ID- Position statements Flashcards
After a needle stick injury do you need prophylaxis for HepC? Hep B?
Hep C- No
Hep B- yes (Depending on their status), can survive up to 1 week in blood
What are some management steps after needle stick injury
wash the wound with soap and water
assess for blood exposure
assess status for tetanus and Hep B
When should you consider HIV prophylaxis following needle stick injury?
Recommended if all of the following present
Source considered likely to have HIV
Needle/syringe with visible blood
Blood may have been injected
when do you need to start HIV prophylaxis? How long do you treat?
within 1-4 hours
prophylaxis is not indicated if >72 hours
treat for 28 days
what are some prophylactic medications for HIV
young child: zidovudine + lamivudine+ lopinavir
For children at least 12 years old and weighing at least 35 kg: emtricitabine plus tenofovir plus raltegravir or dolutegravir
What is the treatment following needle stick injury for HepB prophylaxis if: Fully vaccinated and HBsAg+ HBsAb+ HBsAg- and HBsAb -
HBsAg+= refer
HBsAb+= give nothing
HBsAg- and HBsAb -= give vaccine and HBIG
- if you cannot get the results in 48 hours then give vaccine
What is the treatment following needle stick injury for HepB prophylaxis if: NOT vaccinated and HBsAg+ HBsAb+ HBsAg- and HBsAb -
HBsAg+= refer
HBsAb+= complete vaccine series
HBsAg- and HBsAb -= give vaccine and HBIG
- if you cannot get the results in 48 hours then give vaccine and HBIG
What is the transmission risk of HepB, C and HIV from needle stick injury
Hepatitis B: 2% to 40%
Hepatitis C: 3% to 10%
HIV: 0.2% to 0.5%
NO documented cases of accidental HIV transmission from needle stick in community
For HIV positive source, what is the most important risk factor
For HIV positive source, viral load is the most important risk factor
what are the initial investigations and followup investigations for needle stick injury
Baseline –HIV and HCV serology, HBsAgand anti-HBsAg
6 weeks –HIV serology
3 months –HIV and HCV serology
6 months –HIV and HCV serology and anti-HBsAg
* the last tests for infection are done at 6 months
What HepB prophylaxis is required if:
Biting child- status unknown
Bitten child- status unknown
vaccinate both
Biting child: HBV carrier
Bitten child: Non-immune or incompletely immunized
HBIG& vaccine to bitten child
what is the incubation period for chicken pox
can be as long as 21 days after contact
when can children return to school with chickenpox?
as soon as they feel well enough
Children with mild illness be permitted to return to child care or school as soon as they feel well enough to participate normally in all activities, regardless of their state of rash
how many doses of varicella are recommended?
2 doses
If a child at camp is immunocompromised who should be excluded (due to risk of varicella)
those with active VZV or exposure history in last 21 days who are non-immune should be excluded
Immunization rates in Canada are suboptimal. What are some strategies to improve immunization rates (4)
- accurate immunization records at school entry
- implementing immunization registries at the provincial/territorial level
- educating parents and school-aged children about vaccine-preventable diseases
- making it more convenient for parents to ensure their children are fully immunized
Establish electronic immunization registry
Notify parents when their child is missing an immunization (Text messages with e-mail follow-up)
Offer Canimmunize app to help parents keep track of immunizations
Timely vaccine availability from walk-in clinics or GP office (wait time >2 weeks)
In every community, there should be at least one ‘walk-in’ clinic offering immunizations on certain days without appointment
Immunization records mandatory for school entry
Provide a school-based immunization program at least once a year
Guide hesitant parents to resources
Curriculum with info on vaccine-preventable illnesses and benefits of vaccines, such that the next generation of parents better understands disease risks, vaccine effects and the importance of community immunity
what are the two most common causes of Osteoarticular infections in kids
staph aureus** the most common cause kingella kingae (milder and more subacute course)
what is the treatment for Osteoarticular infections? for how long? when would you switch to oral?
IV cefazolin (start after taking blood cultures)
Conversion to oral antimicrobials should occur when the patient has clinically improved, is afebrile and has decreasing inflammatory markers.
treat for 3-4 weeks
what is the most common site for Osteoarticular infections?
