ID & Immunization Flashcards
CPS recommends all children > ___ years should be offered mRNA vaccine for COVID 19.
12
What rare side effect must you discuss when providing informed consent for an mRNA COVID vaccine?
Informed consent should include discussion about the rare reports of myocarditis and pericarditis following this vaccine, what warning signs to watch out for, and the fact that the vaccine’s benefit of preventing hospitalization for COVID-19 infection outweighs the risk of myocarditis or pericarditis.
COVID19 mRNA vaccine cannot be given with routine immunizations. True or false?
COVID-19 vaccines may be given simultaneously with, or at any time before or after, any other vaccine(s).
Name 3 groups of patients who warrant a third dose of mRNA COVID vaccine.
Active Rx for malignancies, receipt of solid organ transplant and on immunosuprpessants, HSCT within 2 years, immunodeficiency (DiGeorge, WAS), untreated HIV, on immunosuppressive therapies
A woman presents in labour and does not have a documented HIV status. What do you do?
Rapid HIV testing of mom - If she declines, then test baby, if she refuses that.. you may need to involve child protection services.
A rapid HIV test is done for mom and found to be positive. Within what time frame do you start antiretroviral prophylaxis?
Immediately and no later than 72 hours post-delivery. Also, If rapid HIV antibody testing is unavailable and there is concern that the mother is at high risk for HIV infection, starting newborn antiretroviral prophylaxis pending test results should be considered.
A mother asks if she can breast feed her baby while awaiting results of a rapid HIV test. What do you say?
No. Breastfeeding should be deferred until the confirmatory HIV antibody test result is available and proves negative.
What are the short and long term side (2 each) effects that need to be monitored for infants exposed to HIV infection or antiretroviral agents?
Short term: anemia, neutropenia
Long term: growth, neurodevelopment
Name 2 risk factors for perinatal HIV 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 significant risk for HIV infection), diagnosis of sexually transmitted infections during pregnancy, emigration from an HIV-endemic area or recent incarceration.
What are the most common pathogens causing acute osteomyelitis and septic arthritis (2)?
S. aureus (most common >4yrs) and K. kingae (Kingae esp. in infants). Other common orgs: S. pneumoniae, S. pyogenes.
What is the empiric antimicrobial choice for acute osteomyelitis and septic arthritis and what is the duration of treatment?
IV cefazolin. Duration is 3-4 weeks (4-6 weeks in hip SA). Dose: 100mg/kg/day to 150mg/kg/day divided Q6H or Q8H.
What is the most sensitive and specific noninvasive test for acute osteomyelitis?
MRI using gadolinium enhancement. Radionucleotide bone scans may be useful when MRI is not available, but it is important to note that they have a lower sensitivity and specificity compared with MRI. XR: lytic lesions and localized periosteal lifting.
When can IV therapy be stepped down to PO in a patient with acute osteomyelitis or septic arthritis?
Clinical improvement, normalizing inflammatory markers, and compliance and F/U is assured. CRP is recommended to monitor response to therapy and should be N prior to D/C. Step down therapy: cephalexin 120-150mg/kg/day, TID dosing.
What is the most common site for acute osteomyelitis?
Metaphysis in long tubular bones (such as femur, tibia or humerus).
A 5yo presents with hip pain, limp and T38.0. He is able to weight bear. History of URTI 2 weeks ago. CRP 14. Pain is improved w/ NSAIDs. No swelling or point tenderness of bones. Appears non-toxic. What is the most likely dx? A. Acute osteomyelitis B. Transient synovitis of hip C. Fracture D. Lyme disease arthritis
B. Usual age is 4–10 years. Hip pain and new limping, fever generally low-grade. Child can usually weight-bear but also may not. History of upper respiratory tract infection in the preceding 2 weeks. Nontoxic appearance, usually < 38.5°C fever. CRP is usually < 20 mg/L. Gradually improves over several days, which may be hastened by nonsteroidal anti-inflammatory agents.
What is the gold standard for diagnosis of acute osteomyelitis?
Bone specimen
What is the optimal method for diagnosis of septic arthritis?
Joint aspiration
What is prevented by HPV vaccination?
Because the vaccine prevents infection with the papillomavirus (a necessary first step in cancer development), the cellular dysplasia (intraepithelial neoplasia) that predates invasive cancer does not occur, effectively preventing the development of cancer. If vaccine is administered before exposure to the targeted HPV types, efficacy is close to 100% against type-specific cervical disease.
