ID Flashcards
Congenital CMV
- features
General
IUGR, prematurity
Skin
Petechiae, purpura, echymoses, jaundice
Hematopoietic Thrombocytopenia,anemia,splenomegaly
Hepatobiliary
Hyperbilirubinemia, elevated ALT, hepatomegaly
CNS
Microcephaly, seizures, periventricular calcifications
Eye
Chorioretinitis, strabismus, optic atrophy, microphthalmia
Ear
Sensorineural hearing loss
Congenital CMV
- who to tx
- how to tx
Neonates with “moderate to severe” symptomatic disease
During neonatal period
Valganciclovir for 6 months
Syphillis
early mainfestations
General
Prematurity, IUGR, FTT
Mucocutaneous
Snuffles, maculopapular rash followed by desquamation, blistering and crusting, condyloma lata
Reticuloendothelial Hepatosplenomegaly, lymphadenopathy
Hematologic
Coomb’s negative hemolytic anemia, thrombocytopenia
Skeletal
Pseudoparalysis, osteochondritis, diaphyseal periostitis, deminiralization/destruction of proximal
tibia metaphysis, osteitis
Neurologic
Aseptic meningitis, hydrocephalus, cranial nerve palsies
Ophthalmologic
Salt and pepper chorioretinitis, glaucoma, uveitis
When does a baby born to mom w syphilis not need workup/tx?
Appropriate treatment prior to or during pregnancy
Four-fold or greater fall in maternal RPR titer
Infant RPR non- reactive
OR
Infant RPR = mothers and asymptomatic
If baby needs workup for syphliis what does it include
• Physical exam
▫ Stigmata
▫ Ophthalmology,audiology
assessments
• CBC, (LFT’s)
• Lumbar puncture
▫ CSF WBC count
▫ CSF protein
▫ Treponemal & non- treponemal serologic tests
• Skeletal survey
• Syphilis serology
▫ Non-treponemal ▫ Treponemal
Tx for congenital syphilis
Intravenous crystalline penicillin G for 10 days
Congenital zika syndrome
CNS only
▫ Severe microcephaly with partially collapsed skull
▫ Thin cerebral cortices, subcortical calcifications
▫ Macular scarring, focal pigmentary retinal mottling
▫ Congenital contractures (arthrogryposis, club foot etc)
Toxoplasmosis - triad
hydrocephalus,
cerebral calcifications
chorioretinitis
Rubella - triad
cataracts, PDA, SNHL
Risk factors for early onset sepsis?
- Maternal intrapartum GBS colonization during current pregnancy
- GBS bacteriuria during current pregnancy
- Previous infant with invasive GBS disease
- Prolonged rupture of membranes (≥ 18 hours)
- Maternal fever (≥ 38.0oC)
Well baby with GBS+
what to do
No risk factors:
Adequate IAP: routine care
No IAP: observe 24-48 hrs (vital signs q3-4h), reassess & counsel pre-discharge
With risk factors:
at least observe 24-48 hrs (vital signs q3-4h)
consider CBC at 4h
Well baby with GBS- or unknown
what to do
No RF: Routine care
1 RF:
Adequate IAP: routine care
No IAP: observe 24-48 hrs (vital signs q3-4h), reassess & counsel pre-discharge
2 or more RF, or chorio:
at least observe 24-48 hrs (vital signs q3-4h)
consider CBC at 4h
Low risk criteria for febrile infant 1-3 mo
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)
Bacterial pathogens for fever for:
0-28d
29-90d
3-36 m
0-28 d:
Most common: Group B streptococcus, E. coli
Less common: L. monocytogenes, S. aureus, group A streptococcus, K. pneumoniae
29-90 d:
Most common: Group B streptococcus, E. coli, S. pneumoniae
Less common: N. meningitidis, L. monocytogenes, S. aureus, group A streptococcus
3-36 mo:
Most common: S. pneumoniae
Less common: S. aureus, group A streptococcus, N. meningitidis
Empiric therapy for toxic infants (community aqcuired)
0-28d
29-90d
3-36 m
No/Yes = meningitis
Amp is for listeria
0-28 days
No Ampicillin + gentamicin or cefotaxime
Yes Ampicillin + cefotaxime
29-90 days
No Ceftriaxone + vancomycin ± ampicillin
Yes Cefotriaxone + vancomycin ± ampicillin
3-36 months
No Ceftriaxone + vancomycin
Yes Ceftriaxone + vancomycin