AO can occur in any bone but the most common site is the METAPHYSIS in long tubular bones, such as the femur, tibia or humerus
What is the most sensitive and specific non-invasive test for osteomyelitis?
MRI with gadolinium enhancement = most sensitive and specific non-invasive test for AO
The earliest finding of AO on MRI is bone marrow edema
what bug causes osteomyelitis in sickle cell disease?
salmonella (more commonly due to non-typhoidal salmonella)
what should you document prior to stopping antibiotics for osteomyelitis
normal CRP
clinical improvement
when should the HPV vaccine be administered?
HPV-9 vaccine should be administered routinely to all girls and boys between the ages of 9 and 13 years of age
what serotypes are included in the HPV quadrivalent vaccine
types 6, 11, 16, 18
6, 11- genital warts
16, 18- cervical cancer
what are some risk factors for HPV
More sexual partners History of other STIs History of sexual abuse Early age of first sex (majority in Canada 15-19 years) Partner’s number of partners Tobacco and marijuana use Immune suppression HIV HPV and anal warts and cancers are highly prominent among men who have sex with men (particularly if HIV positive)
can immunocompromised patients have the HPV vaccine?
yes!
it is a recombinant vaccine
how many doses of HPV vaccine are recommended
2 doses 6 months apart in children 9-14 years otherwise 3 doses
3 doses for immunocompromised
what additional coverage is offered by HPV- 9 versus HPV- 4
The five additional types contained in the HPV-9 vaccine (31, 33, 45, 52 and 58) are estimated to cover an additional 15% to 20% of cervical cancers, 24% of vaginal cancers, 9% of penile and anal cancers, and 2.5% of vulvar cancers.
What are 4 ways that transmission of HIV from mother to child can be reduced **
HIV testing during pregnancy
appropriate perinatal antiretroviral therapy
reducing HIV exposure during delivery
avoiding breastfeeding
When a mother or newborn tests positive for HIV antibody, the infant should be tested immediately for infection by what method?
HIV DNA or RNA polymerase chain reaction (PCR), within 48 hours of birth if possible.
what are the two main serogroups responsible for invasive meningococcal disease?
serogroups B and C
B peaks in <5 years
C peaks in adolescents
When is conjugated MenC vaccine given
12 months
What meningococcal vaccines are available in Canada
Conjugated meningococcal C: MenC-C
Quadrivalent conjugated vaccine: Men C-ACYW= used for adolescent booster in all provinces
Meningococcal B vaccine: 4CMenB= for children with high risk of invasive meningococcal disease, it is poorly immunogenic and efficacy is uncertain therefore not recommended routinely
what patients are at increased risk of invasive meningococcal disease? (9) * table
- asplenia or functional asplenia (including SCD)
- properdin, factor D or complement deficiency
- those on eculizumab
- primary antibody deficiency
- HIV
those at increased risk due to exposure:
- laboratory workers who work with meningococcus
- military personnel living in close quarters
- travellers to endemic areas (Sub-Saharan Africa and Hajj pilgrims)
- close contacts of a case of invasive meningococcal disease
what meningococcal vaccines should at risk children receive?
Men B 2 months, 12-23 months, 5 years, then every 5 years
MenC-ACYW (booster every 3-5 years if <7, every 5 years thereafter) as soon as diagnosis of predisposing condition (must be at least 2 months old)
MenC-ACYW at 2 months, 12-23 months, every 3-5 years until 7 and then every 5 years
what is the preferred MenC-ACYW vaccine before 2 years of age
Men-C-ACYW-CRM
how is rotavirus transmitted
fecal-oral contamination and fomites (can live for months on objects if not disinfected)
rotaviruses are double stranded RNA viruses
what are the two rotavirus vaccines that are available in Canada
RotaTeq (RV5)= live oral, 3 doses, covers 5 strains
Rotarix (RV1)= live-attenuated, given orally in 2 doses
when does the rotavirus vaccine have to be given
can be given as early as 6 weeks
before 15 weeks for the first dose
last dose prior to 8 months
need 4 weeks between doses
* can give with fever/mild illness
* do not repeat dose if infant spits it out, continue with schedule
usually given at 2, 4 and 6mo (for RotaTeq)
is rotavirus a live vaccine?