True or false? HPV is associated with Guillain-Barré syndrome, autoimmune diseases, stroke, venous thromboembolism, acute disseminated encephalomyelitis, multiple sclerosis or any other serious health condition.
False. There is no association.
What is the recommended age for HPV vaccination?
9-13 years to increase likelihood of vaccine administration before onset of sexual activity. Vaccine should be given in 2 doses, 6 months apart.
What are the risks of neonatal circumcision?
Minor bleeding (1.5%), local infection (minor), severe infection (rare), death from bleeding (rare), unsatisfactory cosmetic results, meatal stenosis (<1% when petroleum jelly is applied for 6months post op)
Does the CPS recommend the routine circumcision of every newborn?
No
What are the benefits of neonatal circumcision?
Prevention of phimosis, decrease in early UTI or UTI in those with RFs, decreased acquisition of HIV, HSV, HPV, penile cancer, cervical cancer in female partners
What is the treatment for phimosis?
Apply topical therapy (ex. betamethasone 0.05%) BID accompanied by gentle traction.
When may antibiotic prophylaxis for UTI be considered?
Grade IV or V VUR or a significant urological anomaly. These patients should be D/W or seen by nephrology or urology.
Note: An increasing risk for antibiotic resistance may soon negate the benefits of prophylaxis even in these cases.
What are the recommended antibiotic choices for UTI prophylaxis?
Septra or nitrofurantoin
True or False? There is no evidence that UTI antibiotic prophylaxis prevents renal scarring or other long term sequelae.
True. Moreover, there is increasing evidence that recurrent UTIs do not contribute to chronic renal failure in children with no structural renal anomaly. Therefore, more harm than benefit may result from prophylaxis. Long-term antibiotics may cause adverse events as well as promote resistance to all available oral antibiotics. Managing constipation appropriately may be helpful for decreasing UTI recurrences.
A 2 year old female presents with T39.1 and no apparent source of infection. There are no features of a viral infection. Which investigation will you order? A. NPS for viruses and atypicals B. Chest x-ray C. U/A and culture D. CBC and CRP
C. As previously recommended by the CPS, a urinalysis and urine culture should be obtained from children <3 years of age with a fever (>39.0°C rectal) with no apparent source.
What is the meaning of nitrites on a U/A?
The nitrite test measures the conversion of dietary nitrate to nitrite by Gram-negative bacteria. A positive nitrite test makes UTI very likely, but the test may be falsely negative if the bladder is emptied frequently or if an organism that does not metabolize nitrate (including all Gram-positive organisms) is the cause of infection.
What is the recommended empiric treatment of UTI with PO and IV antibiotics?
PO: Cefixime
IV: gentamicin +/- ampicillin
Initial Tx for febrile UTIs in nontoxic children with no known renal abN can be PO provided we are assured they will take it.
A 4 year old female with UTI is admitted and started on appropriate antimicrobial therapy. She is noted to have an abdominal mass. What investigation do you order next?
RBUS
Children w/ UTI should receive more extensive assessment when they are hemodynamically unstable, have an elevated serum Cr level at any time, have a bladder or abdominal mass, have poor urine flow, or are not improving clinically within 24 h or fever is not trending downward within 48 h of starting appropriate antibiotics. A clinician would usually start with a renal and bladder ultrasound (RBUS) to look for obstruction or an abscess.
A 1 year old is receiving treatment for a febrile UTI. You order a RBUS. What are you looking for?
RBUS reliably detects hydronephrosis, which usually occurs with high grade (grade IV or V) VUR.
What is the best test for assessing VUR?
VCUG
A 1 year old female just completed treatment for a second well documented UTI. What test do you order? A. RBUS B. VCUG C. DMSA D. CT
A VCUG is usually indicated for children <2 years of age with a second well-documented UTI. Although a VCUG is often postponed until the child finishes antibiotics, there is no evidence that this delay is necessary.
What are the most common organisms causing UTI?
E. coli, Klebsielle pneumonia, Enterbacter species, Citrobacter species, Serratia species or in adolescent females only, Staph. saprophyticus
What is the most common treatment for oropharyngeal candidiasis (thrush)? What is the most effective?
Most common: nystatin
First-gen imidazoles are more effective: clotrimazole
A child presents with refractory thrush. What do you need to consider?
In cases of refractory thrush, consultation with an infectious disease specialist is recommended for additional investigations of immune function (e.g., human immunodeficiency virus infection) and fungal susceptibility
What organism causes pityriasis versicolor?