Mother with HSV
how to treat:
• First episode; born vaginally or by C/section after membrane rupture
• First episode; C/section prior to membrane rupture
• Recurrent episodes
• First episode; born vaginally or by C/section after membrane rupture
▫ Empiric acyclovir recommended
▫ If 24 hr swabs positive – full workup (incl LP and bcx for PCR) and start treatment
▫ If 24 hr swabs negative, complete 10 days of IV acyclovir
• First episode; C/section prior to membrane rupture
▫ Empiric acyclovir not recommended
▫ Swab at 24 hr swabs and observe
if positive – full workup and treatment
• Recurrent episodes
▫ Empiric acyclovir not recommended
▫ Swab at 24 hr and observe
if swabs positive – full workup and treatment
Septic arthritis pathogens abx when to switch how long
S aureus
Kingella kingae if <4 yo
▫ IV cefazolin
- Switch to oral when clinically improved, CRP decreased, compliance and follow-up assured
▫ If uncomplicated, antibiotic duration 3-4 weeks; 4-6 weeks for septic hip
Necrotizing fascitis
- bug
- mgmt
S.pyogenes
IV penicillin + clindamycin and surgery consult
Asplenic prophylaxis
- 0 – 5 years: amoxicillin 10 mg/k/dose bid
* > 5 years: Penicillin V 300 mg BID or amoxicillin 250 mg BID
Well young w chronically draining cervical node
Atypical mycobacterium
Lymph nodes
Acute bilateral
Respiratory viruses, enteroviruses, adenovirus, EBV, CMV
Acute unilateral
S. aureus, S. pyogenes (80%)
Subacute bilateral
HIV, EBV, CMV, toxoplasmosis
Subacute unilateral
Non-tuberculous mycobacteria,
M. tuberculosis, Bartonella henselae, tularemia, plague (Y. pestis)
Cat scratch disease
- bug
- presentaiton
- treatment
Bartonella hensalae
▫ Lymphadenitis (axillarymostcommon) ▫ Perinaud oculoglandular syndrome ▫ Hepatosplenic bartonellosis (granulomatous disease) ▫ Neuro-retinitis ▫ Encephalopathy ▫ FUO
▫ Azithromycin for lymphadenitis (shortens duration)
▫ Doxycycline + rifampin for neuroretinitis/CNS disease
Lyme disease
- bug
- presentation
- tx
• Borrelia burgdorferi
Erythema migrans Arthritis Bells palsy radiculoneuropathy (uncommon: meningitis, cardiac)
doxycycline
unilateral facial weakness, and vesicles in ear canal
Ramsay hunt
acyclovir and steroids
Acute flaccid myelitis
- eitiology
▫ Non-polio enteroviruses (EV D68, EV A71)
▫ Polioviruses (vaccine derived mainly)
▫ West Nile virus and some other arboviruses
Complications of varicella
Most likely after 12yo
most common - pneumonia
• General
▫ Pneumonia
▫ Hepatitis, pancreatitis, nephritis, orchitis
▫ Thrombocytopenia
• Bacterial infections
▫ Cellulitis, softtissue abscess, necrotizing fasciitis
• Neurologic ▫ Cerebellar ataxia ▫ Encephalitis ▫ Reye syndrome ▫ Stroke ▫ Zoster (including Ramsay Hunt syndrome)
mother with untreated gonorrhea
• Well appearing
▫ Conjunctival culture
▫ IM ceftriaxone 50 mg/kg (maximum 125 mg)
• Unwell
▫ Conjunctival, blood and CSF cultures
▫ Consult ID with established disease
C diff treatment
Mild (<4 abn stools/d)
Discontinue precipitating Abx; Follow-up
First episode; Mild/moderate; No change with Abx stoppage
PO metronidazole 10-14 days
First episode; Severe uncomplicated
PO vancomycin 10-14 days
First episode; Severe complicated
PO vancomycin 10-14 days
PLUS
IV metronidazole 10-14 days
First recurrence
Repeat as above
Second recurrence
Vancomycin in tapered or pulsed regimen
Fever in traveler
- emergency infections
▫ Malaria
▫ Typhoid fever
▫ Meningococcemia
▫ Viral hemorrhagic fevers
Positive TST
> /= 10 mm in no RF
> /= 5mm if RF
• HIV infection (well)
• Close contact with active contagious case (past 2 years)
• Presence of fibronodular disease on CXR (healed TB)
• Organ transplant
• TNF-α inhibitors
• Other immunosuppressive medications (e.g.
