WEEK 3 – INFECTION, IMMUNOLOGY, PHARMACOLOGY Flashcards by Kitty Eichner

Key points?

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Associated Diagnoses of:
- Fever?
- Recurrent fever?
- Fever & erythema?
- Fever & purpura?

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CAHS Guideline - Neonatal Sepsis
- Clinical Presentation of Infection - General or Non-specific?
- Suggestive or Specific symptoms? (5)

Suggestive or Specific:
1. Respiratory distress.
2. Gastrointestinal: vomiting (may be bile-stained), diarrhoea, abdominal distension.
3. Central Nervous System: irritability, seizures, and full fontanel.
4. Skin: septic lesions.
5. Eyes, umbilicus: discharge.

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CAHS Guideline - Neonatal Sepsis
- List 14 Risk Factors?
- Outline the consequences of infection?

Preterm labour and birth
Resuscitation required at birth
Premature rupture of the membranes
Ongoing respiratory disease
Clinical chorioamnionitis and / or discoloured liquor.
Colonisation with pathogens
Maternal peripartum pyrexia (> 38°C).
Invasive presence of indwelling plastic devices
Maternal group B Streptococcal colonisation
Inadequate hand hygiene
Maternal UTI
Parenteral nutrition
Multiple gestation
Nursery colonisation with pathogens

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CAHS Guideline - Neonatal Sepsis
- Investigations of Suspected Early Onset Sepsis Sepsis? (7)
- Investigations of Suspected Late Onset Sepsis Sepsis? (6)

Investigations of Suspected Sepsis
For all infants ≥ 35 weeks gestation refer to the Neonatal Clinical Guideline – Earlyonset Sepsis Risk Calculator: Assessment of Early-Onset Sepsis in Infants ≥ 35 weeks
Gestation

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CAHS Guideline - Neonatal Sepsis
- General Management and Antimicrobial Treatment of Early Onset Sepsis?
- What tool can you use in this situation?

Antibiotics should be administered to any neonate with clinical signs of sepsis.
The presence of risk factors for sepsis may indicate investigation but are not in themselves an indication for antibiotic administration if the neonate is well.
Common pathogens include Group B Streptococci (S. agalactiae) and Gram negative organisms, esp. E. coli and H. influenzae.
Parenteral therapy with Penicillin and Gentamicin should be started immediately after the septic screen.
If the infant is ill, speed of intervention is of the essence.
For cases where there is immediately life-threatening sepsis or deterioration
despite first line antibiotics, a stat dose of Meropenem should be initiated and
clinical microbiologist/infectious diseases should be consulted promptly to tailor antibiotic choice for the patient, as there maybe need for additional antibiotics.

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CAHS Guideline - Neonatal Sepsis
- General Management and Antimicrobial Treatment of Hospital acquired Late-Onset Sepsis?
- Length of Treatment?

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CAHS Guideline - Neonatal Sepsis
- When to obtain a lumbar puncture? (4)

Obtain cerebrospinal fluid (CSF) for:
1. Infants with suspected meningitis or sepsis.
2. Drainage of CSF in communicating hydrocephalus.
3. Diagnoses of metabolic disorder.
4. Diagnostic procedure in seizure activity.

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CAHS Guidelines: Eye Care: Eye Infections and Conjunctivitis
- Background?
- 3 Stages of Eye Irritation?
- 4 Eye Irritation causes other than infective causes?

Eye Irritation other than infective causes
1. Naso-lacrimal duct obstruction may cause ongoing stickiness to eyes.
2. Corneal abrasion due to trauma at delivery
3. Foreign body
4. Glaucoma which can present with corneal cloudiness, or proptosis (protrusion
of the eyeball)

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CAHS Guidelines: Eye Care: Eye Infections and Conjunctivitis
- Causes of Neonatal Conjunctivitis & Clinical features?

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CAHS Guidelines - Cytomegalovirus CMV Neonatal Pathway
- Who to test?
- How and when to test?

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CAHS Guidelines - Cytomegalovirus CMV Neonatal Pathway
- Clinical assessment?
- Investigations? (3)

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CAHS Guidelines - Cytomegalovirus CMV Neonatal Pathway
- Who to treat?
- How and when to treat?

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CAHS Guidelines - Cytomegalovirus CMV Neonatal Pathway
- Follow-up?
- What do Infants with congenital CMV on valganciclovir require?

Infants with congenital CMV on valganciclovir require:
1. ID review: Early review at 1-2 weeks, then 2-4 weekly thereafter to monitor compliance, side effects and complications, increase valganciclovir dose with growth and coordinate follow-up.
2. Neutrophil count (FBC): At least weekly for 2-3 weeks, then at 6 weeks and monthly thereafter.
3. Liver Function Test (LFT) and renal function (EUC): At least monthly throughout therapy.
4. Paediatrics, audiology and ophthalmology.

CMV viral load testing is not routinely required after commencing therapy, except if there are acute septic features or if there are specific concerns about absorption. CMV viral loads are expected to rebound after ceasing therapy, confirmation of this by viral load testing is not warranted.

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CAHS Guidelines - Cytomegalovirus CMV Neonatal Pathway
- Management of Postnatally Acquired CMV Infection?

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What is the definition of fever? for a Neonate?
- Is High fever more of a concern? When?
- Which investigations would you order for children you suspect are unwell?

Fever
- >37.5oC in a neonate
- >38oC in a child older than one month
- Helps the immune system eradicate pathogens.
- Hypothermia is an equally concerning sign.
- High fever (>39) is more of a concern in infants <6m - there is more of a correlation with invasive bacterial infection in this (immune naive) age group
- High fever is not so useful in understanding risk of invasive bacterial infection in >6m of age.
- Most febrile illnesses are benign & transient (usually viral).

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Fever Case 1 - Would you:
- Observe at home?
- Observe in hospital?
- Temperature significant?
- Investigations?
- Give antibiotics orally?
- Give antibiotics parentally?