Malassezia
What are the treatment options for pityriasis versicolor?
Topical ketoconazole, selenium sulfide, and clotrimazole are the most common treatments. Treatment usually consists of applying shampoo preparations, such as ketoconazole 2% or selenium sulfide as a 2.5% lotion or 1% shampoo, to the affected area for 15 min to 30 min nightly for one to two weeks, and then once a month for three months to avoid recurrences.
What is the treatment for tinea corporis?
There is little difference in efficacy among clotrimazole, ketoconazole, miconazole, or terbinafine. A good response usually occurs when any of these agents are applied topically, once or twice daily for 14 to 21 days. Continuing topical applications for at least 14 days beyond clinical resolution is recommended to reduce likelihood of relapse. Topical agents mixed with corticosteroids should be avoided.
A child presents with a boggy/fluctuant round are with associated hair loss on the head. What is the treatment?
A kerion responds to terbinafine and usually does not require antibiotics or surgical drainage.
What serious side effects are associated with ketoconazole?
In 2013, Health Canada released an advisory that ketoconazole had been associated with reports of serious hepatotoxicity and death. Ketoconazole is no longer recommended for the treatment of mild to moderate fungal infections.
Who should receive the influenza vaccine?
ALL children and youth >6 months of age
Note that the first year that a child <9yrs receives flu vacc, two doses at least 4 weeks apart are required. If a child <9yrs has received at least one dose of any flu vacc in the past, only one dose is required in the current season.
What are the contraindications to the influenza vaccine?
Anaphylactic reaction to a previous dose of influenza vaccine or to any components of the vaccine (except egg), or onset of GBS within 6 weeks of flu vaccine with or without other known cause.
When is the live attenuated influenza vaccine contraindicated?
Immunocompromised (except stable HIV), severe asthma, during pregnancy, 2-17yo patients receiving ASA because of risk for Reye’s syndrome.
What is the youngest age oseltamivir approved for treatment of influenza?
1 year. Children <1 year should be treated on a case-by-case basis depending on severity of illness.
Oseltamivir for treatment of infuenza is most effective if delivered in what time period?
48 hours. Ideally, start antivirals immediately and can discontinue if testing is negative.
Name a few risk factors for MRSA?
Clusters or increased rates have been reported in Aboriginal populations, athletes, daycare attendees, military recruits, intravenous drug users, men who have sex with men, and prisoners, but many infected children have no risk factors.
A 3 week old presents with skin abscess. How do you treat it?
Most should be admitted for intravenous antibiotics (usually vancomycin with or without other agents).
Outpatient management with clindamycin can be considered if the abscess is small (<1 cm), the child was previously well and has no fever or signs of systemic illness, and the parents seem reliable
A previously well 2 month old presents with skin abscess, no fever and no other systemic signs of illness. You drained the abscess. What is the next step in your treatment plan?
Previously well children 1-3 months with no fever or systemic signs of illness are treated with TMP/SMX PO pending cultures after drainage.
A previously well 5 month old with a skin abscess, T38.0 and no systemic signs of illness. You drained the abscess. What is the next step in your treatment plan?
> 3mths, low grade fever or none and no systemic signs of illness:
Observe after drainage – consider antibiotics only if the child does not improve or the culture grows an organism other than Staphylococcus aureus (such as group A streptococcus).
A previously well 6 month old presents with skin abscess with significant surrounding cellulitis, is afebrile and has no systemic signs of illness. You drained the abscess. What is the next step in your treatment plan?
> 3mths, sig. cellulitis, low grade fever/none, no systemic signs of illness:
TMP-SMX and cephalexin orally pending cultures
What antibiotic options are recommended for postdrainage ABx for skin abscess?
TMP/SMX
Doxycycline: >8yo, pills
Clindamycin: increasing resistance, risk of C. Diff
Linezolid: not advised for uncomplicated skin abscess
What is in the DDx for fever in the returned traveller who has jaundice?
Viral: Hep A, B, E, viral hemorrhagic fever
Bacterial: typhoid, leptospirosis
Parasitic: malaria
What is in the DDx for fever in the returned traveller who has lymphadenopathy?
Viral: EBV, CMV, HIV
Bacterial: Rickettsiae, Brucellosis, Mycobacterium TB
Parasitic: viscerl leishmaniasis, trypanosomiasis
What is in the DDx for fever in the returned traveller who has diarrhea?
