
Vaccine should be given within 12 hours of birth (provides 90% of protection) Ig should also be given within 12 hours, but can be given up to 7 days after birth. Efficacy signficantly decreased after 48 hours
281
What is the HepB vaccine schedule for exposed newborns?
0, 1, 6 months
282
When should infant HepB serologies be done after administering the full vaccine series?
4 weeks after Usually at 9-12 months of age If HBsAg-, HBsAb -, reimmunize
283
Who should get the 4 dose schedule of HepB vaccine (0, 1, 2, 6 months)
Infants <2.0 Kg at birth
284
What does the following HepB serology mean: HBeAg−, HBcAg−, HBsAg− HBeAb−, HBcAb−, HBsAb+
Immunized, uninfected
285
What does the following HepB serology mean: HBeAg+, HBcAg+, HBsAg+ HBeAb−, HBcAb+, HBsAb−, IgMHBcAb+
Acute infection
286
What does the following HepB serology mean: HBeAg−, HBsAg+ | HBeAb+, HBcAb+, HBsAb−
Healthy carrier
287
What does the following HepB serology mean: HBeAg+, HBsAg+ | HBeAb−, HBcAb+, HBsAb−
Chronic infection
288
What does the following HepB serology mean: HBeAg−, HBcAg−, HBsAg− HBeAb+/−, HBcAb+, HBsAb+
Past infection
289
What is the risk of transmission of maternal HCV ?
5%
290
What factors increase the risk of maternal HCV transmission?
HIV co-infection, higher HCV viral load, elevated ALT, cirrhosis
291
Is elective C/S recommended for mothers with HCV?
No
292
What and when do you test an infant exposed to HCV?
HCV serology at 12 to 18 months PCR can be done between 3-6 months of age, but not essential (to relieve anxiety)
293
Name 5 indications for VZIg (within 10 days of exposure)?
Immunocompromised children without history of varicella or varicella immunization Susceptible pregnant women Newborn infant whose mother had onset of chicken pox within 5 days before delivery or within 48 hours of delivery Hospitalized premature infant (≥28 weeks gestation) whose mother lacks a reliable history of chicken pox or serologic evidence of protection against varicella Hospitalized premature infant (< 28 weeks gestation or birth weight ≤1000 gram) regardless of maternal history of varicella or varicella-zoster virus serostatus
294
What things would you do on an infant born to mom with varicella prior to delivery?
- Test for presence of IgG(serology) - VZIg if rash within 7 days before delivery or 2 days after - Treat with acyclovir IV if develops chickenpox
295
What three infection control precautions should you take in mom with varicella?
Mom should be in negative pressure isolation if still has active lesions Baby should be isolated with mom (incubation period 7-21 days post-exposure) Non-immune family members should not come to the hospital (incubation period)
296
What are 5 things you would do to manage a dog bite?
Clean, irrigate (saline) &debride X-ray if concerned about fracture Wound closure –controversial; hand wounds often left open Antibiotic prophylaxis (amoxicillin-clavulanatefor 5 days) Rabies immune globulin into wound Initiate rabies vaccination series (5 doses) Notify public health Advise elevation of the hand first 48 to 72 hours
297
What are the indications for rabies prophylaxis (RIG and vaccine)?
Direct contact with bat+ bite, scratch, or saliva exposure into a wound or mucous membrane cannot be ruled out Unprovoked dog, cat, ferret, skunk, fox, coyote, raccoon, other carnivores bite Healthy dog, cat, ferret-observe x 10 days and if signs of rabies, initiate prophylaxis
298
What are the management steps in a possible rabies exposure?
Notify public health Handling of animal - Domestic animal can be observed 10 days for signs of rabies; if develop –animal euthanatized and tested - If wild animal –euthanize and test immediately Rabies immune globulin - 20 IU/kg; as much as possible should be infiltrated into wound - Remainder can be given IM ``` Rabies vaccine (Human diploid cell vaccine) -Four (or five) doses of vaccine days 1, 3, 7, 14, (28) ```
299
How should rabies immunoglobulin be given?
Infiltrated into wound, remainder should be given IM
300
How many doses of rabies vaccine are given?
