ID II Flashcards
1
Q
definition of a high fever?
A
- rectal temp that exceeds 100.4
- not an illness by itself but rather a sx of an underlying condition most often an infection
- normal response
- 20% of childhood fevers have no apparent cause
- risk is greatest among febrile infants and kids younger than 36 mos
2
Q
3 most common causes of FUO in order of frequency?
A
- infectious disease
- connective tissue diseases (JRA, SLE)
- neoplasms (leukemia, lymphoma)
3
Q
Bacteria that cause serious bacterial infections?
A
- S. pneumoniae leading cause of bacterial URI
- meningitidis
- Hib
- E Coli: most common cause of UTIs, 75% of UTIs have pyelonephritis can lead to scarring
- approx 13-15% of ESRD is believed to be related to undertx childhood UTI
- salmonella
4
Q
Hx questions for FUO?
A
- fever hx
- fever at presentation
- current level of activity or lethargy
- activity level prior to fever onset
- current eating and drinking pattern
- appearance: fever can make kids appear ill
- vomiting or diarrhea
- ill contacts
- medical hx
- immunization (especially recent)
- urinary output: # of wet diapers?
5
Q
Workup for FUO?
A
- lab studies based on appearance, age and temperature
- begin IV or IM abx admin for infants that appear ill once urine and blood specimens obtained
6
Q
Workup for non toxic appearing FUO?
A
- CBC with diff
- UA by bladder cath and urine culture based on following criteria:
all males less than 6 mos and all uncircum. males less than 12 mos
all females younger than 24 mos and older if sxs suggest a UTI - rapid testing for viruses (influenza, RSV)
- consider stool for WBC counts and guaiac if diarrhea is present
7
Q
Workup for toxic appearing FUO?
A
- CBC with diff and CMP
- obtain blood cultures
- consider obtaining a chest X-ray, esp for pts with elevated WBC count
- UA by bladder cath and urine culture based on:
males younger than 6 mos and uncirum. younger than 12 most
all females younger than 24 months and older if sxs suggest UTI - obtain CSF for studies and culture
- consider stool for WBCs and guaiac if diarrhea is present
- rapid testing for virus
- admit these pts for further tx
8
Q
Imaging for FUO?
A
- CXR for thorough eval of febrile child
- CXR indicated if tachypnea, retractions, focal auscultatory findings or O2 sat on RA less than 95%
- abdominal U/S
9
Q
Procedures for FUO?
A
- bladder cath
- suprapubic aspiration
- LP
10
Q
Tx FUO non toxic?
A
- after complete eval to identify source:
- pts 2-36months may not reqr admission if they meet following criteria:
pt healthy prior to fever
pt fully immunized
pt has no sig RFs
pt appears nontoxic and is otherwise healthy
pt’s parents appear reliable and have access to transportation if sxs should worsen - considerations on empiric abx therapy isn’t warranted
- schedule serial f/u w/in 24-48 hrs and instruct parents to return with child sooner if conditions worsen
- hosp admission for kids whose condition worsen or whose eval findings suggest a serious infection
11
Q
Tx for FUO toxic?
A
- admit for further tx, pending culture results, admin parenteral abx
- initially admin ceftriaxone, cefotaxime or amp/sulbactam
12
Q
Embiric antimicrobial therapy should be what?
A
- ceftriaxone (rocephin), broad spectrum, gram - coverage
- cefotaxime )claforan): for septicemia and tx, alt to ceftriaxone in infants inf 1st month or 2 in whom bili displacement from protein binding sites by latter abx may be harmful
- amp/sulbactam (unasyn): drug combo of beta lactamase inhibitor with ampicillin. Covers skin, enteric flora and anaerobes
13
Q
What is impetigo? 2 types?
A
- acute highly contagious gram + bacterial infection of superficial layers of epidermis
- occurs most commonly in kids especially in hot, humid climates
- 2 types:
- nonbullous: most common skin infection in kids, staph aureus or GABHS
- bullous: almost exclusively S. aureus
14
Q
PP of impetigo?
A
- intact skin usually resistant to colonization or infection
- factors that can modify usual skin flora:
high temp or humidity
preexisting cutaneous diseaes
young age
recent abx tx - common mech. for disruption of skin that facilitates colonization or infection:
scratching, dermatophytosis (ringworm), herpes simplex, scabies, pediculosis, trauma, insect bites
15
Q
DDx for impetigo?
A
- herpetic impetigo
- pemphigus vulgaris (rare in kids)
- follicular mucinosis
- folliculitis
- erysipelas
- insect bites
- cutaneous candidiasis
16
Q
Dx impetigo?