YES!
should be stored in a refrigerator
what risk is associated with the rotavirus vaccine
small increased risk of intussusception 1-7 days post vaccine
fecal shedding of virus up to 1 week post-vaccine (especially with the first dose) (still vaccinate even if they live with immunocompromised patients or pregnant woman)
what are the contraindications to the rotavirus vaccine (3)
*intussusception or immunocompromised
history of intussusception or greater susceptibility to intussusception (uncorrected Meckel’s)
hypersensitivity to any of the ingredients in rotavirus vaccines
know or suspected SCID or other significant immunocompromising condition
Do you continue rotavirus vaccinations if the infant has a history of rotavirus infection?
Yes, continue vaccination
when can NICU babies get rotavirus vaccine
at or following discharge from NICU
what are some risk factors for AOM
- crowding
- frequent child contact
- orofacial abnormalities
- smoke exposure
- pacifier use
- shorter breastfeeding
- prolonged bottle feeding
- family history
- first nations
what are the main bacterial causes of AOM (3)
S. Pneumonia
M. catarrhalis
H. influenza
what are some complications of AOM (6)
mastoiditis facial nerve palsy 6th nerve palsy (Gradenigo's syndrome) labrynthitis sinus venous thrombosis meningitis
what are the antibiotic options for AOM (4)
first line: amoxicillin
first line with penicillin-allergy (nonlife threatening): Cefuroxime
of Ceftriaxone
If initial therapy fails: amoxicillin-clavulanate
what criteria must be met for the watch and wait approach tx of AOM
>6 months of age MEE and bulging tympanic membrane mildly ill- alert, responsive, no rigors, responding to antipyretics, mild otalgia, able to sleep temp <39 degrees <48h of illness
what is the duration of antibiotics for treatment of AOM
<2 years treat for 10 days
>2 years treat for 5 days
perforated tympanic membrane with purulent drainage- treat for 10 days
if initial therapy failed treat for 10 days
what vaccine is available for RSV? how many doses?
Palivizumab
given every 30 days for max 5 doses
what are the two most important ways to prevent RSV
hand hygiene
avoiding sick contacts
- also encourage breastfeeding and avoid smoke
If a patient is hospitalized with breakthrough RSV during prophylaxis should you continue with vaccinations?
No! do not continue with prophylaxis as repeat infection unlikely
who is eligible for RSV vaccine (4)
children with significant CLD and CHD with ongoing therapy (diuretics, oxygen, steroids) and <12 months at the start of RSV season
prem <30 weeks and <6 months at start of RSV seasons
remote community who would require air transport for hospitalization, <36 weeks and <6 months at start of seasons
Consideration may be given to administering palivizumab during RSV season to term Inuit infants until they reach six months of age only if they live in communities with documented persistent high rates of RSV hospitalization.
what is neonatal ophthalmia?
conjunctivitis in first 4 weeks of life
What do you do for a baby exposed to N. gonorrhea
conjunctival culture and treat with Ceftriaxone IM or IV x 1
if unwell do blood and CSF culture
what do you do for a baby exposed to C trachomatis
monitor closely for symptoms (conjunctivitis, pneumonitis) and treat if infection occurs
NO routine cultures if asymptomatic
Prophylaxis NOT recommended (increased risk of pyloric stenosis with macrolides)
Is ocular prophylaxis effective in preventing chlamydial conjunctivitis?
Ocular prophylaxis is not effective in preventing chlamydial conjunctivitis.
what is the most effective method for preventing neonatal ophthalmia?
screen all pregnant women for gonorrhea and chlamydia infection, and treatment and follow-up of those found to be infected.
what are the two antibiotics that are recommended for UTI prophylaxis? how long should it be used?
septra
nitrofurantoin
max 3 to 6 months of prophylaxis then reassess need
*If resistance to both Abx, stop prophylaxis (don’t want to use broad-spectrum Abx as risk of resistance to all PO meds)
when would you consider UTI prophylaxis
grade IV or V VUR
what is antibiotic stewardship
optimizing the prescribing of antimicrobials
what are some principles of antibiotic stewardship (8)
use clinical judgement and test judiciously
treat infections, not contamination
take a careful history of potential antibiotic side effects and confirm allergies if possible
narrow the spectrum of antibiotics when a causative organism is identified
optimize the dose of antibiotics to obtain max benefit
use the shortest recommended course of therapy for uncomplicated infections
take care not to change or prolong antibiotics unnecessarily
promote vaccinations to decrease likelihood of clinical disease
children with Asplenia or hyposplenia are at increased risk of sepsis from what bacteria?