Viral: rotavirus
Bacterial: E. coli, shigella, salmonella, campylobacter, yersinia
Parasitic: Giardia, amebiasis
What is in the DDx for fever in the returned traveller who has hepatomegaly?
Viral: EBV
Bacterial: Typhoid
Parasitic: Malaria, Visceral leishmaniasis
What is in the DDx for fever in the returned traveller who has a hemorrhagic rash?
Viral: Dengue, viral hemorrhagic fever
Bacterial: meningococcus, rocky mountain spotted fever
What is in the DDx for fever in the returned traveller who has a fever and rash?
Viral: Dengue, Chikungunya, acute HIV, measles, Zika, roseola
Bacteria: Ricketsiae, salmonella, leptospirosis
What is in the DDx for fever in the returned traveller who has a fever and eosinophilia?
Acute schistosomiasis, Fascioliasis, Strongyloidiasis, Toxocariasis, Trichinellosis, Other parasites (esp. if immunocompromised)
What are the 3 most important travel related causes of fever in a returned traveller?
Three of the most important travel-related causes of fever are malaria (20% to 30% of cases, onset within 6 months of return), traveller’s diarrhea and enteric fever (10% to 20% and 2% to 7% respectively, onset within 60 days of return), and dengue (5%, within 14 days of return).
How is the diagnosis of malaria made?
Diagnosis of Plasmodium falciparum is made by microscopy +/- rapid diagnostic testing, when available.
What is Dengue fever?
- Flavivirus
- From mozzies that bite in daytime
- High risk in SE Asia, South Pacific, Central America and the Caribbean
- Sx: fever, chills, H/A, myalgias, a classi cerythematous reticulate rash over the thorax, face and flexion areas
- Invx: lymphocytosis, neutropenia, transaminitis
- Rpt dengue can cause hypoNa, hypoprotein and circulatory collapse
List your basic investigations for fever in a returned traveller.
Complete blood count with differential: liver enzymes; electrolytes; creatinine
Malaria smears ± antigen detection testing, when available (immediately and at least 2 subsequent samples over 24 to 48 hours when the child has visited a malaria-endemic area)
Blood culture (ensure adequate weight or age-based volume collected)
Urinalysis +/– urine culture
What are the risk factors for development of acute otitis externa?
Swimming, trauma, foreign body, hearing aids, certain dermatological conditions, chronic otorrhea, wearing tight head scarves and being immunocompromised
What physical exam finding differentiates acute otitis media from acute otitis externa?
Tenderness of the tragus when pushed and of the pinna when pulled occurs in acute otitis externa (but not in AOM)
What are the 2 most common organisms causing acute otitis externa?
Psuedomonas aeruginosa and Staphylococcus aureus. Isolates are polymicrobial in many cases, Gram neg are uncommon. Rarely fungal species.
What is the treatment for mild to moderate acute otitis externa?
Topical ABx +/- topical steroids x7-10 days
Pain control
If ear canal not visible can place expandable wick
What is malignant otitis externa?
- Risks: IDDM, immunodeficiency
- Invasive infxn of cartilage and bone of canal and external ear may present with facial nerve palsy and pain
- CT for dx
- Aggressive debridement and systemic Abx for coverage of P. aeruginosa and Aspergillus
What some of are the suppurative complications of GAS pharyngitis?
Peritonsillar and retropharyngeal abscess, cervical lymphadenitis, mastoiditis, other focal infections or sepsis are less common
Name 2 of the important non-suppurative complications of GAS pharyngitis.
PSGN, Acute rheumatic fever
Who should be tested for GAS pharyngitis?
- CENTOR score >/=3: 1 point for each of exudate or swollen tonsils, tender or swollen anterior cervical lymph nodes, fever, NO cough.
- Note: rare in children <3y and testing only indicated for them in outbreak settings or when scarlet fever suspected
What is the gold standard test for diagnosis of GAS pharyngitis?
Bacterial culture from a swab of the tonsils and posterior pharyngeal wall
-Rapid antigen testing have a lower sensitivity and are acceptable for low ARF settings but in a higher burden setting, the test should be confirmed with culture
Within what time period is antimicrobial treatment for GAS pharyngitis required to prevent ARF and suppurative complications?
Within 9 days of symptom onset
What is the optimal treatment for GAS pharyngitis?