A
- usually based solely on:
hx and clinical appearance: erosions covered by “honey colored” crust - labs: gram stain and culture to ID bacteria
17
Q
Tx of impetigo?
A
- local wound care
- abx therapy:
topical - mupirocin (bactroban)
oral - must cover staph aureus and strep pyogenes, MRSA also:
cephalexin or dicloxacillin (1st line)
erythro and clarithro (2nd line)
Trimethroprim-sulfamethoxazole, clinda, or doxy (MRSA) - after being on abx for 24 hrs - can return to school
18
Q
What is molluscum contagiosum? Cause? Common in?
A
- benign viral infection (poxvirus)
- characteristic skin lesions
- single or must, rounded dome-shaped, pink, waxy papules, 2-5 mm, umbilicate
- common in kids and immunosuppressed
19
Q
Presentation of molluscum?
A
- usually asx
- pt may recall contact with family member or other person
- children sharing bath
- athletes sharing equip.
- parents may recally camp, school, or public recreation
- swimming pools
- sexual activity
20
Q
PE of molluscum?
A
- lesions may be located anywhere
- predilection for face, trunk and extremities
- predilection for groin, and genitalia in adults
- distribution influenced by mode of infection
21
Q
Molluscum differential?
A
- cutaneous manifestations of other opportunistic infections:
cryptococcosis
histoplasmosis
aspergillosis
other conditions: keratocathmoma, flat warts
22
Q
Dx molluscum?
A
- easily est by distinctive, central umbilication of dome shaped lesion
- if uncertain can consider bx
- if adolescent or adult - STD workup
23
Q
Tx molluscum?
A
- benign neglect: usually resolves within months
- direct lesional trauma
- antiviral: cimetidine
- topical: imiquimod, cantharidin
- cryotherapy with curettage
- activity: avoid sports, avoid physical contact b/t infected areas, sexual abstinence
24
Q
Pediculosis?
A
- lice, ectoparasites that live on body and feed on human blood after piercing skin
capitus: head lice
corporis: body lice - very common
25
Q
Pediculosis presentation?
A
- parents and teachers usually discover
- pruritis most common sx: kids have hard time sleeping b/c of itching, eyelashes, eyebrows, watch for secondary infection from scratching
- adults usually assoc with sex and have groin and body involvement
26
Q
Lice physical exam?
A
- observation of: eggs (nits) nymphs mature lice - secondary infection from excoriation - examine under microscope - wood lamp of area: yellow-green fluorescence of lice/nits
27
Q
DDx of lice?
A
- dandruff
- dried hairspray/gel
- acne
- impetigo
- scabies
28
Q
Tx of lice?
A
- use as directed to ensure eradication through their life cycle:
permethrin (nix) cream
malathion
benzyl alcohol
spinosad
ivermectin - careful combing and removal of all nits
- cleaning of other articles: hair accessories, towels, bedding, clothing
- enviro control: tx all persons who have contact with infested pts (esp sexual partners)
29
Q
What are scabies? Dx? Tx?
A
- sarcoptes scabiei - smaller than a louse
- linear burrows at wrist, ankles, finger webs, axillary folds, genitalia or face
- can have excoriations
- dx: scrape unscratched papule with #15 blade and examine micro. in immersion oil
tx: 1st line: permethrin creme, ivermectin
30
Q
Upper UTIs (pyelonephritis) may lead to what? Need to distinguish pyelonephritis from?
A
- UTIs are most common ped infections
- pyelo may lead to renal scarring, HTN and endstage renal disease
- difficult to dist b/t cystitis and pyelo
31
Q
Most common bacterial cause of UTI?
A
- E. coli (80%)
32
Q
Host factors - of UTIs?
A
- age: prevalence high in boys less than 1 and girls less than 4
- lack of circumcision - uncircum. with fever have 4-8 higher prevalence than circumcised
- race/ethnicity: caucasian greater than african american by 2-4 x
- urinary obstruction: anatomic
- VUR
33
Q
Signs and sxs of UTIs?
A
- varys with age
- no one specific sign or sx
- watch for:
poor feeding
fever
FTT
vomiting
abdominal pain
flank pain
frequency, urgency, dysuria
suprapubic tenderness
34
Q
Dx UTIs?
A
- hopefully kid is potty trained (easier to collect urine specimen)
- midstream clean catch (need to be potty trained)
- clean voided bag for collection
- bladder cath
- suprapubic bladder aspiration
35
Q
How does clean voided bag collection work?