HR 160 = upper limit of normal
RR 52 = little on the high side
Temp 35.2 = HYPOTHERMIC
Investigate with: Sepsis 6 - FBC, Inflammatory markers, Blood culture, Urinalysis, Urine MC&S, LP
Give antibiotics parentally (IV penicillin & gentamicin usually for ?sepsis)

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Fever Case 2 - Spotty in the bath:
- Measles?
- Septic screen?
- Observe at home?
- Observe in hospital?
- Other virus?

Diagnosis = Roseola
Not measles as they would still have a fever with the rash!
Don’t need to a septic screen
Observe at home
Roseola caused by herpes virus

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Fever Case 3 - 2.5yo miserable:
- Septic Screen?
- Antibiotics?
- Meningococcal can present like this?
- Observe in hospital?
- Observe at home?

Don’t need to septic screen if the child is alert etc. (we know its most likely going to be a viral illness). Examine the child.
Don’t need antibiotics - even with OM
Meningococcal can present like this but unusual and goes to shit quickly (5-30% nasopharyngeal carriers)
Observe at home

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Fever Case 4 - 10yo and tummy ache & CRP 200:
- Its a virus?
- Investigate - bloods only?
- Investigate - bloods & imaging?
- Agitation is significant?
- Abdo pain is significant?
- Fall in shower is significant?

Diagnosis = septic arthritis of the hip
Persisting tachycardia = a concern
Agitation is significant here!
Abdo pain is significant - Sepsis, DKA, trauma = hypovolaemic shock (adrenaline = vasoconstriction of splancnic circulation mesenteric arteries)
Fall was a distractor but not necessarily the pathophysiological cause of the septic arthritis?

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Fever Case 5 - Fever & Company
- Do the LP right away?
- This could be shock?
- Resus: ABC first, LP only when stable?
- Treat with broad spectrum AB ASAP?
- Allow 10mins for IV access?
- Allow 2 min for IV access?

This could definitely be shock
Do resus first then LP
Use fluid bolus to resus
Treat with broad spectrum ABs
Only 2mins for IV access!! (then introsseous)
Subclavian is the last vein to shut down

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Use of Antipyretics in children with a fever?
- 3 Contraindications to ibuprofen and 1 to paracetamol?

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PCH ED Guidelines - Communicable diseases exclusion

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PCH ED Guidelines - Communicable diseases exclusion

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**PCH ED Guidelines - Communicable diseases exclusion**

**PCH Guidelines - Cervical lymphadenitis** - Assessment? - Definition? - Clinical Examination? - Investigations? -

**Investigations** - The majority of children have mild disease and require no investigations. - Indicated only if systemic symptoms, suspicion of underlying infection or in immunocompromised patient. - Full blood count, C-Reactive Protein (CRP) and blood cultures are indicated in the unwell or septic appearing child. Refer to Sepsis Recognition and Management (ED Guidelines). - Ultrasound may be considered if atypical or clinical doubt about drainable collection.

**RCH Guidelines - Cervical lymphadenopathy** - 2 Key Points? - Assessment - History?

**Key points** - Cervical lymphadenopathy is common and may be found in more than one third of otherwise healthy children. - Observation and reassurance without investigation is usually appropriate for the well appearing child with cervical lymphadenopathy.

**RCH Guidelines - Cervical lymphadenopathy** - Examination? - Differential Diagnoses of acute cervical lymphadenopathy?

**Examination** - Characterise the lump: location, size, colour, warmth, mobility, tenderness, overlying skin changes. - Unilateral or bilateral - Features on palpation: eg soft, rubbery, firm, matted, fluctuant, discharging. - Neck range of motion. - Lymphadenopathy at other sites. - Other focus of infection: scalp, face, ear, nose, throat or teeth. - Further examination should be guided by history and differential diagnosis.

**RCH Guidelines - Cervical lymphadenopathy** - Differential Diagnoses of Persistent cervical lymphadenopathy & their clinical features? - Approach to differential diagnosis?

**Persistent cervical lymphadenopathy** - Subacute cervical lymphadenopathy (2–6 weeks) – commonest cause viral infection. - Chronic cervical lymphadenopathy (>6 weeks) - has a number of possible. cause. Many viruses will cause cervical lymphadenopathy lasting up to 6 weeks. - Some cases may be unexplained.

**RCH Guidelines - Cervical lymphadenopathy** - Investigations? - Treatment?

**PCH Guidelines - Fever - Without source** - Definition? - Key Points? - Fever without a source flowchart?

**Definition**: Fever without source (FWS): A child or infant presenting with a fever >38C (axillary or rectal) without a readily identifiable source on history and/or physical examination (e.g. no coryzal or other respiratory signs/symptoms).1 Fever is nature’s way of killing viruses / bacteria. **Key points** - Fever > 38oC in the 3-6 month age group is concerning as they are not fully immunised. - After 6 months of age the height of the fever is unhelpful. - Most fevers are caused by a viral illness. - Lack of response to antipyretics does not predict a serious illness.

**PCH Guidelines - Fever - Without source** - Assessment? - System for identifying the likelihood of serious illness?

**Assessment** - General features of the child’s behaviour, interaction and appearance over a period of time provide the best indicator of whether serious infection is likely - Beware of the unimmunised child - Beware of the partially treated child.

**PCH Guidelines - Fever - Without source** - Management of Neonates with a temperature >38°C? (5) - Management of 1 Month - 3 months of age with a temperature >38°C? - Management of >3 months of age with a temperature of >38°C Sick looking child vs. well looking child?

**Management** - No tepid sponging - Treating fever with antipyretics is not recommended if the child is not miserable or in distress. - Treat child for discomfort or pain with paracetamol or ibuprofen. **Neonates with a temperature >38°C** 1. FBC, U&E, CRP and blood cultures 2. Urine (SPA specimen) 3. Lumbar puncture 4. Consider CXR if indicated 5. Admit for empiric IV antibiotics.