Penicillin or amoxicillin for 10 days because all GAS are susceptible to penicillin :)
-If concerns for adherence can do Pen G IM x1
A 6 year old presents with a T38.), moderate to severe sore throat, very tender anterior cervical LNs, absence of cough and rhinorrhea and inflamed tonsils. You make a diagnosis of GAS pharyngitis which is noted on bacterial culture. They report a history of rash with penicillin in the past. No anaphylaxis. What is the recommended treatment for them?
For children with non-anaphylactic hypersensitivity reactions to penicillins, an oral amoxicillin challenge or cephalexin is recommended . For the very rare patient with a clear history of anaphylaxis or documented type 1 hypersensitivity to penicillins, acceptable options are azithromycin, clarithromycin, and clindamycin. However, resistance to macrolides and clindamycin has been documented in up to 20% of isolates.
What are the most common clinical presentations of invasive GAS infections?
The most common clinical presentations of IGAS infections are toxic shock syndrome (TSS), with or without a focus of infection, necrotizing fasciitis (NF) or myositis, bacteremia with no septic focus, and pneumonia.
What are the risk factors in children for invasive GAS infections?
Recent pharyngitis, and varicella, soft tissue trauma, NSAID use
What is the diagnostic characterization of Streptococcal TSS per CPS?
Hypotension (less than the fifth percentile for age) AND at least two of the following signs:
-Renal impairment (creatinine level of at least 2XULN for age or 2X baseline)
Coagulopathy (Plts of 100×109/L or lower, or DIC)
Liver function abnormality (levels of AST, ALT or total bilirubin >2X the upper limit normal for age)
Acute respiratory distress syndrome
Generalized erythematous macular rash that may later desquamate
What is the recommended empirical antimicrobial therapy for TSS or suspected TSS?
Rx should include coverage of Staphylococcus aureus and GAS with a beta-lactamase stable beta-lactam (i.e., cloxacillin) in combination with clindamycin. Because TSS has been associated with methicillin-resistant Staphylococcus aureus (MRSA), addition of empiric vancomycin, pending culture results, may be prudent for areas or populations with significant rates of MRSA colonization.
What is the recommended empiric therapy for necrotizing fasciitis?
Broad coverage for gram+, gram - , and anaerobic organisms = Tazocin or a carbapenem in combination with clindamycin with consideration of adding vancomycin for MRSA coverage depending on prevalence
What is the role of clindamycin for treatment of GAS?
- Inhibits toxin production (recommended for all empiric and confirmed cases of severe invasive GAS as is assoc. with improved outcome
- May D/C after 48-72hrs if patient is hemodynamically stable, blood sterile, no further necrosis
- Not recommended as monotherapy as there is resistance
In addition to antimicrobials, what other treatment would you consider for severe cases of streptococcal TSS?
IVIG should be considered on the day of clinical presentation in the treatment of streptococcal TSS or other severe invasive (toxin-mediated) disease, especially when the patient is severely ill or the condition is refractory to initial aggressive therapy with fluids
What is the treatment of confirmed invasive GAS?
Penicillin + clindamycin
When is chemoprophylaxis indicated with a case of invasive GAS?
Close contacts from 7 days before onset to 24hr after Abx for SEVERE cases of iGAS. Recommended for all children and staff in family or home child care settings. Rx ideally within 24hr w/ cephalexin. Routine cultures are NOT needed.
What is the leading cause of non-genetic childhood sensorineural hearing loss?
Congenital CMV
What is the gold standard testing for congenital CMV?
Urine CMV PCR/shell vial before 21 days postnatal age
Which infants with congenital CMV should receive treatment?
- CNS disease
- Chorioretinitis
- Severe single or multi-organ disease
What is the recommended treatment for congenital CMV?
Antiviral treatment should commence in first month of life and be administered for 6 months
- Valganciclovir (16 mg/kg/dose by mouth, twice per day, for 6 months)
- IGanciclovir (6 mg/kg/dose IV twice per day) may be used for the first 2 to 6 weeks before transitioning to valganciclovir for very sick neonates
How do you treat an infant with asymptomatic congenital CMV?
- Regular audiological evaluation
- Prompt ENT referral if SNHL detected
What must you rule out in cases of congenital cataracts?
Congenital Rubella Syndrome
What are the key features of measles?
Cough, coryza, conjunctivitis, Koplik’s spots in mouth
Complications: otitis media, PNA, encephalitis or death
What are the key features of diptheria?