Usually 4 or 5 doses
301
What is the recommended post-exposure prophylaxis for Hib type B?
Rifampin x 4 days
302
What is the recommended post-exposure prophylaxis for N. meningitidis?
Rifampin x 2 days
303
What is the definition of invasive GAS and what is the recommended chemoprophylaxis for close contacts of invasive GAS?
Invasive GAS= Strep TSS Soft tissue necrosis (NF, myositis, gangrene) Meningitis Cephalexin x 10 days
304
What is the recommended post-exposure prophylaxis for B. pertussis?
Azithromycin x 5 days | Erythromycin x 14 days
305
What is the recommended post-exposure prophylaxis for measles?
IG within 6 days of exposure MMR within 72 hours
306
What is the recommended post-exposure prophylaxis for rubella?
Generally none IG may be considered in pregnancy if termination not an option MMR within 72 hours
307
What are the indications for palivizumab?
Children < 12 months of age with CLD of prematurity who require ongoing medical therapy at the start of the RSV season Children < 12 months of age with hemodynamically significant heart disease Infants without CLD born at < 30 weeks gestation if they are < 6 months of age at the start of the RSV season Consider in infants who live in remote communities and born at < 36 weeks gestation if < 6 months of age at the start of the RSV season Consider in full-term Inuit infants < 6 months of age at onset of RSV season living in remote communities with persistently high rates of RSV hospitalization May be considered in children < 24 months of age who are on home oxygen, have had a prolonged hospitalization for severe pulmonary disease or are severely immunocompromised
308
Name 4 infectious contraindications to breastfeeding
HIV HTLV-1/2 Active HSV lesions on breast (until crusted) Active TB (until after 2 weeks of treatment in mom) Untreated brucellosis
309
By what rate does palivizumab decrease admissions related to RSV?
50%
310
What part of RSV is palivizumab directed against?
Humanized murine monoclonal immunoglobulin G-1 directed against an epitope on the F glycoprotein of RSV
311
Should palivizumab be continued after natural RSV infection has occurred?
NO-Continuation of monthly palivizumab is not recommended for children hospitalized with breakthrough RSV infection
312
Which intervention will result in the best form of infection control for RSV?
Isolate everyone with respiratory symptoms
313
What do you if you have diarrhea on your hands?
Wash with regular soap and water
314
What infections require airborne precautions?
Varicella Measles TB Smallpox
315
What infections require droplet/contact?
``` RSV Influenza Rhinovirus Coronavirus Parainfluenza ```
316
What infections require droplet precautions?
S. pneumoniae N. meningitiditis S. pyogenes Pertussis
317
What infection require contact precautions?
Diarrhea ARO VRE MRSA
318
When can children with impetigo return to daycare?
24 hours after treatment initiated
319
When can children with strep pharyngitis return to daycare?
24 hours after treatment initiated
320
When can children with pertussis return to daycare?
5 full days after treatment initiated
321
When can children with E. Coli 0157:H7 return to daycare?
Resolution of diarrhea & stool culture negative x2
322
When can children with shigella return to daycare?
Resolution of diarrhea ≥24 hrs ±neg stool cultures
323
When can children with non-typhi salmonella return to daycare?
Until resolution of diarrhea
324
When can children with C. difficile return to daycare?
Until resolution of diarrhea
325
When can children with typhoid fever return to daycare?
Resolution of symptoms & negative stool cultures x3
326
When can children with HepA return to daycare?
Until 1 week after onset of illness or jaundice
327
When can children with chickenpox return to daycare?
Whenever
328
When can children with mumps return to daycare?
Until 5 days after parotid gland swelling
329
When can children with measles return to daycare?
Until 4 days after onset of rash
330
When can children with scabies return to daycare?
Until after treatment given
331
Do children with lice and varicella need to be exlcuded from daycare?
NO
332
Name 4 methods to practice antimicrobial stewardship
Use clinical judgement (accurate diagnosis, investigate judiciously) Treat infection, not contamination/colonization Assessment of antibiotic allergy Know local antibiogram Select narrowest spectrum antibiotic needed Optimize dosing to obtain maximal benefit - e.g. high dose Q24H for aminoglycosides, rather than traditional Q8H - e.g. BID for AOM, TID for pneumonia Use the shortest recommended course of therapy for uncomplicated infections Do not change or prolong antibiotics uneccessarily Promote vaccination
333
What are causes of facial nerve palsy in children?