**PCH Guidelines - Fever - Without source** - When would you consider an LP? (5) - When would you consider a CXR? (4) - Paracetamol & Ibuprofen doses?

**Chest X-ray** - Usually only considered if signs of respiratory illness: 1. Cough 2. Increased respiratory rate 3. Crepitations or dullness on auscultation 4. Decreased oxygen saturations.

**PCH ED Guidelines - Herpes stomatitis** - Complications? - Clinical Features? - Diagnosis? - 4 Differentials?

**Herpes stomatitis - Clinical Features** - Children typically present with fever, bad breath, and refusal to drink due to painful oral lesions involving the buccal and gingival mucosa. - Half to two-thirds of patients also have extra-oral skin lesions around the mouth. These painful lesions begin as typical herpetiform vesicles, which may progress to pustules or erode to become ulcers. Untreated, the lesions may last for 12 days. - Fever (< 39C) is common (especially if primary infection), and there may be enlarged cervical lymph nodes.

**PCH ED Guidelines - Herpes stomatitis** - Analgesic management? - Aciclovir management? - Adjunct treatment? - Topical antivirals? - Antibiotics? - 4 Indications for admission?

**Adjunct treatment** - Chlorhexidine mouthwash 0.2% – hold 10mL in mouth for 1 minute 2-3 times a day while ulcers are present - If younger children are unable to use a mouthwash, the alternative is chlorhexidine 0.5% dental oral gel. - Substitute for toothpaste as an adjunct to oral hygiene. **Topical antiviral agents** - Topical antiviral agents are not helpful in the treatment of primary herpes gingivostomatitis in immunocompetent patients and are not recommended. **Antibiotics** - Antibiotics are not routinely used unless a secondary bacteria infection is diagnosed. **Indication for admission** 1. Inability to maintain adequate hydration 2. Immunocompromised host 3. Eczema herpeticum 4. Encephalitis, epiglotitis or pneumonitis (usually in immunocomprised patients)

**Western Australian Immunisation Schedule** - Children 0-12months? - 18 months? - 4 years?

**Western Australian Immunisation Schedule** - Adolescent & Adult? - Seasonal Influenza?

**PCH ED Guidelines - Impetigo** - 2 General Types? - Pathogens? - 7 Complications? - Examination? - Investigations? - 4 Differentials?

**Pathogens** - Staphylococcus aureus and Streptococcus pyogenes (either individually or in combination). Consider MRSA. **Complications** - These are relatively uncommon but include: 1. Lymphadenitis 2. Scarlet fever 3. Osteomyelitis 4. Septic arthritis 5. Pneumonia 6. Septicaemia 7. Post-streptococcal glomerulonephritis - rarely and does not appear to be influenced by antibiotic treatment. Impetigo often spreads rapidly, and the infection is generally more severe in children suffering atopic dermatitis (and other dermatological conditions).

**PCH ED Guidelines - Impetigo** - Management? - Hygiene issues? - Isolation?

**Hygiene Issues** - Soap and water cleansing, air-drying whilst at home, use of child’s own face wash towels, importance of hand washing. - The use of disinfectant solutions or medicated soaps probably gives no advantage over plain soap and water and drying. - In recurrent cases associated with nasal and other site carriage, chlorhexidine body wash may be preferred, as part of a broad eradication regimen – consultation with microbiology is recommended in this situation. **School / Day Care Exclusion** - Exclude from school / daycare until lesions are healed and crusted over and no longer weeping, or until 24 hours after commencing antibiotic (topical or systemic) treatment. - Whilst at school, lesions on exposed areas should be covered with a waterproof dressing. - Single-room isolation is not required for skin infections.

**PCH ED Guidelines - Petechiae** - Key points? - Define: Petechiae, Purpura, Fever? - Causes of Petechiae: 2 Viral? 3 Bacterial? 3 Mechanical? 4 Other?

**Background** - The cause of petechiae and fever is difficult to diagnose on presentation. Always err on the side of caution and obtain senior medical advice early. **Definitions** - **Petechiae**: Pinpoint (1 - 2 mm) red or purple non-blanching spots on the body. - **Purpura**: Larger (> 2 mm) red or purple non-blanching spots on the body. - **Fever**: > 38°C in the > 1 month age group and > 37.5°C in the < 1 month age group.

**PCH ED Guidelines - Petechiae** - Management if Temperature > 38oC and looks unwell? - Management if If looks well? - Management if mechanical cause? - 3 Discharge Criteria?

**Management** - All patients with petechiae need to be reviewed by an Emergency department senior doctor - No discharge home between midnight and 8am. **Discharge Criteria** 1. No signs of deterioration or progression of rash: 2. Emergency Department Senior Doctor must review the patient prior to discharge 3. Follow up: General Practitioner within 24 hours.

**PCH ED Guidelines - Measles** - Transmission and Epidemiology? - Examination - 3 C's? - 4 Complications?

**Complications** 1. Pneumonia - is the most common cause of death in measles and may progress onto bronchiolitis obliterans. 2. Acute otitis media 3. Acute encephalitis (affects 1 per 1000 cases) 4. SSPE (Sub Acute Scelerosing Pan Encephalitis) – a rare late complication

**PCH ED Guidelines - Measles** - Investigations? - Clinical Management? - Public Health Management?

**Clinical Management** - There is no specific antiviral treatment for measles infection. - Management of measles is supportive.

**PCH ED Guidelines - Meningitis** - Background? - How do the usual cause of meningitis in children differ according to age and immunisation status?

**PCH ED Guidelines - Meningitis** - History - Important Qs to ask early? - Examination?

**Important questions to ask early:** - Immunisation status, ensure immunisations are not 'alternative medicine' or 'homeopathic'. - Recent antibiotic use - as it could be partially treated meningitis, and recent antibiotic use may also be a risk factor for carriage of relatively resistant pneumococci requiring addition of vancomycin to the treatment regimen.