Sore throat, weakness, fever and a rapidly progressive swelling of the neck, within a few days a thick pseudomembrane builds up in the throat or nose that can lead to resp compromise, can also be disseminated
What must you test for in a case of parotitis?
Mumps - test with urine, serology, NPS
How do you test for measles?
Serology, NPS and urine
How do you test for polio?
Stool, throat swab
What is the most common presentation of a recent tick bite?
Erythema migrans
- Develops 7-14 days after bite, resolves spontaneously
- Can be single/multiple
- Uncommon to have typical bulls eye
- Often accompanied by fever, malaise, H/A, mild neck stiffness, myalgia and arthralgia
What is the most common manifestation of late stage symptoms of lyme disease?
Pauciarticular arthritis affecting large joints, especially the knees approx. 4 mths post tick bite
-Other sx: nerve palsy, arthritis, heart block (carditis), meningitis
True or false? Patients with erythema migrans and history of tick bite need to have laboratory confirmation prior to treatment.
False. Patients with EM should be diagnosed and treated without laboratory confirmation, because antibodies against B burgdorferi are often not detectable by serodiagnostic testing within the first four weeks after infection.
A patient presents with symptoms of lyme disease (NOT include erythema migrans). What is your next step?
All other clinical manifestations of possible LD should be supported by laboratory confirmation. Two-tiered serological testing, including an ELISA screening test followed by a confirmatory Western blot test, is used to supplement clinical suspicion of extracutaneous LD.
What is the Jarisch-Herxheimer reaction?
The Jarisch-Herxheimer reaction (fever, headache, myalgia and an aggravated clinical picture lasting <24 h) can occur when therapy for Lyme Disease is initiated. Nonsteroidal anti-inflammatory agents should be started and the antimicrobial agent continued.
What is the treatment for Lyme Disease that presents with Erythema Migrans?
Doxycycline x10d Amoxicillin x14d Cefuroxime x14d Azithromycin x7d -These agents can also be used for arthritis
What is the treatment for Lyme Disease that presents with isolated facial palsy?
Doxycycline x14d
What is the treatment for Lyme Disease presenting with meningitis?
Doxycycline or IV ceftriaxone x14d
When can live vaccines be given for a patient who was on high dose steroid therapy?
Live vaccines may be given 1 mth after discontinuation of high dose steroid therapy, 3 mths or more after completion of other immunosuppressive chemotherapy, or 6 mths after treatment with anti-B-cell antibodies, provided that the underlying disease is not immunosuppressive or is no longer active. (N.B. ‘High dose steroid therapy is defined as systemic treatment with the equivalent of prednisone ≥2 mg/kg/day or ≥20 mg/day if weight >10 kg for ≥14 days.)
What are the features of congenital Zika Virus Syndrome?
- Microcephaly, cerebral atrophy, abN cortical development, callosal hypoplasia and diffuse subcortical calcifications
- Features of CZS that distinguish it from other congenital infections are: severe microcephaly w/ partially collapsed skull; thin cerebral cortices w/ subcortical calcifications; macular scarring and focal pigmentary retinal mottling; congenital contractures; and marked early hypertonia and symptoms of extrapyramidal involvement
How do you diagnose Zika virus syndrome?
- Serology (IgM or IgG or neutralizing antibody) OR
2. Detection of ZIKV RNA by PCR testing
What time period should pass from receiving a live vaccine and the onset of immune suppression?
The minimum interval between the last dose of a ‘live’ vaccine and onset of immune suppression should be four weeks
What can be expected for infections in the first month post organ transplant?
Greater than 95% of infections occurring in this critical period are similar to infections incurred by nonimmunosuppressed patients who have undergone a comparable surgical procedure
What can be expected for infections in the 1-6 months post organ transplant?
2 types of opportunistic infections:
- Viruses: CMV, EBV, HHV6, Hep B and C
- Listeria monocytogenes, Apsergillus fumigatus, Pneumocystis jirovecii
Name 7 vaccines that the CPS recommends for post organ transplant patients should receive?
- Pneumococcal *most important, high risk for invasive disease, esp. cardiac pts
- Meningococcal conjugate quadrivalent
- HPV
- Hep B & A
- Inactivated polio, H. flu type B, diphtheria, tetanus, pertussis (post-transplant)
- Influenza
Name the vaccines contraindicated post organ transplant.
Influenza, MMR, varicella, rotavirus, BCG
- Basically, ALL life attenuated vaccines!
What antimicrobial prophylaxis should ALL post organ transplant patients receive?