``` Idiopathic (incl. HSV) Otitis media Lyme disease VZV (Ramsay Hunt syndrome) Cholesteatoma Facial nerve schwannoma Vestiular schwannoma Meningioma ```
334
How do you treat bell's palsy (excluding Ramsay Hunt syndrome)?
Corticosteroids
335
What are the typical clinical features of Ramsay Hunt syndrome?
Reactivation herpes zoster in geniculate ganglion Facial nerve LMN palsy Ear pain Vesicles on ipsilateral face, ear, ear canal Deafness Vertigo
336
How do you treat Ramsay Hunt syndrome?
Antiviral and steroids
337
Name 4 high risk groups for severe influenza infection
Children 6-59 months of age Children with chronic health conditions - Cardiovascular, liver, renal, metabolic disease - Neurologic or neurodevelopmental conditions - Anemia or hemoglobinopathy - Malignancy and other immune compromising conditions Children and adolescents on chronic ASAt herapy Pregnancy Aboriginal peoples
338
What are indications for oseltamivir?
- Moderate/severe, progressive influenza - Patients 1-4 years with mild influenza within 48 hours - Patients >1 year with mild influenza and risk factors
339
When do you give zanamavir in the treatment of influenza?
Moderate/severe influenza with no response to oseltamivir or previous oseltamivir prophylaxis
340
What EBV serology results would you get in acute EBV infection
``` Monospot + VCA IgM + EA IgG + VCA IgG + EBNA IgG - ```
341
What EBV serology results would you get in past EBV infection?
``` Monospot - VCA IgM - EA IgG - VCA IgG + EBNA IgG + ```
342
What is the interaction between clarithromycin and cyclosporine?
Clarithromycin reduces cytochrome P4503A activity leading to reduced cyclosporin clearance
343
What 2 infections can mimic terminal ileitis (especially think about in children with exposure to farm animals)?
Yersinia enterocolitica | TB
344
What antibiotic do you use to treat sinusitis?
Amoxicillin
345
What are effective regimens for treating lice?
Permethrin1% (Nix) (>2 months) Pyrethrin (R+C shampoo) (>2 months) 50% isoprophyl myrisate (ResultzR) (>4 years)
346
Why do we not use lindane to treat lice?
Lindanehas slow killing time, more resistance | and more toxicity
347
What antibiotics do you empirically use for pulmonary exacerbation in cystic fibrosis?
Ceftazidime and tobramycin
348
What interventions should you immediately do for suspected HSV keratitis?
Swab for HSV PCR IV acyclovir Optho consult
349
What are cardiac indications for endocarditis prophylaxis?
Prosthetic valve or prosthetic material in valve repair Prior infective endocarditis Unrepaired cyanotic CHD Completely repaired CHD with prosthetic material during first 6 months after procedure Repaired CHD with residual defects adjacent to prosthetic material Cardiac valvulopathy in heart transplant patients
350
What are procedure indications for endocarditis prophylaxis?
Dental procedures that involve: - Manipulation of gingival tissue - Manipulation of periapical region of teeth - Perforation of oral mucosa Invasive procedures of the respiratory tract that involve incision or biopsy of mucosa Prophylaxis no longer recommended routinely for GI or GU procedures
351
What conditions can be associated with erythema nodosum?
``` Group A streptococcus M. pneumoniae M. tuberculosis B. henselae Yersinia Sarcoidosis Bechet’s disease Malignancy IBD ```
352
What children are at high risk of invasive streptococcal disease?
``` Chronic CSF leak Congenital immune deficiencies Cochlear implants Asplenia Chronic neurologic conditions Sickle cell disease and other hemoglobinopathies Chronic renal disease HIV infection Chronic liver disease Immunosuppressivetherapy Chronic cardiacdisease Malignancy Chronic respiratory disease(excluding asthma) Solid organ transplant Poorly controlled diabetes mellitus Hematopoieticstem cell transplant ```
353
What empiric antibiotics do you use for orbital cellulitis?