**PCH ED Guidelines - Meningitis** - Investigations - Lumbar Puncture? - 8 Contraindications for LP? - 4 Signs/Symptoms that are NOT Contraindications for LP? - Recommended tests to be requested on Cerebrospinal Fluid (CSF)? - Cerebrospinal Fluid (CSF) Volumes Required?

**Lumbar Puncture** - LP is the only way to confirm the diagnosis of meningitis. - It allows identification of the organism with antibiotic susceptibility testing, thus ensuring appropriate use of antibiotics. - LP should (with few exceptions) be performed in every child who may have meningitis. - A good rule of thumb is that if you are asking yourself "should this child have an LP?" the answer generally is "yes". **Cerebrospinal Fluid (CSF) Volumes Required** - An absolute minimum of 500 microlitres (0.5mL) is required, with 1mL preferred. - One drop of CSF = 30‐40 microlitres, thus a minimum of 15‐20 drops is needed (30-40 drops preferred), collected in three bottles.

**PCH ED Guidelines - Meningitis** - 10 investigations to order in addition to an LP? - Role of Cranial CT?

**Cranial CT** - This is of limited use in acute bacterial meningitis. - CT does not reliably exclude raised intracranial pressure, and a normal CT should not reassure one about the risk of coning following an LP. - CT does have a role when the diagnosis is in doubt (e.g. posterior fossa tumours can also cause meningism), or when complications of meningitis (e.g. brain abscess) are suspected.

**PCH ED Guidelines - Meningitis** - Antimicrobials? - Steroids? - Fluids?

**Steroids** - The role of steroids in the treatment of meningitis has been controversial. - A recent Cochrane review states that steroids may reduce neurological sequelae (particularly hearing loss) in meningitis in developed countries such as Australia. - Current management at PCH is to give IV Dexamethasone: 3 months – 18 years, 0.15 mg/kg (maximum 10 mg) every 6 hours for 4 days. - Where possible, give the first dose just prior to or at least concurrently with antibiotics. - Antibiotics should never be delayed when dexamethasone is not immediately available.

**PCH ED Guidelines - Serious Illness** - 7 Causes of Respiratory Failure? - 6 Causes of Circulatory Failure? - 4 Causes of Central Neurological Failure? - Recognition of the deteriorating child?

**Respiratory Failure** - Asthma, Bronchiolitis, Aspiration. Pneumonia, Foreign body, Croup, Poisoning **Circulatory Failure** - Anaphylaxis, Septic shock, Hypovolaemia, Congenital Heart Disease, Arrythmiam, Trauma **Central Neurological Failure** - Raised intracranial pressure, Infections, Trauma, Seizures

**PCH ED Guidelines - Serious Illness** - The ABCDE approach - Airway? - 5 Signs of airway obstruction? - 5 Components of Airway Resuscitation?

**PCH ED Guidelines - Serious Illness** - The ABCDE approach - Breathing? - Assessment of Breathing: 5 Effort? 3 Efficacy? 3 Effects? - Ventilation?

**PCH ED Guidelines - Serious Illness** - The ABCDE approach - Circulation? - 3 Signs of inadequate circulation? - 4 Signs of cardiac disease / heart failure? - Resuscitation?

**PCH ED Guidelines - Serious Illness** - The ABCDE approach - Disability? (6) - The ABCDE approach - Exposure? (4)

**PCH ED Guidelines - Tonsillitis** - Definition? - 4 Risk Factors? - Assessment? - History?

**Definition**: Tonsillitis is inflammation of the tonsils due to infection. **Risk factors**: 1. Low socio-economic status 2. Aboriginal and Torres Strait Islander 3. Maori and Pacific Islander 4. Existing rheumatic heart disease. **Assessment** - It can be difficult to distinguish clinically between viral tonsillitis (majority) and bacterial tonsillitis. - Viral tonsillitis is more likely where there are other symptoms of a viral upper respiratory tract infection.

**PCH ED Guidelines - Tonsillitis** - Examination? - 7 Clinical features that are more suggestive of GABHS? - Investigations? - 9 Differentials? - Management - Resus? Dehydration?

**Investigations** - Bacterial throat swab for culture is usually not indicated. Results take 24 to 48 hours. Consider throat swab in high risk patients. **Differential diagnoses** 1. Epstein-Barr virus (Glandular Fever) 2. Herpes stomatitis 3. Hand foot and mouth disease 4. Herpangina 5. Croup 6. Epiglottitis 7. Peri-tonsillar abscess (Quinsy) 8. Retro-pharyngeal absces 9. Oral thrush (Candidiasis)

**PCH ED Guidelines - Tonsillitis** - Analgesia? - Antibiotics? - 5 Admission Criteria?

**Admission criteria** 1. Upper airway obstruction 2. Fever with significant signs of sepsis 3. Suppurative complications 4. Severe dysphagia and inadequate oral hydration (require intravenous fluids) 5. Pain not controlled with oral analgesia.

**PCH ED Guidelines - Tonsillitis** - 6 Suppurative Complications? - 2 Non-Suppurative complications of GABHS?

**Suppurative Complications** 1. Peri-tonsillar abscess (Quinsy) 2. Retro-pharyngeal abscess 3. Cervical lymphadenitis 4. Sinusitis 5. Mastoiditis 6. Otitis media **Non-Suppurative complications of GABHS** 1. Acute rheumatic fever 2. Post-Streptococcal glomerulonephritis

The 10 signs of Primary Immunodeficiency in Children?

**Australian criteria for Acute Rheumatic Fever diagnosis.**

**Risk groups for ARF** - High? - May be at risk? - Additional considerations which increase risk?

**PCH ED Guidelines - Kawasaki disease** - 5 Complications? - 5 Diagnostic Criteria? - 5 Associated non-specific symptoms?