TMP-SMX for PJP prophylaxis
Which types of HPV cause cervical and other genital cancers?
- High risk (16 and 18) types can lead to cervical and other genital cancers
- Higher prevalence in females <25 years of age, lower SES, Indigenous women
Name 3 risk factors for STI.
- Any sexually active youth <25 years old
- Inconsistent or no condom use
- Contact with someone known to have STI
- New partner
- > 2 partners in past year
- Serial monogamy
- No contraception or only non-barrier contraception (e.g. oral contraceptive, intrauterine device, or Depo-Provera)
- Injection drug use
- Any drug use (e.g. alcohol, marijuana, others – especially if associated with sex)
- Previous STI
- Any unsafe sexual practices (e.g. involving exchange of blood or sharing sex toys)
- Sex workers and their clients
- Survival sex (e.g. exchange of sex for food, shelter, or drugs)
- Street involvement/precarious housing
- Anonymous sex (sex with a stranger after meeting online or elsewhere)
- Experience of sexual assault or abuse
An adolescent presents to clinic and is sexually active. What tests do you offer them?
- Chlamydia NAAT (first catch urine, vaginal, endocervical or urethral specimens
- Gonorrhea first catch urine, pharyngeal when oral sex, rectal if anal sex; Cx>NAAT
- Syphilis serology
- HIV serology
- Other serologies to consider: Hep A, B and C
What testing do you send a genital ulcer?
Swab of ulcerative, erosive, pustular or vesicular lesions for HSV culture OR HSV PCR
AND
Syphilis serology
What is the preferred treatment for gonococcal and chlamydial co-infection, anogenital infections?
CTX 250mg IM in a single dose PLUS azithromycin 1g PO in a single dose
OR
cefixime 800mg PO in a single dose PLUS azithromycin 1g PO in a single dose
What is the treatment for a first episode of genital/perianal HSV infection?
Valacyclovir 1000mg PO BID x10d OR
Acyclovir 200mg PO 5x/d x5-10d OR
Famiciclovir 250mg PO TID x5d
What is the treatment for trichomonas?
Metronidazole 2g PO in a single dose OR metronidazole 500mg PO BID x7d
True or false. Retesting at six months is indicated for adolescents and adults with N gonorrhoeae and/or chlamydia because the risk for reinfection is a major concern in this age group..
True
What patient group should receive RSV prophylaxis?
Children with hemodynamically significant CHD or CLD (defined as need for oxygen at 36wks GA who require ongoing diuretics, bronchodilators, steroids, or supplemental oxygen) should receive palivizumab if <12mo of age at start of RSV season
- Not indicated in second RSV season for infants except for CLD still on or weaned off supplemental oxygen in last 3mo
Per the CPS statement, what testing should be completed for a genital ulcer?
- HSV PCR/culture
- Syphilis serology
What STI testing should you offer for a sexually active teenager?
First-catch urine for Chlamydia trachomatis, Neisseria gonorrhoeae
Pharyngeal and/or rectal swabs for C trachomatis, N gonorrhoeae (history of unprotected receptive oral or anal exposure)
Serology for:
-Syphilis
-HIV
Other serological tests to consider:
-Hepatitis A (particularly with oral-anal contact)
-Hepatitis B (if no history of vaccine)
-Hepatitis C (particularly in PWIDs)
What is the treatment for gonoccocal and chlamydia co-infection?
CTX (gonorrhea) + azithromycin (chlamydia) x1
-If chlamydia only can just give azithromycin but if gonorrhea, treat for both
What is the treatment for an genital/perianal HSV infection?
Valacyclovir OR Famicyclovir OR Acyclovir
What is the treatment for a trichomonas vaginitis?
Metronidazole
A child has chicken pox. When can they return to school/daycare/camp?
-Per CPS, children with mild illness should be allowed to return to school or child care as soon as well enough, regardless of rash
A child has head lice. When can they return to school/daycare?
Anytime! CPS states: DO NOT exclude from school even if active disease, just avoid head to head contact, alert all parents of the infestation but educate them (common, not a sign of poor hygiene, not a vector of disease)
Can children with the following infections attend day care?
-Common cold, roseola, CMV, Otitis, Parvovirus B19, Pneumococcal, Varicella, Hep B, Hep C, HIV, Head lice, Molloscum, Pinworms, Candida thrush, Candida diaper
Yes as long as they are well enough to go. For Hep B, they cannot go if there is a behavioural concern related to Hep B such as biting.