IV cloxacillin+ ceftriaxone±metronidazoleor clindamycin
354
What organisms is most responsible for bacterial tracheitis?
S. aureus, mixed organisms
355
What organisms are most responsible for epiglottitis?
Hib | S. aureus
356
What is the differential for recurrent fevers?
``` Recurrent viral infections True infections with immune deficiency Chronic non-infectious (e..g autoimmune) Cyclic neutropenia Periodic fever syndromes ```
357
Should you do a full septic work up, HSV OCR lesion scraping, and start IV acyclovir for mucocutaneous HSV?
YES
358
Until what age could a baby develop neonatal HSV?
6 weeks
359
When should you do surface swabs in mom with active HSV lesions at delivery?
24 hours | Mouth, conjunctiva, nasopharynx, anus
360
How do you treat children <2 years of age who are exposed to pulmonary TB and have negative TST/CXR?
INH x 3 months, recheck TST, if negative can stop INH If >2 years, can observe (age 2-5 is controversial)
361
What vaccines should you give a previously unimmunized child >7 years?
TdAP IPV MMR NO Hib over 7 years
362
Name 4 conditions that HPV vaccine prevents
Genital warts Cervical cancer Anorectal cancer Penile cancer
363
What is most likely serology pattern in fully immunized 9 month old infant born to mom with HepBsAg positive?
HepBcAb+, HepBsAb+ (cAb from mom)
364
Spot diagnosis: http://accessmedicine.mhmedical.com/data/books/1843/cmdt17_ch35_f008.png
Cutaneous larva migrans
365
Spot diagnosis: https://www.atsu.edu/faculty/chamberlain/images/koplik_spots2.jpg
Koplik spots
366
What are the Jones criteria for acute rheumatic fever?
Need 2 major or 1 major+2 minor WITH evidence of GAS infection: Major: ●Carditis and valvulitis (eg, pancarditis) that is clinical or subclinical – 50 to 70 percent ●Arthritis (usually migratory polyarthritis predominantly involving the large joints) – 35 to 66 percent ●Central nervous system involvement (eg, Sydenham chorea) – 10 to 30 percent ●Subcutaneous nodules – 0 to 10 percent ●Erythema marginatum – <6 percent Minor: ●Arthralgia ●Fever ●Elevated acute phase reactants (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) ●Prolonged PR interval on electrocardiogram
367
What is the common bacteria causing osteomyelitis?
S. aureus (in all age groups)
368
What % of patients with osteomyelitis have positive blood cultures?
50%
369
In what part of the bone does osteomyelitis typically begin?
Before growth plate closure-METAPHYSIS After growth plate closure-DIAPHYSIS
370
Empiric treatment of osteomyelitis in the following age groups: i) Neonates ii) Infant iii) Child
i) Neonates: cloxacillin and gentamicin/cefotaxime ii) Infant: cefotaxime and cloxacillin iii) Child: Cefazolin
371
How long do you typically treat acute osteomyelitis?
4-6 weeks
372
How do you treat chronic osteomyelitis?
Surgical debridgement | Antibiotics several months or longer
373
When do you see changes on XR in osteomyelitis?
After 7-14 days-lytic bone changes
374
What is the most common site of osteomyelitis?
Femur
375
How many hours after starting antibiotics should you see clinical improvement with a bacterial pneumonia?
48 hours If no improvement, consider CXR to r/o complications AND consider alternative diagnoses (viral, aspiration, PID, congenital pulmonary anomaly, TB)
376
What are the 3 most common bacteria causing complicated pneumonia
1. S pneumo 2. S aureus 3. S pyogenes
377
What antibiotics should be used for complicated pneumonia and for how long (CPS)?
``` Ceftriaxone +/- clindamycin (for anaerobic + community acquired MRSA) OR vancomycin (for confirmed or severe suspected MRSA) ``` 3-4 weeks duration; can switch to oral clavulin when drainage complete and off O2
378
What procedural intervention should be used for complicated pneumonia (CPS)?