**Complications** 1. Coronary artery aneurysms - Infants under 12 months are at increased risk of coronary artery aneurysm. Delay of treatment (after 10 days) increases risk of coronary artery aneurysm by five times. 2. Depressed myocardial contractility and heart failure. 3. Myocardial infarction 4. Arrhythmias 5. Peripheral arterial occlusion.

**PCH ED Guidelines - Kawasaki disease** - Incomplete (atypical) Kawasaki Disease? - 5 Laboratory findings? - 4 Investigations? - 6 Differentials? - Initial management? - Further managemnt? - Discharge treatment?

**Investigations** - No diagnostic lab tests for Kawasaki Disease but can be supportive or used to exclude other causes of fever. 1. CPR, ESR, FBC, ALT, Albumin 2. ASOT/AntiDNAse B 3. Urinalysis - clean catch or in-out catheter 4. Blood culture. **Differential diagnoses** 1. Adenovirus 2. Epstein Barr Virus 3. Scarlet fever 4. Toxic Shock Syndrome 5. Steven-Johnson Syndrome 6. Measles.

**PCH ED Guidelines - Henoch-Schönlein Purpura** - What is it? - 5 Clinical Features?

**Clinical Features** - The child is generally well-looking. - There is often a history of a recent URTI. - Small-vessel vasculitis may involve several organ groups, in particular the skin, joints, gastrointestinal tract and kidneys. - Rarely, there may be central nervous system or pulmonary involvement.

**PCH ED Guidelines - Henoch-Schönlein Purpura** - 5 Differential Diagnoses? - Investigations? - Management? - Admission Criteria?

**Differential diagnosis** 1. Meningococcal septicaemia disease 2. Thrombocytopenia 3. Other vasculitides 4. Patients initially presenting with only with abdominal pain or arthralgia may pose a diagnostic challenge 5. Patients initially presenting with haematuria only should have other causes of haematuria excluded.

**Comparisons of the effects of diseases and the side effects of vaccines** - Diptheria? - Hepatitis A? - Hepatitis B? - Hib?

**Comparisons of the effects of diseases and the side effects of vaccines** - HPV? - Influenza? - Measles? - Meningococcal?

**Comparisons of the effects of diseases and the side effects of vaccines** - Mumps? - Pertussis? - Pneumococcal? - Polio?

**Comparisons of the effects of diseases and the side effects of vaccines** - Rotavirus? - Rubella? - Tetanus? - Varicella?

**PCH ED Guidelines - Immune Thrombocytopaenia (ITP)** - Definition? How do children present? - Background? 2 clinical conditions? - Algorithm?

**Definition**: ITP is an uncommon disorder, affecting 1- 3 in every 10,000 children. The platelet count is < 100 x 109/L, and may be as low as < 20 x 109/L. Children present with petechiae, purpura (bruising), and sometimes mucosal bleeding. Rarely there may be rectal bleeding or haematuria. The risk of intracranial haemorrhage (ICH) is < 1%.

**PCH ED Guidelines - Immune Thrombocytopaenia (ITP)** - Assessment? - 5 increased risk factors for intracranial haemorrhage (ICH)? - History? - Examination?

**Assessment** - Well children presenting with petechiae and purpura; mucosal bleeding is uncommon. - The clinical assessment is aimed at excluding other causes of petechiae / purpura and thrombocytopenia e.g. malignancies. - The severity of the disease is determined by the clinical picture, not the platelet count, which may be < 20 x 109/L. - Intracerebral haemorrhage is rare, but should be considered in any patient with ITP presenting with neurological symptoms or signs. **Consider increased risk factors for intracranial haemorrhage (ICH):** 1. Head trauma 2. Non-steroidal anti-inflammatories (NSAIDS) in last 5 days 3. Haematuria – micro or macroscopic 4. History of prolonged/episodic mucosal bleeding 5. Bleeding from multiple mucosal sites.

**PCH ED Guidelines - Immune Thrombocytopaenia (ITP)** - Investigations? - 7 Differential diagnoses? - Management? - Severity scoring of bleeding in patients with IPT: Bleeding Grades 0-5?

**Differential diagnoses** 1. Systemic Lupus Erythematosus (e.g. SLE). 2. Haematological malignancies (e.g. leukaemia). 3. Aplastic anaemia. 4. Infections - viruses, meningococcal disease. 5. Drug induced thrombocytopenia. 6. Haemolytic uraemic syndrome. 7. Other coagulation disorders e.g. disseminated intravascular coagulation (DIC). **Management** - ITP will spontaneously remit without any treatment within 6 months in most paediatric patients. - Treatment decisions should be based on bleeding rather than platelet count.

**PCH ED Guidelines - Immune Thrombocytopaenia (ITP)** - Management of patients with no to low / moderate risk of severe bleeding (Grade 0 to 3A)? - Management of patients with special considerations/social issues? - Management of patients with increased risk of ICH? - Management of patients with high-moderate risk (Grade 3B)?

**PCH ED Guidelines - Immune Thrombocytopaenia (ITP)**

**PCH ED Guidelines - Immune Thrombocytopaenia (ITP)** - Treatment for Severe Bleeding?

**PCH ED Guidelines - Immune Thrombocytopaenia (ITP)** - Admission criteria? - 4 Discharge criteria? - Referrals and follow up?

**Admission criteria** = Bleeding Grade 3B and above

**PCH ED Guidelines - Urticaria** - Background? - 5 Common Causes? - 7 Differentials?

**Common causes** 1. Infection - 80% of acute urticaria is related to viral, bacterial, and parasitic infections 2. Allergic reactions to medications 3. Foods - allergic reactions to foods can cause urticaria, typically within 30 minutes of ingestion. Milk, egg, peanuts, tree nuts, soy, and wheat are the most common foods to cause generalised urticaria in children 4. Insect stings and bites 5. Medications.