A young child has a unilateral, nontender anterior cervical LN which is chronically draining. What do you think is the most likely cause?
NonTB mycobacteria; M. avium complex (MAC), M. abscessus, M. fortuitum, M. marinum
- Lymphadenitis is most common presentation: unilateral, nontender anterior cervical or submandibular LNs, overlying skin violaceous, sinus tracts can develop
- Systemically well, no constitutional symptoms
What is the treatment for cat scratch disease?
Bartonella henselae infection
Unilateral lymphadenopathy after cat bite or scratch to the ipsilateral side
Self-limited with resolution in months; rarely causes persistent draining lesion
Diagnosis: IgM titres to Bartonella
Treatment: observation may be considered for mild to moderate cases in immunocompetent hosts
Otherwise, first line antimicrobial most often consists of macrolides (ex. azithromycin)
What are the most common pathogens implicated in febrile neutropenia?
Gram positives > gram negatives
- (+): S. aureus (inc. MRSA)
- (-): Streptococci, enterococci, pseudomonas, enterobacteriaceae
- Fungal: Candida, Aspergillus, Mucormycosis, PJP
- Viral: Herpesviruses, resp viruses
What is the treatment for Bordatella pertussis?
Azithromycin, clarithromycin, erythromycin
- Treat all infants <12 months if diagnosed within 6 weeks of cough
- Treat all children >1 year of age if diagnosed within 21 days of cough
True or false. All household contacts should be given post exposure prophylaxis, regardless of age or immunization status.
True
What common helminth is associated with eosinophilia?
Ascaris lumbricoides
Presentation:
-Loffler PNA: cough, wheeze, hemoptysis, “shifting” pulmonary infiltrates
-Abdo pain, intestinal obstruction
-Malnutrition, malabsorption
Dx: Stool ova, peripheral eosinophilia and pulm infiltrates suggestive
Rx: albendazole, mebendazole
A 4yo child is a TB close contact with TST <5mm. What do you do?
Children <5y with TST <5mm: Prophylaxis with 1 TB drug (isoniazid) and repeat TST in 8-10 weeks, if <5mm can stop prophylaxis.
A 6yo child is a TB close contact with TST <5mm. What do you do?
> 5y with TST <5mm: No prophylaxis but repeat TST in 8-10 weeks
A 7yo child is a TB close contact with TST >5mm with no symptoms, normal physical exam and normal CXR. What do you do?
Treat for latent infection (isoniazid, rifampin).
What is the recommended criteria for watchful waiting in a patient with AOM?
> 6mo, illness not severe (mild otalgia, T<39C w/o antipyretics), parents are reliable (must have good D/C instructions)
What are the indications for treatment of Campylobacter diarrhea and what do you treat with?
Treatment: supportive care
If severe symptoms, immunocompromised = erythromycin or azithromycin
What is visceral larva migrans and what worm causes it?
Toxocara:
Visceral larva migrans: fever, bronchospasm/wheezing (mimicking asthma), hepatomegaly, peripheral eosinophilia, hypergammaglobulinemia
Ocular larva migrans: unilateral vision changes resulting from invasion and granuloma formation within the retina
-May have history of pica
-Most patients recover without treatment
For which pathogens implicated in bacterial meningitis is adjuvant steroids indicated per the available evidence?
Hib or S. pneumo only
Consider giving if gram stain shows GN coccobacilli (Hib) or Gram pos diplococci (S. pneumo)
What is the recommended treatment for GBS meningitis as per the CPS?
Ampicillin and gentamicin
What investigation should ALL children with bacterial meningitis have before discharge or within 1 month of discharge?
Formal audiology assessment!
What are the contraindications to rotavirus vaccine?
Immunocompromised (ex. SCID), or history of known condition predisposing them to intussusception (ex. uncorrected Meckel’s diverticulum), hypersensitivity to any of the ingredients
When can rotavirus vaccine be given?
It cannot start after 15 weeks of age and additional doses must not be given after 8 months of age
-Start at 6 weeks, if premature in NICU follow same schedule but may choose to give at discharge to decrease risk of rotavirus to other infants
What are contraindications to the live attenuated influenza vaccine?
- Age <2years
- Severe asthma (current high dose inhaled steroids or systemic steroids)
- Medically attended wheezing in past 7 days
- Immunodeficiency, pregnancy
- ASA treatment (risk of Reye’s)