encapsulated organisms
Strep pneumoniae, H influenzae type B, N meningiditis, Salmonella, E coli
**Streptococcus pneumoniae is the most common organism causing sepsis and is isolated in at least 50% of cases.
Children with Asplenia and hyposplenia are at increased risk of sepsis following animal bites and should be treated with what?
animal bites – need for Amox-Clav
Increased risk of infection after animal bites, especially with Capnocytophaga canimorsus from dog bites
when can PPV23 be given
after 24 months of age
what children with Asplenia or hyposplenia should receive antibiotic prophylaxis
Because S pneumoniae is the most common cause of severe infections in children with asplenia or hyposplenia, with significant associated mortality, patients younger than five years of age should all receive antibiotic prophylaxis.
Give for 1 year post-splenectomy if > 5 years
Give for 2 years post-splenectomy if < 5 years
lifelong prophylaxis in all cases is ideally recommended
Antibiotic prophylaxis recommendations for children with asplenia or hyposplenia
birth to 3 months
3months to 5 years
>5 years
birth to 3 months: amoxicillin 10mg/kg/dose BID
3 months- 5 years: amoxicillin 10 mg/kg/dose BID
> 5 years- Penicillin V 300 mg per dose BID OR amoxicillin 250 mg per dose BID
*For penicillin anaphylaxis, refer the patient for allergy testing and administer clarithromycin 250 mg by mouth two times per day pending results
what vaccinations are recommended for patients with Asplenia/ hyposplenia
- Prevnar13 & 23-valent polysaccharide vaccine
- Quadrivalent meningococcal vaccine & 4CMenB
- H. Influenzae type b
- Influenza vaccine, annually
- S. typhi vaccine pre-travel
- Household contacts need routine vaccines & annual influenza vaccine
•Caregiver needs to understand that child needs urgent assessment for fever
Management summary for asymptomatic infant of mother with active herpes lesions at delivery
case 1: First episode; born vaginally or by C/section after membrane rupture
Empiric acyclovir recommended
If swabs positive –full workup and treatment
If swabs negative, complete 10 days of IV acyclovir
Management summary for asymptomatic infant of mother with active herpes lesions at delivery
case 2:
First episode; C/section prior to membrane rupture
Empiric acyclovir not recommended
If swabs positive –full workup and treatment
Management summary for asymptomatic infant of mother with active herpes lesions at delivery
case 3: Recurrent episodes
Empiric acyclovir not recommended
If swabs positive –full workup and treatment
what swabs need to be done on a baby with exposure to HSV
mucous membrane swabs should be obtained from the mouth, nasopharynx and conjunctivae at least 24 h after delivery.
what is first episode non primary HSV
Mother has a new infection with one HSV type in the presence of Abs to the other type
what is first episode primary HSV
Mother has no serum Abs at onset of first episode
* highest risk
although 60-80% of women who deliver an HSV-infected child have no history of genital herpes
if HSV swabs are positive on the baby then what investigations should be done
CSF and blood PCR
if positive then treat for 21 days (Disseminated and CNS = 21 days)
if negative then treat for 14 days (SEM = 14 days)
SEM: Skin, eye, mucous membrane (SEM) infection
(ie only the swabs were positive but not blood or CSF)
what is the treatment for neonatal HSV infection
Intravenous acyclovir is the treatment of choice for treating NHSV. The dose is 60 mg/kg/day in three divided doses administered every 8 h, assuming that renal function is normal
what followup is recommended after neonatal HSV infection
structured follow-up program that allows for neurodevelopmental, ophthalmological and hearing assessments.
what infection control precautions are required for a baby with neonatal HSV
contact precautions
until lesions crusted over
Asymptomatic, but mother with active lesions until end of incubation period (14 days) or until 24 hour swabs negative
what precautions should be taken for a mother with herpes labialis and infant < 6 weeks (4)
Use disposable mask until lesions crusted
Avoid kissing baby until lesions crusted and dried
Avoid breastfeeding from breast with lesions until crusted an dried
Skin lesions should be covered in presence of the newborn
what is the current recommended empirical therapy for suspected bacterial meningitis?