**PCH ED Guidelines - Urticaria** - Management? - Medications? - Role of Glucocorticoids?

**Management** - Approximately two-thirds of cases of new-onset urticaria will be self-limited and resolve spontaneously. If symptomatic: - Consider application of a cold compress to affected area(s). - Avoid aggravating factors such as excessive heat or spicy foods. - Aspirin and other NSAIDs (e.g. ibuprofen) should be avoided as they can worsen symptoms. - The below antihistamines can be considered to alleviate itching.

**RCH Guidelines - Sore Throat** - 3 Key points? - Background? - History - High risk groups? - 8 Exam findings? - 8 Red flag features?

**Key points** 1. Most children with sore throats do not need antibiotics. 2. With the exception of scarlet-fever type rash, there are no clinical features alone that reliably discriminate between Group A streptococcal (GAS) and viral pharyngitis. 3. Antibiotic therapy is ONLY recommended for a high-risk group of children to prevent non-suppurative complications of GAS infection. **Background** - The most common cause of sore throat in children is a viral illness. - Group A streptococcal (GAS) pharyngitis is rare under four years of age. - GAS can cause non-suppurative complications (acute rheumatic fever, post-streptococcal glomerulonephritis) and suppurative complications (peritonsillar abscess, retropharyngeal abscess.

**RCH Guidelines - Sore Throat** - Management algorithm?

**RCH Guidelines - Sore Throat** - Investigations? - Treatment? - Antibiotic therapy for suspected group A streptococcal pharyngitis?

**Treatment** - Supportive management is adequate for most sore throats including scarlet fever: - Simple analgesia (see Acute pain management). - Corticosteroids can be considered in patients with severe pain unresponsive to simple analgesia: - dexamethasone 0.15 mg/kg (max 10 mg) oral/IV/IM as a single dose OR - prednisolone 1 mg/kg (max 50 mg) oral as a single dose - Maintain hydration

**RCH Guidelines - Sore Throat** - Management of suppurative complications? - Peritonsillar abscess (Quinsy)? - Retropharyngeal/Parapharyngeal abscess? - Epiglottitis/Bacterial Tracheitis?

- What does an Erythematous rash look like? 4 Examples of causes?

- What does an Urticarial rash look like? 3 Examples of causes?

- What does a Purpuric rash look like? 3 Examples of causes?

- What does a Vesicular rash look like? 3 Examples of causes?

- What does a Papular rash look like? 3 Examples of causes?

**Acute Rheumatic Fever** - Australian guidelines for the diagnosis of acute rheumatic fever?

**Clinical features raising a high suspicion of acute rheumatic fever** - Symptoms & History? - Examination? - Laboratory Markers?

Work-up and management of suspected acute rheumatic feve?

Key investigative findings in Bill's case?

**Case discussion** It is likely that Bill had ARF in April when he first saw his GP. Important clues supporting the diagnosis of ARF include his Aboriginality and his social circumstances, including living in an overcrowded home. Appropriate management at this time would have been to confirm the diagnosis of ARF and prescribe aspirin for Bill's arthritis and IM benzathine penicillin G. It is possible Bill had had a recurrent episode of ARF leading to valvular compromise by the time he saw the paediatrician. This recurrence could have been prevented by the prompt administration of secondary prophylaxis. This case highlights the importance of educating patients about the consequences of recurrent ARF and involving family, friends and community carers in improving adherence to prophylactic treatment.

This infant has been unwell in last the last 12 hours with flu like symptoms. She developed a rash this morning and when her mother did the tumbler test the rash didn't blanch. She has a temperature of 39.1C. This rash may be caused by: - Chicken pox - Meningococcus - MRSA - Viral Urticaria

= **Meningococcus** This rash is not consistent with chicken pox or urticaria. MRSA in itself does not cause a rash.

This young girl has been unwell for 2-3 days with a runny nose and mild fever. Her mother is concerned she has developed a rash to her chest. She is eating and drinking well. This rash may be found in the following: - Simple Viral illnesses - Chicken Pox - Meningococcal disease - Cradle Cap

- Simple Viral illnesses - Meningococcal disease In the very early stages of meningoccal disease the rash may blanch so it is important a through assessment is carried out. Chicken pox has a more vesicular appearance and cradle cap is an eczetamous rash found on the scalp of babies.

This young infant developed rash in the morning after being introduced to solids. She appears to has been itching the rash (no sound). What is this rash called? - Vesicular - Urticaria or Hives - Slapped cheek syndrome - Maculo-papular

= Urticaria or Hives This is an urticarial rash. It is itchy, and generalised. - (A) Vesicles are little blisters. - (C) Slapped cheek syndrome affects mainly the cheeks - (D) The rash is not raised or distinct

The young infant has had persistent dry skin since birth which has recently become increasingly inflamed. Which of the following would be useful at assessment in this child? - Glucose - Temperature - Swab of the rash - Allergy testing

= **Temperature** - Assessment of the likelihood and severity of infection is important. A raised temperature, weeping lesions and malaise may be caused by infected eczema. - (A) A glucose is not indicated in this situation. - (C) Current NICE guidance on atopic eczema in children recommends health care providers only taking skin swabs if they suspect microorganisms other than Staphylococcus aureus to be present, or if they think antibiotic resistance is relevant.

The young girl had contact with chicken pox 14 days ago. She has recently developed numerous small lesions and has a temperature. She has not been drinking well. What is this rash? - Measles - Mumps - Shingles - Chicken Pox

= **Chicken Pox** - (A) Measles is a more confluent, maculo-papular rash and she does not have red eyes or obvious respiratory signs. - (B) Mumps does not cause a rash - (C) Although children do get shingles, its distribution is limited to a single dermatome

Discuss the immunological changes which occur between birth and 12 months of age.