A
- noninvasive
- properly clean perineum b/f applying
- bag must be immediately removed after void
- shouldn’t be used for culture (high rate of false positives)
- acceptable for UA in infants and kids b/t 2 mos and 2 yrs who have unexplained fever and don’t appear ill enough to reqr immediate antimicrobial therapy
- don’t admin abx on basis of UA from clean voided bag urine specimen
36
Q
Bladder cath?
A
- child is restrained
- anterior urethra cleansed thoroughly with povidone-iodine soln
- sterile lube applied to end of approp sized cath
- intro via urethra until urine returns
37
Q
Suprapubic bladder aspiration?
A
- reserved for male in whom cathing is difficult
- uncircumcised boys with tight foreskin
- girls with tight labial adhesions
- children of either sex with clinically sig periurethral irritation
38
Q
Labs for UTIs?
A
- CBC and CMP with presumptive pyelo
- blood cultures (susp bacteremia or urosepsis)
- renal fxn studies
- electrolytes
39
Q
UTI imaging?
A
- not indicated for infants and kids with a first episode
- UTI should be confirmed
- VCUG
- renal US
40
Q
When should pt with UTI be hospitalized?
A
- toxemic or septic
- signs of obstruction or sig underlying disease
- pts who are unable to toelrate adequate oral fluids or meds
- younger than 2 mos with febrile UTIs (presumed pyelo)
- all infants younger than 1 mo with suspected UTI even if not febrile
41
Q
Tx of UTI?
A
- obtain urine for UA and culture prior to tx
- amoxicillin and bactrim first line
- abx for parenteral tx:
ceftriaxone
cefotaxime
ampicillin - empiric:
1st or 3rd gen cephalosporin
amox/clavulanate (augmentin) or sulfamethoxazole trimethoprim (bactrim)
42
Q
What is sepsis? SIRS?
A
- infection, an insult caused by any pathogen
- SIRS: systemic inflammatory response syndrome - widespread inflammatory response that may or may not be assoc with an infection
- sepsis: SIRS in the presence of suspected or proven infection
43
Q
Epidemiology of peds sepsis? RFs?
A
- US: 75,000 kids are hosp. each yr
- resp and bloodstream infections in 2/3 of cases
- RFs:
younger than 1 month
serious injury
chronic debilitating medical condition
44
Q
Pathogens of sepsis?
A
- bacteria
- viruses
- fungi (immunocompromised)
- parasites
- toxic products of these organisms
- early recog. and intervention clearly improve the outcome for infants and kids
45
Q
Hx ?s for sepsis?
A
- fever (most common presenting sx)
- racing heart
- rapid or labored breathing
- cool extremities
- color changes
- activity level, mental status, urine output, immunizations, exposures to infectious disease, drug allergies
46
Q
Physical exam for sepsis?
A
- subtle changs in vital signs
- hypotension
- mental status changes
- anuria
- hypothermia
- localizing signs of infection
47
Q
Dx sepsis?
A
- CBC
- measures of clotting fxn and coag
- electrolyte levels
- renal and LFTs
- UA
- tests for inflammatory markers
- culture of blood, urine, cerebrospinal fluids
48
Q
Imaging for sepsis?
A
- CXR
- U/S (abdominal abscess?)
- CT
- echo
49
Q
Management of sepsis?
A
- aggressive fluid resuscitation and support of cardiac output
- ventilatory support with supp O2
- maintenance of adequate hemoglobin concentration
- correction of physiologic and metabolic derangements
- monitoring urine output and other end organ fxns
50
Q
Common antimicrobial agents used in sepsis?
A
- newborns and infants in first 6-8 wks of life:
amp and gentamicin
ampicillin and cefotaxime
amp and ceftriaxone - older infants and kids with unclear etiology:
3rd gen cephalosporin + vanco, add clinda if S aureus or GABHS are possible etiologies
51
Q
Meningitis - causes?
A
inflammation of meninges:
- bacterial (life threatening)
- viral (serious but rarely fatal - enteroviruses)
- fungal
- parasitic
- non infectious: cancers, SLE, head injury
52
Q
Signs and sxs of meningitis? classic triad?
A
- classic triad: fever, HA, stiff neck - other sxs: nausea vomiting sleepiness irritability delirium
53
Q
Dx meningitis?
A
- early ID and tx with acute bacterial meningitis
- ID causative organism
- blood studies: CBC with diff, serum electrolytes, serum glucose (compare with CSF glucose), BUN or creatinine and liver profile
- in addition consider:
blood, nasopharynx, respiratory secretion, urine or skin lesion cultures - syphilis testing
- LP and CSF analysis
- neuroimaging (CT and MRI)
54
Q
Management of meningitis?