Ceftriaxone OR Cefotaxime AND vancomycin
ADD ampicillin to cover Listeria if patients are at risk because they are immunocompromised
what does dexamethasone do when given for suspected meningitis
Reduces mortality and hearing loss in meningitis due to H. influenzae and possibly S. pneumoniae
Should be administered before or within 30 minutes of antibiotics
IfS pneumoniaeor Hib is cultured or identified by molecular testing, steroids should be continued for a total duration of two days.
When should you repeat CSF for E. coli meningitis?
Repeat CSF at 24-48h in E. coli meningitis
what is the duration of antibiotics for the following (meningitis) GBS S. pneumoniae Hib N. meningitidis
GBS = 10-14 days
S. pneumoniae = 10-14 days
Hib = 7-10 days
N. meningitidis = 5-7 days
when should audiology testing be completed for bacterial meningitis?
Audiology assessment before discharge or within 1 month is recommended after bacterial meningitis
The close contacts of any patient diagnosed with meningococcal disease or Hib should be treated with?
rifampin
what is the primary mode of transmission of c difficile
Person-to-person spread by the fecal-oral route is the primary mode of transmission
what are the two toxins from c difficile
toxin A is an enterotoxin
toxin B is a cytotoxin
what is considered mild c diff and what is the treatment
<4 watery stool per day without systemic toxicity
Discontinue precipitating antibiotic; adequate follow-up and reassessment
c. diff: initial episode of moderate or mild, not responding to discontinuation of precipitating antibiotic
≥4 abnormal stools per day
Metronidazole, 30 mg/kg/day in four divided doses by mouth for 10 to 14 days; maximum 2 g/day
C diff: Initial episode, severe
what is the presentation
what is the treatment
Evidence of systemic toxicity (eg, high-grade fevers, rigors)
Vancomycin, 40 mg/kg/day in four divided doses by mouth for 10 to 14 days
C. diff: Initial episode, severe, complicated
Evidence of systemic toxicity and severe colitis, including hypotension, shock, peritonitis, ileus or megacolon
Vancomycin and IV metronidazole
C. diff:
First recurrence
Second recurrence
Repeat regimen used for initial episode or vancomycin 40 mg/kg/day in four divided doses by mouth for 10 days
Vancomycin tapered or pulsed regimen
what are some ways to prevent c diff infection
Hand hygiene – alcohol does not kill C. diff
Identifying and removing environmental sources of C difficile (Wash surfaces with chlorine)
Contact precautions until 48h diarrhea-free
Isolation
Use of private rooms or cohorting
antimicrobial stewardship initiatives in institutions is regarded as a key step in reducing CDI risk
what type of precautions are required for respiratory viruses (ex RSV)
droplet and contact
What precautions are required for airborne
N95 mask
negative pressure room
what requires airborne precautions (4)
Varicella
Measles
TB
smallpox
what type of toys are better in an office setting (soft or hard)
hard toys- easier to clean and should be cleaned weekly
what type of disinfection is required for
Noncritical items** – Items that touch only intact skin (e.g., stethoscopes or blood pressure cuffs, electronic devices such as tablets, computers that are shared between patients)
Intermediate- or low-level disinfection
what type of disinfection is required for
Semicritical items – Items that contact mucous membranes or nonintact skin but do not enter tissue (e.g., laryngoscopes, specula)
Sterilization or high-level disinfection
what type of disinfection is required for
Environmental surfaces – Doorknobs, tabletops, carts, floors
low level disinfection
or detergent and water
what is break through varicella
Breakthrough disease is usually defined by the onset of varicella-like illness occurring ≥42 days after immunization with varicella vaccine.
72% of hospitalized breakthrough varicella cases occurred in immune-compromised individuals
In the setting of AOM with purulent conjunctivitis (otitis-conjunctivitis syndrome) _______________ are common pathogens and, therefore, treatment with a beta-lactamase inhibitor-amoxicillin combination
H influenzae and M catarrhalis
and, therefore, treatment with amox/clav