- A baby’s immune system is not fully developed when they are born. It gets stronger as the baby gets older. The immune system works throughout our lives fighting germs that can cause disease. - A mother’s antibodies are shared with their baby through the placenta during the third trimester (last 3 months) of pregnancy. The mother’s antibodies help protect the baby from illnesses when the baby is born. The type of antibodies passed from mother to baby depends on the mother’s own level of immunity. - Good bacteria in our gut help our immune system to work well. During birth, these good bacteria are in the vagina and are passed on to the baby. This helps good bacteria to start living in the baby’s gut. - After birth, more antibodies are passed to your baby from the colostrum and in breast milk.

Which 16 factors should be considered in determining whether an infant or child is more vulnerable to infectious morbidity?

**15 Major reasons for the nosocomial spread of sepsis and meningitis in a neonate?**

**Major reasons for the nosocomial spread of sepsis and meningitis in a neonate** 1. Lack of essential equipment and supplies 2. Failures in sterilization/disinfection or handling/storage of multi-user equipments, instruments, equipment and supplies, leading to contamination. 3. Inadequate environmental cleaning and disinfection. 4. Overuse of invasive devices 5. Re-use of disposable supplies without safe disinfection/sterilization procedures 6. Pooling or multiple use of single-use vials 7. Overcrowded and understaffed labor and delivery rooms. 8. Excessive vaginal examinations 9. Failures in isolation procedures/ inadequate isolation facilities for babies infected with antibiotic-resistant or highly transmissible pathogens. 10. Unhygienic bathing and skin care 11. Lack of early and exclusive breast feeding 12. Contaminated bottle feedings 13. Absence of mother–baby cohorting 14. Lack of knowledge, training, and competency regarding infection control practice 15. Inappropriate and prolonged use of antibiotics

Describe the management of a child who presents with fever in each of the following scenarios: a. A two day old b. A two month old (unvaccinated)

Describe the management of a child who presents with fever in each of the following scenarios: a. Two-Year-Old Child?

Describe how the following factors affect which antibiotics are considered for an infant or child with a **UTI**: - Age? - Severity of disease? - Likely pathogens? - Investigations (e.g. culture, serology, PCR)? - Side effects?

**TGA Guidelines - Antibiotic choice for UTI in children** - Antibiotic choice for UTI in children? - Approach to empirical therapy choice for UTI? - Empirical oral antibiotic therapy for UTI? - Empirical intravenous antibiotic therapy for UTI?

**Approach to empirical therapy choice for UTI** - Recommendations for empirical antibiotic therapy for urinary tract infection (UTI) are based on factors including efficacy, convenience, cost, availability, and harms associated with antibiotic use (eg adverse effects in the patient, development of antibiotic resistance; see also Types of adverse effects of antimicrobials). - If available, the susceptibility of organisms recently identified in samples from the patient guides empirical antibiotic choice. - Empirical therapy choice is also guided by the resistance rates of common pathogens (in particular Escherichia coli) and a consideration of the risk of adverse outcomes from clinical failure. - As the prevalence of a pathogen’s resistance to an antibiotic increases, the likelihood of treatment failure increases, which outweighs the benefits of using the narrower-spectrum drug empirically for serious infections. Pyelonephritis has a higher likelihood of serious complications, so a lower resistance threshold is required than for cystitis.

Describe how the following factors affect which antibiotics are considered for an infant or child with **infected eczema**: - Age? - Severity of disease? - Likely pathogens? - Investigations (e.g. culture, serology, PCR)? - Side effects?

TGA Guidelines for Antibiotics in the treatment of infected atopic dermatitis (Eczema)?

Atopic skin is particularly susceptible to bacterial infection (eg staphylococci, streptococci) and viral infection (eg Herpes simplex virus, molluscum contagiosum virus, human papillomavirus [warts]). Patients with dermatitis have higher rates of skin staphylococcal carriage than those with normal skin. Infection stimulates further inflammation and reduces the effectiveness of topical treatments.

Describe how the following factors affect which antibiotics are considered for a child with **community acquired pneumonia**: - Age? - Severity of disease? - Likely pathogens? - Investigations (e.g. culture, serology, PCR)? - Side effects?

- **Local Antibiotic Resistance Patterns**: Knowledge of local antibiotic resistance patterns can guide antibiotic selection. In areas with high rates of antibiotic resistance among common pathogens, a broader-spectrum antibiotic may be preferred. - **Duration of Treatment**: The duration of antibiotic treatment for CAP in children typically ranges from 5 to 7 days, although it may be extended in severe or complicated cases. - **Allergies and Drug Interactions**: Determine if the child has any known allergies or drug sensitivities that could affect antibiotic selection. Be aware of potential drug interactions with any other medications the child may be taking.

**CAP in children 2 months or older** - Clinical Features? - Aetiology?

**Clinical features** - Typical clinical features of community-acquired pneumonia (CAP) in children include cough, tachypnoea, tachycardia and increased work of breathing. Fever is usually, but not always, present.

**CAP in children 2 months or older** - Is a viral diagnosis likely? - 4 Investigations? - Assessing disease severity? - Complications of pneumonia?

**Investigations** 1. A chest X-ray is recommended to confirm the diagnosis of pneumonia and may help to differentiate between bacterial and viral CAP. 2. Identification of the pathogen can be difficult in children with CAP because children rarely produce sputum and some microbiological tests are unreliable in children. 3. The pneumococcal urinary antigen assay has limited use in children because nasal carriage of Streptococcus pneumoniae can lead to false-positive results. 4. NAAT (eg PCR) is useful to detect Bordetella pertussis (see Diagnosis of pertussis) or respiratory viruses. Investigations for atypical bacteria (eg Mycoplasma pneumoniae) are not routinely recommended; positive NAAT (eg PCR) results can represent asymptomatic carriage, and serological testing is rarely helpful in the acute setting.