A
- shock or hypotension: IV fluids
- altered mental status: seizure precautions and tx along with airway protection
- stable with normal vital signs: O2, IV access and rapid transport to ED
55
Q
When should abx be admin for meningitis?
A
- avoid delay
- start immediately after LP and blood cultures
- agent must be bactericidal against infecting organism
- agent must be able to penetrate BBB to reach sufficient concentration in CSF
abx: vanco + ceftriaxone or cefotaxime
56
Q
STIs in kids and adolescents?
A
- kids:
suspect if unsusual injury pattern or behavior on visit, may disclose to care giver, sexual assault suspicion - adolescents: screen appropriately, fairly common
57
Q
Types of STIs?
A
- syphilis
- chlamydia
- gonorrhea
- chancroid
- HPV
- herpes
58
Q
Syphilis - presentation, stages?
A
- great mimicker
- may start in genitals and can spread
- 1st sx: may be sore that forms on genitals or mouth
- fever, sore throat, HA or jt pain usually follow
stages:
- primary: one or more painless sores
- secondary: copper penny rash on hands and feet
- latent: inactive (dormant)
- teriary: severe probs with heart, brain, nerves if not tx
59
Q
Syphilis cause? How does it appear in the newborn, young infants, and kids?
A
- spirochete Treponema pallidum
- acquired: sexual contact
congenital:
-newborn - usually asx
can present with: jaundice, hepatosplenomegaly, edema, signs of meningitis- bulging fontanelle - young infants: mucocutaneous lesions, pseudoparalysis of arms and legs, hepatomegaly, rash on palms and soles
- children: bilateral interstitial keratitis, periosteum thickening of tibias
60
Q
Dx of syphilis?
A
- darkfield microscope
- serologic testing:
VDRL and RPR (nontreponemal)
FTA-ABS (treponemal)
61
Q
Tx of syphilis?
A
- PCN G 50,000 units/kg/dose q 8-12 hrs for 10 days
62
Q
Most common bacterial cause of STI in US?
A
- Chlamydia
63
Q
Chlamydia presentation? labs? Tx?
A
- asx in 75% of females and 70% of males
- sxs can include dysuria, vaginal d/c, cervicitis, PID, epididymitis in males
- if not tx in women: lead to infertility
- labs: urine specimen, culture
- tx: pt and partner (need to abstain for 7 days)
doxy 100 mgx7 days
or
azithro 1000 mg po once
64
Q
2nd most common bacterial STI in US?
A
- Neisseria Gonorrhea
65
Q
Sites of Gonorrhea infections? sxs?
A
- cervix
- urethra
- rectum
- pharynx
- sxs:
dysuria
white, yellow or green d/c
painful or swollen testicles
66
Q
Dx and tx of gonorrhea?
A
- dx: first catch urine for NAAT culture (thayer-martin agar) gram stain (gram - diplococci) - tx: ceftriaxone 250 mg IM + azithro 1 gram single dose
67
Q
Cause of chancroid? Sxs?
A
- Haemophilus ducreyi
- mainly found in developing and 3rd world countries
sxs:
- 1 day to 2 wks develop small papule in genitals which tehn becomes an ucler within a day of its appearance
- ulcer is painful (unlike in syphilis)
- sharply defined borders
- base bleeds easy
68
Q
Dx and tx of chancroid?
A
- dx: gram stain
- tx:
azithro 1 g single dose
ceftriaxone 250 mg single dose
69
Q
cause of HPV? How many adolescent females have this? Types?
A
- condylomata acuminata
- 32-50% of adolescent females having sexual intercourse in US have HPV
- types 6 & 11 = warts
- types 16 & 18 = cervical dysplasia and cancer
- asx: develop lesions on genitals
70
Q
Dx HPV? Tx?
Vaccines?
A
- dx: bx and pap smear
- tx:
podofilox, trichloroacetic acid, cryotherapy, laser surgery - vaccines:
gardasil, gardasil 9, and cervarix (just covers 16 and 18)
71
Q
Diff types of herpes? signs and Sxs?
A
- HSV-1: oral
- HSV-2: genital herpes
- recurrences can be spontaneous or due to stress and immunosuppression
-signs and sxs:
grouped vesicles on erythematous base, fever and malaise, tender regional adenopathy
72
Q
Dx and Tx herpes?
A
- cultured vesicles from epithelial sites
- immunofluorescent stains
- ELISA
- tx:
antivirals - acyclovir, famciclovir and valacyclovir