Three options with equivalent outcomes: 1. VATS 2. Early thoracotomy 3. Small-bore percutaneous chest tube placement with instillation of fibrinolytics (tPA x 3 days)
379
When should CXRs be repeated in complicated pneumonia (CPS)?
2-3 months
380
How long are patients with Hep A contagious?
2 weeks before to 7 days after onset of jaundice
381
List 3 complications of HepB infection
Acute liver failure Chronic liver disease Glomerulonephritis Hepatocellular carcinoma
382
List 3 risk factors for otitis externa
``` Swimming Trauma Foreign body Hearing aid Skin conditions Chronic otorrhea Wearing tight head scarves Immunocompromised ```
383
Diagnostic criteria for otitis externa
1. Rapid onset (within 48h) in the past three weeks 2. Symptoms of ear canal inflammation → otalgia, itching, fullness +/- hearing loss, jaw pain 3. Signs of ear canal inflammation (i.e. tender pinna/tragus) OR diffuse ear canal edema/erythema +/- otorrhea, regional lymphadenitis, TM erythema, or cellulitis of pinna/skin
384
What are the two most common bacteria causing otitis externa?
Pseudomonas aeruginosa + Staph aureus
385
Treatment of otitis externa
- First Line (mild-to-moderate): topical antibiotic +/- topical steroid for 7-10 days - First Line (severe): systemic antibiotics covering staph and pseudomonas
386
List 3 reasons why you might not have response to treatment for otitis externa
If no clinical response in 24-48 hours, consider - Obstruction - Foreign body - Non-adherence - Antimicrobial resistance - Viral/fungal infection
387
What is required for the diagnosis of AOM? (CPS)
Acute onset of symptoms such as otalgia AND Signs of a middle ear effusion associated + inflammation of the middle ear (ie, a TM that is bulging and, usually, very erythematous or hemorrhagic, and yellow or cloudy in colour) OR ruptured TM
388
Treatment of oral thrush
Nystatin suspension 200 000 U PO QID x 2 weeks
389
Treatment of tinea pedis that involves toe nail
Oral antifungal (e.g. terbinafine)
390
Treatment of cradle cap
Treat with mild soap; if severe can use shampoos with selenium sulfide or azole
391
What is the only oral antifungal not metabolized through cytochrome P450?
Terbinafine
392
What is the best strategy to prevent influenza in infants <6 months of age?
Influenza vaccine for pregnant women
393
What are the 8 components of Canada's vaccine system?
1. Evidence-based pre-license review and approval process 2. Regulations for manufacturers: 3. Evidence-based vaccine use recommendations 4. Immunization competencies training for health care providers 5. Pharmacovigilance for adverse events following Immunization (AEFIs) 6. AEFI causality assessment 7. Safety and efficacy signal detection 8. Canadian Immunization Research Network special immunization clinics (SICs)
394
How long should athlete with EBV be excluded from sports and what are the requirements for resuming activity?
Minimum 3 weeks Resume activity if: 1. Resolution of symptoms 2. Normalization of labs 3. Resolution of splenomegaly (CONFIRM WITH ULTRASOUND)
395
Hoow does posterior element overuse syndrome or “hyperlordotic back pain” present?
``` Similar to spondylosis Extension related back pain Lumbar spine/paraspinal muscle tenderness BUT Investigations NEGATIVE ```
396
Treatment of hyperlordotic back pain?
Ice and NSAIDS Physiotherapy +/- Bracing until pain resolves
397
How does vertebral body apophyseal avulsion fracture present?
Acute-onset flexion-related lumbar pain, similar to disc herniation, although with no associated neurological symptoms Physical exam: Spinal flexion and extension limitation Paraspinal muscle spasm
398
Diagnostic tests for apophyseal avulsion fracture
Lateral lumbar spine x-rays | CT
399
Treatment of apophyseal avulsion fracture
Rest (3-6 months for symptoms to resolve), heat and NSAIDs Urgent neurosx if spinal cord compression symptoms
400
Management of ankle sprain
PRICE (protection, rest, ice, compression, elevation) - Functional bracing (rigid lateral stirrups-->lace up brace x 3-6 months) - NSAIDs - Physiotherapy - Stepwise RTP usually within 1-6 weeks

FRCPC (27 decks)

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