**Low Severity CAP in children 2 months or older** - Empirical therapy for children 2 months or older with low-severity CAP? - Empirical therapy for children 2 months or older with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins? - Empirical therapy for children 2 months or older with immediate severe or delayed severe hypersensitivity to penicillins? - Use of doxycycline? - What to use if Chlamydia trachomatis is suspected?

Doxycycline has not been associated with tooth discolouration, enamel hypoplasia or bone deposition, even in children younger than 8 years, so is increasingly used in this age group. However, use is limited by the lack of a suitable formulation.

Describe 10 peri- or post-infectious immune related paediatric conditions.

What are 12 general management principles of peri- or post-infectious immune related paediatric conditions?

Discuss the 5 risks (side effects and adverse events) and 6 benefits (immunogenicity, efficacy & effectiveness) of the current immunization program.

Explain the differences between the MMR vaccine, the acellular pertussis vaccine and the influenza vaccine.

What tool can be used to assess the risk of neonatal sepsis? - Which parameters are assessed?

Neonatal Early-Onset Sepsis Calculator

= MMR – attenuated virus - Can get a fever & rash about 10 days post vaccine. - About 1/20 kids - **Bexsero** = a vaccine approved for 10- through 25-year-olds to prevent meningococcal group B disease (also known as meningitis B) caused by Neisseria meningiditis - **Prevnar** = Pneumococcal conjugate vaccine is a pneumococcal vaccine and a conjugate vaccine used to protect infants, young children, and adults against disease caused by the bacterium Streptococcus pneumoniae. - **Infantrix Hexa** = combined diphtheria, tetanus, pertussis, hepatitis B and inactivated poliovirus vaccine. The second part is the Hib vaccine and is a white pellet in a separate glass vial. - **Vaxigrip** = influenza

= Coxsackie virus (Hand, foot and mouth) Hand, foot and mouth disease is a common but highly contagious infection in children caused by enteroviruses, including coxsackieviruses.

- Amoxicillin use - Rolling on buffalo grass - Peanut consumption - Recent URTI - Cefaclor use

= Recent URTI

= Scarlet fever = B-lactam antibiotics (usually penicillin) - Group A Strep pharyngitis

= Meningococcal sepsis suspected - You need to give IM Ceftriaxone!!

- Meropenem - Methyprednisalone - Tazocin - IV Immunoglobulins - Loratadine

= Kawasaki – IV Immunogloblin

- Differentials for purpura = IgA vasculitis - Tx = **Rest, analgesia & urinalysis** - Stay away from ibuprofen (NSAID) not good for the kidneys

= School sores/Impetigo = treat topically for the 1st time then oral or IV if repeated - Fluclox or ceflex or tricomoxaole - Best answer = After cefalexin and the lesion is dry

= Slapped cheek **= The fetus for hydrops** = The child for anaemia (if they have sickle cell can develop aplastic anaemia) Also, this will not usually impact your pregnancy or have long-term impacts on your baby. However, if you get infected with parvovirus B19, it is possible to spread the virus to your developing baby. As a result, your developing baby could develop severe anemia. This is not common but may cause a miscarriage.

Discuss the immunological changes which occur between birth and 12 months of age.

**Answer**: Essentially, humans are born with an immature immune system, which undergoes priming under the influence of both genetic and environmental factors both antenatally, and postnatally. Special note must be made of the protective effect of maternal immunoglobulin G (IgG) for which the transfer from mother to fetus begins as early as 13 weeks of gestation, and transport happens in a linear fashion as the pregnancy progresses, with the largest amount transferred in the third trimester.

Which factors should be considered in determining whether an infant or child is more vulnerable to infectious morbidity?

**Analysis**: One of the more frequent clinical challenges when faced with an acutely unwell child, is determining whether antibiotics are indicated. Perhaps it is all too easy to default to safety, prescribe the antibiotic – but unfortunately that has been leading us to ever increasing incidence of antibiotic resistant microbes. Vulnerability factors are one set of data clinicians routinely include in diagnostic and management reasoning.

Describe the management of a child who presents with fever in each of the following scenarios: a. A two day old

* Treatment is determined by the diagnosis and the severity of that diagnosis. Refer to the ChAMP guidelines. - For the 2 day old for suspected sepsis, gentamicin and benzylpenicillin IV (cefotaxime and benzylpenicillin if meningitis is not excluded). Education and follow-up is determined by the diagnosis. o A particular note to make in this regard is that there is a risk of irreversible sensory neural hearing loss with meningitis, which requires audiological review in the months and years after diagnosis. o Children who have had serious CNS infections (meningitis or severe viral encephalitis) are usually followed up for developmental screening. o Children with repeated serious bacterial infection may be referred to immunology for investigation of a primary immunodeficiency disorder.

Describe the management of a child who presents with fever in each of the following scenarios: a. A two day old

o For the 2 month old for suspected sepsis, but without haemodynamic instability (i.e. shock), ceftriaxone IV If they have haemodynamic instability (i.e. shock) give ceftriaxone, gentamicin, and maybe even vancomycin

Describe the management of a child who presents with fever in each of the following scenarios: c. A two year old

o For the 2 year old, if there is no sign of serious illness sepsis, then treat as for the 2 month old, but the ChAMP guideline suggests just observation if no signs of serious illness

Describe the relationship between paediatric infections, and the management of subsequent immune system related complications. a. How many and which peri- or post-infectious immune related paediatric conditions can you describe? b. What are the general management principles?

Discuss the risks (side effects and adverse events) and benefits (immunogenicity, efficacy & effectiveness) of the current immunization program (you do not need to know the current schedule). a. Explain the differences between the MMR vaccine, the acellular pertussis vaccine and the influenza vaccine.

WEEK 3 – INFECTION, IMMUNOLOGY, PHARMACOLOGY Flashcards

(140 cards)