CPS statements - ID Flashcards
Azole antifungals
- important to remember
- monitor liver enzymes
- drug drug interactions
- may prolong QT interval
Benefits of reducing antimicrobial use
- decrease adverse events
- decrease superinfections
- costs savings
- possible association between preivous abx therapy and development of obesity and allergies
Duration of antibiotics: (CPS AMS) - strep pharyngitis - children > 2 for uncomplicated AOM - uncomplicated PNA - UTIs
- Strep: 10 days
- AOM: 5 days > 2 yr (10 days if < 2 yr, recurrent or perforated TM)
- PNA: 7 days
- UTIs: 7-10 days
Risk factors for AOM
- young age
- frequent contact with other children
- household crowding
- cigarette smoke
- pacifier use
- shorter duration of breastfeeding
- prolonged bottle feeding while lying down
- family hx
- First Nations or Inuit
- low levels of IgA or biofilms in middle ear
Most common bacteria causing AOM
- S. pneumo
- H. flu
- M. catarrhalis
Less commonly: GAS (strep pyogenes)
Watchful waiting in AOM if:
- > 6 months of age
- no perforated TM with purulent drainage
- mildly ill (T<39, <48h of illness)
Risk factors for spread of CA-MRSA
- close skin-skin contact (cuts and abrasions)
- contaminated items
- crowded living conditions
- poor hygiene
- high risk populations: Athletes, daycare, Indigenous, military, IVDU, MSM, prisoners)
CA-MRSA reasons to use antibiotics after drainage
- child < 3 months of age
- significant associated cellulitis, fever or systemic signs of illnesses
(abx usually for a 7 days course after drainage e.g. septra) - child with serious medical problems
C. diff risk factors
- increased duration of hospital stay
- older age
- antibiotics
- chemotherapeutic agents
- immunosuppression
- HIV
- Hypogammaglobulinemia
- manipulation of Gi tract e.g. surgery, tube feeding
- mixed evidence for PPIs
C. diff recurrence rate
25%
C. diff mild illness vs. moderate vs. severe
Mild: watery diarrhea without systemic toxicity and < 4 abN stools
Moderate: 4+ abN stools per day, no systemic toxicity (+/- low grade fever, mild abdo pain)
Severe: high-grade fevers, rigors, hypotension, shock, peritonitis, colitis, megacolon
C. diff initial episode treatment
Mild: - discontinue antibiotic - follow up and reassess Mild/Mod: - metronidazole x 10-14 d Severe: - vancomycin PO x 10-14d First recurrence = repeat regimen for initial episode 2nd recurrence = vanco in a tapered or pulsed regimen
Features of congenital CMV
90% = asymptomatic At birth: IUGR CNS: microcephaly, seizures GI: hepatosplenomegaly Heme/Derm: petechial rash, jaundice
Treatment of congenital CMV
1) asympto
2) mildly symptomatic
3) moderate to severe
Asymptomatic (+/- SNHL): regular audiologic , no evidence for antiviral (awaiting trials for isolated SNHL)
Mild (+/- SNHL, no CNS or chorioretinitis): individualized management, consult ID
Moderate to severe: ID consult, antiviral agents, oral valgan x 6 months (IV ganciclovir can be for first 2-6 weeks if very ill)
Treatment for cCMV
and adverse events of treatment
- valganciclovir x 6 months (IV gancyclovir for first 2-6 weeks if really sick) to commence in first month
adverse events: neutropenia, thrombocytopenia, transaminases, elevated BUN and Cr
Varicella exclusion policy
- return as soon as well enough to participate normally (regardless of state of rash)
Maternal and neonatal risk factors for early onset bacterial sepsis
Maternal GBS+ Maternal GBS bacteriuria during pregnancy Previous GBS infant Maternal fever pROM > 18hrs
Adequate intrapartum antibiotic prophylaxis
- Pen G at least 4hr before birth (or cefazolin)
not clinda/erythro/vanco
Markers of early onset sepsis
WBC < 5 or >30 ANC <1.5 I:T ratio > 0.2 Procalcitonin CRP can be helpful serially
GBS +, not adequate IAP,
no other RFs (risk = 1-2%)
- examine, observe closely (VS q3-4)for at least 24hr
- reassess and counsel before discharge
GBS+ and other RFs (risk > 1-2%)
