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