corticosteroids – equivalent of 315 mg/day for 31 month)
• End stage renal disease
TB tx
Isoniazid, Rifampin, Pyrazinamide, Ethambutol
• Latent TB infection
▫ INH for 9months or RIF for 4 months or INH+RIF for 3 months or INH + rifapentine x12 weekly observed doses
• TB disease
▫ Start with 4 drugs(INH,RIF,PYR,ETH)
▫ Step down to 3 drugs if fully sensitive strain
▫ Two months of 3-4 drugs, then INH+RIF to complete course (total duration depends on specifics of disease)
(4x2mo then 2X4mo)
• Consider DOT
• Pyridoxine in selected cases (malnutrition,
adolescents, pregnancy…)
• Vitamin D usually given for children with TB disease
how to prevent vertical transmission of HIV
• Antiretroviral therapy (zidovudine = AZT)
▫ Triple ART starting in 2nd trimester (or earlier)
▫ IV zidovudine during labor
▫ Zidovudine to infant for 6 weeks
- Elective Cesarean section if VL >1000 copies/mL
- Avoidance of breast feeding
Hep B + mom - what to do w newborn
HBIG and HB vaccine within 12 hours of birth
HB vaccine at 1 and 6 months
Check tires at 9-12 mo
Who to give VZIG to post exposure
Basically those who can’t get varicella vaccine
Give acyclovir if lesions too
1) Immunocomp children w/o hx of varicella or varicella immunization
2) Susceptible pregnant women
3) Newborn infant whose mother had ONSET of chicken pox within 5 days before delivery or within 48 hours of delivery
4) Hospitalized premature infant (>/= 28 wga) whose mother lacks a reliable history of chicken pox or serologic evidence of protection against varicella
5) Hospitalized premature infant (< 28 weeks gestation or birth weight < 1000 gram) regardless of maternal history of varicella or varicella-zoster virus serostatus
Hep A
post exposure
Hep A vaccine within 2 weeks of exposure
If less than 6mo or C/I to vaccine, Ig should be given
Give vaccine + Ig to immunocomp
What are airborne precautions
Varicella, zoster Measles Tuberculosis Smallpox
5 moments of Hand hygiene
- Before touching a patient
- Before clean/aseptic procedures
- After body fluid exposure/risk
- After touching a patient
- After touching patient surroundings
AOM bugs
Streptococcus pneumoniae (25% to 40%) ▫ Non-typeable Haemophilus influenzae (10% to 30%) ▫ Moraxella catarrhalis (5% to 15%)
Skin infections
- bugs
- tx
S. aureus, Group A streptococcus
Impetigo: PO: Cloxacillin, Cephalexin
Cellulitis: IV: Cloxacillin, Cefazolin
PO: Cloxacillin, Cephalexin
Necrotizing Fasciitis: IV: Cloxacillin (or Cefazolin or penicillin) + clindamycin ± vancomycin
Human bites - what to do about Hep B
If unknown status - vaccinate that child
If one of the children has HepB, give HBIG & vaccine to the other child if they are non immune or incompletely immunized
Contraindications to breastfeeding`
HIV HTLA HSV if active lesions on breast TB if contagious Mastoiditis (pump and dump on that breast, BF from other)
West Nile Virus
presentation
Asymptomatic 80%
Fever 20%
Neurologic disease <1%
aseptic meningitis, encephalitis, acute flaccid paralysis
HPV vaccine recommendations
9-14 give 2 doses, otherwise give 3 doses
(at least 6 mo apart)
Also give 3 doses to immunocompromised and HIV children
Rotavirus vaccine
Give preterm on same schedule as term
Start no later than 15 weeks
Complete by 8 mo
most common Side effect of varicella vaccine
most common: fever
What vaccines contraindicated if egg allergy
only yellow fever
Scabies - when can go back to daycare
Once treatment applied
Pertussis - when can go back to daycare
After 5 days of tx
Shigella - when can go back to daycare
Diarrhea resolves
Campylobacter - when can go back to daycare
Diarrhea resolves
Hep A- when can go back to daycare
7 days after onset of jaundice
What does HBeAg tell you
actue infection - active viral replication
Supraclavicular node - first step
CXR
then LN biopsy
Strains of HPV and what they cause
16&18 - cervical cancer and squamous cell cancer
HPV 6&11
CF pt w green sputum - how to tx
IV ceftazidine and tobramycin
How to test baby for HIV if mother is HIV +
transmission risk
HIV PCR at 2-3 wk, 1-2mon, 4-6 mon
HIV serology at 12-18 months
Transmission : 1% if compliant
25% if no meds
Narrowing of distal ilium
Yersinia
Influenza vaccine
Which is more effective - LAIV or NAIV
Contraindications to LAIV
Equally effective
- age < 24 months
- severe asthma (current high-dose inhaled steroids or systemic steroids)
- medically attended wheezing in past 7 days
- immunodeficiency, pregnancy
- ASA treatment
Who is high risk for influenza disease?