- At minimum, observe closely (Vs q3-4hrs) for at least 24hrs
- reassess and counsel before discharge
GBS negative or unknown with multiple risk factors of maternal chorioamnionitis
- At minimum observe closely VS q3-4hr for at least 24hrs
- consider CBC after 4hrs
HIV vertical transmission rate
< 2% in Canada
without intervention can be as high as 25%
Risk factors for HIV vertical transmission
- late or no prenatal care
- injection drug use
- recent illness suggestive of HIV seroconversion
- regular, unprotected sex with a partner known to be living with HIV or with sig risk for HIV
- diagnosis of STIs during pregnnacy
- emigration from an HIV-endemic area or recent incarceration
Woman in labour with unknown HIV status management
- Rapid HIV antibody testing
- if positive: start antiviral prophylaxis while confirmatory antibody tests are pending and consult ped ID
- if mom refuse, baby must undergo rapid antibody testing (consider child protection authorities)
Mom’s rapid test is positive for HIV at time of delivery management
- start antiretroviral no later than 72hrs post-delivery
- baby’s HIV DNA or RNA PCR should be tested within 48hrs (if positive, prophylaxis should be stopped and TREATMENT should be initiated)
- no breastfeeding unless confirmatory test is negative
Risk factors for HPV infection
- higher lifetime # of sexual partners
- previous STIs
- history of sexual abuse
- early age of sexual intercourse
- partner’s # of lifetime sexual partners
- tobacco or marijuana use
- immunosuppression
- HIV
- MSM
HPV vaccine dose schedule
2 doses 6 months apart if 9-13 yrs
3 doses if > 15 yrs or immunocompromised or if have HIV
Asplenic septic organisms:
- strep pneumo (50%)
- Haemophilus influenza type B
- neisseria meningitis
- salmonella species
Other: e.coli, bordetella holmesi, fatal malaria and ticks, capnocytophaga
Asplenia
- most important immunzations
Most impt : S. pneumo, HIB, N meningitidis (can be administered earlier than routine)
- all routine immunizations
- pneumococcal 23 about 8 weeks after receipt of appropriate # of PCV 13 (then 5 year booster)
- MCV4 (Men ACWY)
- Men B
- HiB
- flu vaccine
- salmonella typhi vaccine if travel
Timing immunizations around splenectomy
2 weeks before surgery
- if not possible then 2 weeks after
Antibiotic prophylaxis after splenectomy
amoxicillin < 5 yrs
penicillin or amox > 5 yrs
For a minimum of 2 yrs post splenectomy, and for all children <5 yrs (lifelong is preferred)
Indication for oseltamivir
- moderate, severe, progressive (hospitalized)
- not requiring hospitalization but RFs (other than young age) for severe disease (cardiac, resp, immunocompromised etc.)
- no risk factors but 1 to <5yrs with < 48hrs of sx (to be considered)
High risk for influenza-related complications of hospitalizations
- children <5 yrs
- children with:
- cardiac/pulmonary, diabetes, cancer, immunocompromise, anemia/hemoglobinopathy,, neuro/ neurodevelopmental (includes febrile seizures and isolated dev delay), obesity (BMI >40), treatment on prolonged course of ASA - Indigenous
- chronic care facilities
- pregnant women
- > 65 yrs
Live attenuated influenza vaccine contraindicated for:
< 2 yrs
- immunocompromised (except stable HIV)
- current active wheezing or on high dose IVS or medically attended wheeze within 7 days
- pregnancy
- chronic ASA therapy (Reyes syndrome)
Flu shot dosing regimen
- for the first year a child < 9: 2 doses at least 4 weeks apart (but only 1 if received 1 dose before)
- 9+ years: only 1 dose per year
Significant immunocompromised states (5)
- HSCT (within 2 yrs or still taking immunosuppressant drugs)
- organ transplant
- current or recently treated malignancy
- asplenia
- HIV infection
- SCID
Medications indicating immunocompromised
- steroids > 2mg/kg of body weight or >= 20mg per day of pred when given for > 2 weeks
- cancer therapeutics e.g. cyclophosphamide
- antimetabolites e.g. azathioprine,
- transplant-related immunosuppressive
- biologics
Pretransplant immunizations
Live: 4 weeks before
Inactivated: 2 weeks before
MMRV as early as 6 months of age for solid organ transplant candiates
when to give live vaccines AFTER immunosuppression
- 1 month after high dose steroid
- 3 months after completion of immunosuppressive chemo
- 5 months after tx with anti-B cell antibodies
Immunization after HSCT
- re-immunize with all routine vaccines
- inactivated vaccines 3-12 months after trasnplant
- live vaccines 24 months after transplant if no GVHD/immunosuppression and considered immunocompetent
RFs for IGAS in children
- recent pharyngitis
- varicella
- recent soft tissue trauma
- NSAIDS
- household contacts
Strep toxic shock
Criteria
Hypotension and 2 of the following:
- renal impairment (Cr at 2x baseline or ULN)
- coagulopathy (thrombocytopnia < 100 or DIC)
- liver function abnormalities
- ARDS
- generalized erythematous rash that may desquamate
Features of nec fasc
- severe pain or tenderness (out of proportion to apeparance)
- toxic
- hemodynamic instability
- rapid rate of progression
- woody induration
- anesthesia or hyperesthesia of overlying skin
- crepitus
Management of severe IGAS
- supportive with fluid and electrolytes
- clindamycin + pip-taz or carbapenem +/- vanco
- IVIG - on day of presentation
- other treatment e.g. surgical debridement
Close contacts for IGAS
- household contacts (at least 4hr per day, or 20hr with index case)
- non household who shared bed or sexual relations
- direct mucus membrane contact or unprotected with skin lesion
- shared needles for IVDU
- contact in child care settings
IGAS chemoprophylaxis
1st gen cephalosporin e.g. cephalexin x 10 days (or cefadroxil)
Lyme bacterial spirochete
Borrelia burgdorferi
Lyme treatment
- early localized disease (EM)
Doxy x 10 days
Amox x 14 days
Lyme treatment:
- arthritis
Arthritis: Doxy (or amox) x 28 days
if persistent or recurrent, retreat with oral or do IV CTX 14-28 days
Lyme treatment - carditis
oral agent (e.g. doxycycline) or ceftriaxone 14-21 days
Non treponemal tests
Treponemal tests
Non-treponemal: RPR or VDRL
Treponemal: TP-PA or FTA-ABD
Features of congenital syphilis
General: spont abortion, hydrops fetalis
Resp: snuffles and or rhinitis
GI/Heme: hepatomegaly, splenomegaly, lymphadenopathy, anemia, thormbocytopenia
MSK: osteochondritis, periondritis, pseudoparalysis, bony findings,
Derm: necrotizing funisitis (barbershop pole), hutchings teeth, mulberry molars,
SNHL
When to treat babies for congenital syphilis
- symptomatic
- the infants test is 4x higher than their mother’s at birth
- maternal treatment was inadequate, is unknown, did not contain penicillin, or occurred in the last month of pregnancy or maternal response is inadequate
- adequate follow up of the infant cannot be ensured
Contraindications for LP
- coagulopathy
- cutaneous lesions at puncture site
- herniation
- hemodynamically unstable
CT first if: papilledema, focal neuro signs, decreased LOC or coma
Most common organisms for meningitis > 2 months
Strep pneumo and N. Meningitidis
- also consider e.coli and GBS up to 3 month sof age
- HIB in incompletely immunized or other H. flu types
Empiric antibiotic therapy for meningitis
- 3rd gen cephalosporin (CTX or cefotaxime)
2. Most recommend including vancomycin
Steroids in meningitis indications
- evidence to decrease hearing loss in HIB meningitis
- role in strep pneumo is less certain
Indications for repeat CSF sampling
- Repeat at 24-48hrs for gram negative enteric pathogens e.g. e.coli
- Repeat if not improving with initial therapy
- some say for GBS and s. pneumo to document sterilization at 24-48hrs
Duration of treatment for meningitis by pathogen
- strep pneumo
- Hib
- neisseria
- GBS
- strep pneumo 14 days
- Hib 10 days
- Neisseria 7 days
- GBS 21 days
logner if cerebritis or ventriculitis
When to do audiology for children with meningitis
before discharge!