- all children aged 6-59 months
- anyone with basically any chronic medical condition
- all indigenous children
- all residents of chronic carefacilities
What are live vaccines?
LAIV
MMR
Rotavirus
Varicella
How long to wait for live vaccines if receiving steroids?
if systemic steroids > 2 mg/kg/day (>20 mg/d) dosed for >14 days: wait 1 month
Fever + diarrhea with bradycardia
Salmonella
Cipro, ceftriaxone
Boy who visited farm
Q fever: coxiella burnetii
- Acute infection = flu-like illness, pneumonia, hepatitis
- Incubation = 20 days
- RF = farm animals or downwind from farm animals
- Dx -> early = PCR, after 1 week = IFA
- Tx: within 3 days of symptoms, doxycycline x 2/52 if >8yo, cipro or septra <8 with short course of doxy (5 days) to start
Pneumpnia w pneumantocele - what but?
Staphylococcus
When to treat AOM?
Basically you are only treating if
- Obviously perforated
- MEE + bulging TM and one of:
- -Mod-severely ill
- -Unable to sleep
- -Irritable
- -Not responding to tylenol
- -Severe otalging
- > = 39 in absence of antipyretics
- > 48h of symptoms
If AOM does not improve after 48 of abx, what bugs likely?
H flu, M catarrhalis
Time period of possible HSV infection vertical transmission after delivery?
6 weeks
How to diagnose Rheumatic Fever
Evidence of GAS infection +
2 major or
1 major and 2 minor
J<3NES criteria - major : Joints - migratory arthritis <3 = carditis pericardium/epi/myo/endocardium Mitral valve Pericardial friction rub 1st degree heart block, N = subcutaneous Nodules E = Erythema marginatum S = sydenham chorea
Minor Fever (38.5 PO; 38 accepted in certain popn) Arthralgias Elevated ESR/CRP ESR >60, CRP > 30 Prolonged PR interval
How to treat scabies
Permethrin 5%
Apply to entire body down from neck
Leave on overnight
Repeat in 1 week
Sickle cell with fever and pneumonia
tx
Ceftriaxone + macrolide
Gonorrhea treatment
Ceftriaxone and azithro
Baby born to mother with active Hepatitis B
Give HB vaccine and HBIg within 12 hours of birth
Give vaccine at 1 and 6 months
how to treat head lice
pyrethrins and permethrin remain first-line treatments in Canada
permethrin 1%
Steroids have been proven effective in what infection?