- DEET limits by age
2. Icaridin limits
<= 10% for children <= 12 yrs
<=30% for children >12
Icaridin up to 20% (for all ages)
Factors influencing transmission of HSV infection to newborns
- nature of maternal infection
- mode of delivery
- duration of rupture of membrane
- use of intrapartum instrumentation
Neonatal HSV transmission rates
- first episode primary
- first episode non primary
- recurrent
1st episode primary: 60%
1st episode non primary: <30%
recurrent: < 2%
Pregnancy and HSV exposure prophylaxis
Acyclovir or valacyclovir from 36 weeks until delivery (not clear if it reduces risk)
Timing of neonatal HSV
usually within first 4 weeks but can be up until 42 days of age
Treatment of neonatal HSV
IV acyclovir
x 14 d for SEM
x 21 d for disseminated or CNS
then suppressive antiviral therapy for 6 months
Managing term baby born to mom with active lesions at delivery (presumed 1st episode)
- C-section before rupture of membranes
- 1st episode of herpes delivered after ROM (c/s or SVD)
- C-section before rupture: education, take swabs (+/- blood PCR) at 24hr
- 1st episode after ROM: do swabs and start IV acyclovir do it for at least 10 days (more if swabs are positive)
Managing term baby born to mom with active lesions at delivery
- recurrent HSV and c/section
- recurrent HSV and vaginal
C/S and/or vaginal: swabs at 24hrs then send home with pending
Managing neonates born to moms with untreated to N. gonorrhea
- conjunctival culture
- single dose IM CTX
(if unwell do blood and CSF)
Managing neonates exposed to C. trachomatis
- monitor for conjunctivitis and pneumonitis, treat if sx occur
- generally no prophylaxis (concern about pyloric stenosis)
Post transplant infection
- <1 month
- 1-6 months
- more than 6 months
- normal infections
- opportunistic infections - viral (EV, CMV, HCV, HBV, HHV6) and non viral (PHP, aspergillus, listeria)
- community-acquired if good graft fx and crhonic viral and opportunistic if poor graft function
Chronic osteomyelitis
Symptoms > 1 month (may have Brodies’ abscesses)
Osteomyelitis organisms
- staph aureus
- kingella kingae (<4yrs)
- strep pneumo
- strep pyogenes
sickle cell think salmonella
Indications for surgery in osteomyeltis
- suspected subperiosteal fluid or abscess
- pt fails to improve clinically within first few days on antibiotics
Duration acute osteomyelitis treatment
3-4 weeks of abx
Septic arthritis duration of antibiotics
3-4 weeks
except 4-6 weeks if hip
Otitis externa RFs
Swimming Foreign body in the ear hearing aid Certain derm conditions Chronic otorrhea Wearing tight head scarves Immunocompromise Ear piercing may lead to infection of pinna
Otitis externa organisms
- pseudomonas
- staph aureus
other = polymicrobial
Otitis externa management
Topical antibiotic with or without steroids for 7 to 10 days
Indications for palivizumab:
- hemodynamically significant CHD <12 months
- CLD who require ongoing diuretics, bronchodilators, oxygen or steroids < 12 months
- Prem < 30 weeks GA now < 6 months (reasonable but not essential)
- infants in remote communities born before 36 weeks and <6 months
Infective endocarditis indications for prophylaxis
- prosthetic cardiac valves
- previous infective endocarditis
- unrepaired cyanotic congenital heart disease
- repaired CHD with prosthetic material within first 6 months
- repaired CHD with residual defects e.g. patch leak
- cardiac transplant recipients with cardiac valvulopathy
Procedures for IE prophylaxis
- dental procedures with manipulation of tissue
2. procedures on infected skin, skin structure or MSK tissue
Indication for hospitalization in pneumonia
- inadequate oral intake
- intolerant of oral therapy
- severe illness or respiratory compromise
- complicated pneumonia
- < 6 months of age
Abx in pneumonia 1. outpatient 2. inpatient 3. resp failure or shock 4 pneumatoceles/rapidly progressing
- amox
- amp
- cefotax/CTX
- add vanco
3 stages of empyema
- pus and effusion
- loculations
- fibrinous peel
Most common empyema organisms
- strep pneumo
2 staph aureus - strep pyogenes
Complicated pneumonia when to step down to oral
- drainage has been completed
- pt is improving
- pt is off oxygen
3-4 week total course
Malaria sx and signs
Sx: fever, headache, Nausea +/- V or diarrhea, lethargy, myalgia, abdo pain
Signs: jaundice, low white count, hepatomegaly, splenomegaly
Typhoid (enteric) fever signs and sx
Sx: Fevers, chills, rash, HA, myalgias, confusion, +/- constipation, abdo pain
Signs: jaundice, hepatomegaly, splenomegaly
Chlamydia screening and who to screen and tx
Screen all sexually active < 25 yrs annually (at least)
Screen with NAAT
Culture for medico-legal
Tx: azithromycin
Contraindications to rotavirus vaccine
- hx of intussception or susceptibility to intussuception (e.g. Meckel’s)
- hypersensitivity to ingredients
- known or suspected SCID, or other immunodeficiency
Non-typhoidal salmonella sources of human infection
- Reptiles
- poultry, eggs, dairy, beef or produce
Management non-typhoidal salmonella
- antibiotics if bacteremia or invasive infections
- infection precautions
- abx if < 3-6 months, unwell, immunocompromised, asplenic
e. g. 7 days azithro
Management typhoid/paratyphoid fever
- treat with azithromycin or other abx
Gonorrhoea screening and tx
Screen all sexually active youth < 25 yrs
Screen with NAAT
cultures for medical legal, tx failure etc.
Tx: CTX + azithromycin
TB skin test pros and cons
Pros:
- similar sensitivity and specificity as IGRa for latent TBI
- probably more sensitive for children < 2 yrs
Cons:
- false positives with non-TB mycobacgeria, BCG vaccine
- false negative in immunosuppression
TB skin test interpretation
Positive if
>= 5mm for immunocompromsied and contacts of cases
>= 10 mm for others
0-5mm = infants or young children
Indications for antibiotic prophylaxis for UTI
- may be considered if grade 4 or 5 VUR OR a significant urological anomaly
(should not last more than 3-6 months) - usually septra or nutrofurantoin and consider discontinuing if resistant to both
Children with contact with an index case with TB
Management
- hx and physical (and obtain index case’s drug sensitivities)
- CXR and TST
If < 5 yrs old and TST < 5mm: start window prophylaxis and repeat TST in 2 months
If > 5 yrs with TST <5mm: no prophylaxis
If > 5 yrs and normal CXR with TST >5: treat as per latent infection
Minimum colony counts
CFU/ml
Mid stream: > 10^5
iIn and out: > 5 x10^4
Suprapubic: any growth
Treatment duration UTI
UTI: 7-10days
cystitis: 2-4 days
Features suggesting a complicated UTI
- hemodynamically unstable
- elevated Cr
- abdominal or bladder mass
- poor urine flow
- not improving within 24hr or no improvement in fever in 48hrs
(IV abx for complicated UTIs until child is clearly improving)
Polio sx
- asymptomatic
- short, self-limiting illness
- 1% result in paralysis = acute onset of asymmetric flaccid paralysis
= public health emergency of international concern!
Diphtheria
- sore throat, weakness, rapidly progressive swelling of neck leading to pseudomembrane in throat or nose leading to severe respiratory compromise
Tetanus features
- muscle rigidity, spasm
infection can be fatal
congenital zika virus sx
- severe microcephaly (may have normal HC with ventriculomegaly), may have redundant scalp
- cerebral atrophy
- abN brain development
- subcortical calcifications
- abnormal fetal tone
- SNHL
etc.
Baby with possibly zika virus (sx and travel exposure)
- test serology and PCR on mother and child
- test placenta
- u/s and MR of head
Infant born to mother with potential exposure for zika
- test mother’s serology first (also PCR if exposure was 4 weeks before delivery)
if positive then test baby
Meningococcal serogroups and age they peak
5 serotypes: ABCYW (B+C = most common)
<5 yrs: serogroup B peaks
Serogroup C peaks in adolescents, outbreaks, highest fatality
people at high risk of invasive meningococcal disease
Underlying medical conditions:
- asplenia, sickle cell anemia, properidin, factor D or complement difiency, primary antibody deficiency, HIV
Risk from exposure:
- lab workers who work with meningoococcus, military ppl, travelers to endemic areas, close contacts to a case
Treatment for baby >35 weeks:
- maternal HIV, treated with ART, no viral load
- maternal HIV, uncontrolled
- zidovudine PO x 6 weeks
2. triple ART (or dual therapy in some cases)
Testing baby for HIV
- HIV PCR tests at > 1 month and > 2 month
(if treated with cART then at least 1 at > 4 months) - FINALIZE status with serology testing between 18 and 24 months