Hib meningitis, for which there is evidence that steroids decrease hearing loss in children if they are administered just before or with the initial antimicrobial Therapy (ask staff)
bacterial diarrhea
tx
tx if toxic
PO azithromycin or erythromycin
Pertussis treatment
erythromycin
How to treat pin worms
Albendazole (400mg PO with repeat dose 2 weeks later)
Acute cerebellar ataxia
- cause
- presentation
varicella
gradual onset of gait disturbance, nystagmus and slurred speech
Lemierre disease
infection from the oropharynx extends to cause septic thrombophlebitis of the internal jugular vein and embolic abscesses in the lungs
fusobacterium necrophorum, an anaerobic bacterial constituent of the oropharyngeal flora
presentation:
healthy adolescent or young adult with a history of recent pharyngitis who becomes acutely ill with fever, hypoxia, tachypnea, and respiratory distress
Blood cultures
Epiglottitis
Usually viral but HiB if unvaccinated
Acute rapidly progressive course of high fever, sore throat, dyspnea, respiratory obstruction
Toxic, swallowing difficulty, labored breathing
Drooling and neck hyperextended in attempt to maintain airway
Tripod – sitting up and leaning forward, chin up, mouth open, bracing on arms
Stridor is late finding – near complete obstruction
Xray - thumb sign (epiglottis is think like a thumb)
Parvovirus - when can return to school
As soon as they feel well enough
infectious until rash appears
Hepatitis A
- tx
- exclusion
tx:
<12mo: Ig
1-40yo: Hep A vaccine
Exclusion 7 days post onset of sx
Can you breastfeed w Hep C
Yes
Eosinophilia
Ascaris
food poisoning sx 4 hours later
s.aureus
Prophylaxis for asplenic
Amoxil for <5yo
Pen V or Amoxil for >5yo
Pertussis - contact
A macrolide agent should be given promptly to all household contacts and other close contacts, such as those in daycare, regardless of age, history of immunization, and symptoms.
Azithro, erythro clarithro
Post exposure to varicella
Healthy: give vaccine
Immunocomp: give VZIG
If lesions give acyclovir
When can live vaccines be given after high dose steroids are stopped
1 month
Parinaud ocular glandular syndrome
(atypical Bartonella) after scratch or inoculation around the eye
ipsilateral conjunctivitis + pre-auricular lymphadenopathy + splenomegaly
what kind of bacteria listeria
gram postive rods
AOM - abx
Amox
Cefuroxime
Amox Clav
high risk for invasive pneumococcal disease
<2yo have a cochlear implant immune suppressed chronic organ disease (such as kidney, liver, lung or heart disease) diabetes or asthma Asplenia
measles complications
- Respiratory infections:
- -Pneumonia- most common cause of death (direct viral infection or secondary bacterial) → bronchiolitis obliterans
- -Croup, tracheitis, bronchiolitis
- Acute otitis media (mastoiditis, sinusitis)- most common complication
- Eye disease with corneal ulcer and loss of vision (especially with Vit A deficiency)
- Diarrhea/vomiting → dehydration
- CNS: Encephalomylitis, subacute sclerosing pamencephalitis)(Chronic, 10 years later, behavioral and intellectual
- Higher rate of TB activation
- hemorrhagic measles “black measles”- fatal condition
how to test for measles
Measles serology
IgM (appears 1-2 days after rash onset, and lasts up to 1 month; if sample is collected <72 hours after onset of rash and is negative, it should be repeated)
4-fold rise in IgG antibodies
Viral isolation from blood, urine, respiratory secretions - culture
RNA PCR
leading bacterial cause of foodborne gastroenteritis in children
Campylobacter
bloody diarrhea
unpasteurized cow’s milk
Neisseria meningitidis - type of bacteria
gram-negative encapsulated diplococcus that colonizes the nasopharynx
How to treat H pylori
amox, clarith and PPI
Mom Hep B unknown status
give vaccine within 12h
Hep B serology on mom
give HBIG if serology +
give within 7 days
Two month old has salmonella bacteremia. Why are IV antibiotics indicated?
decrease risk of meningitis
Pertussis presentation
- children
- adolescents
Children: Apnea and pneumonia
Adolescents: URTI sx
severe: syncope, weight loss, sleep disturbance, incontinence, rib fractures, and pneumonia
immunize adolescents to redue transmission to children
Lyme disease: 3 systems involved and their specific involvement
Skin: Erythema migrans (EM- resolves spontaneously over a four-week)
CNS: like facial nerve palsy, papiledema, meningitis, peripheral neuropathy and CNS disease
Heart: Heart-block (carditis) possible but rare
MSK: pauciarticular arthritis at weeks to months post,
indications for conjugated quadrivalent vaccine for meningococcus
asplenia/hyposplenia (ie. sickle cell) immunodeficiency (ie. primary, HIV) potential for exposure healthcare workers endemic areas
how to treat tine capitis
PO terbinafine
Measles presentation
High fever 3 C's Cough Coryza Conjuntivitis
Rash comes when fever subsides
Cranial to caudal
fine red papules
