Immunization and Infectious Disease volume 4

Question 1

Which of the following individuals is not at high risk of influenza related complications?

a) all children with chronic health conditions needing ongoing medical care
b) chronic conditions on ongoing treatment with ASA
c) pregnant teenagers
d) all immigrant children

Answer 1

d) on the list is all Aboriginal children

the rest are on the list of individuals at high risk of influenza related complications

b) is on the high risk list, because association of Reye’s syndrome with influenza and ASA, but live vaccine shouldn’t be given because of this same risk (need to use inactivated vaccine)

all children aged 6 months and over are encouraged to get influenza vaccine
WHEN routine vaccination is not doable for everyone, should focus on the people at higher risk of complications (this includes children 24-59 months were added to the list (because they have a lot of hospitalizations and are “effective vectors”)

other chronic includes morbid obesity, plus any organ gone broken, plus diabetes
chronic care facilities
those who might transmit to close contacts - REGARDLESS of whether child is immunized babies

Question 2

Which of the following people is able to receive the live attenuated influenza vaccine?

a) 18 month old baby
b) child with mild asthma
c) pregnant teenager
d) 4 year old on chronic ASA treatment
e) 5 year old recently hospitalized for influenza pneumonia who completed tamiflu yesterday
f) 8 year old with an egg allergy

Answer 2

b) is able to receive it - is contraindicated in SEVERE asthma currently needing oral or high dose inhaled glucocorticoids or that has needed to be medically attended within the last 7 days

is contraindicated in immunocompromising conditions

a) shouldn’t receive, only for >2 year old because of increased risk of wheezing 2-4 weeks afterreported, also not studied in t lead to enough immunity)
should wait 48 hours after giving the antiviral to give the LAIV
if antiviral must be given within 2 weeks of receiving LAIV, then should give a second dose 48 hours after the antiviral is stopped
g) LAIV NOT for egg allergy at this time, not evaluated in this population. egg allergy is not a contraindication to TIV (used to be a CPS statement, good 2013 question in PREP explaining)

nasal congestion - should wait till it resolves to give LAIV or give TIV

in adults most common side effect of LAIV is nasal congestion and rhinorrhea

Question 3

Which of the following people needs 2 doses of the influenza vaccine?

a) 8 year old receiving the vaccine for the first time
b) 2 year old who received the vaccine last year
c) 1.5 year old who received one dose of the vaccine last year
d) 17 year old pregnant adolescent

Answer 3

a) need 2 doses for all children

Question 4

Which of the following is false?

a) children

Answer 4

I don’t know what I was doing with this question, I think they are all true

84% previously healthy with no underlying comorbidity; 62% previously healthy in the 6-24 month age group, 23 months

childrent vaccinate this group directly

therefore target and NACI recommendations is to decrease risk by immunizing family members and pregnant women, not get uptake

Question 5

Which of the following has not been shown in research studies?

a) pregnant women have higher rates of hospitalization with influenza than they did when they weren’t pregnant
b) influenza immunization of pregnant women leads to decreased febrile respiratory illness for both them and their newborns
c) influenza vaccine in pregnancy is not cost effective
d) the trivalent inactivated vaccine (TIV) for influenza is safe for pregnant women and unborn child

Answer 5

c) false - it is cost effective, and this study didn’t even look at the benefits for the baby (only the mom)

a) Nova Scotia study - 5x more hospitalization with respiratory illness than the year before when they weren’t pregnant
b) thought to be related to antibody transfer between mom and baby, Bangladesh study, risk reduction 64% and NNT of 17, builds on previous observations that maternal natural infection protects the infant
d) true - is safe, inactivated vaccine, in a study no unexpected adverse events, miscarriage rates unchanged from the vaccine

ways to reduce influenza in

Question 6

Which of the following statements is false?

a) infectious endocarditis (IE) is more likely to result from daily activities than from bacteremia caused by GU/GI or dental procedures
b) prophylaxis prevents an exceedingly small proportion of IE cases in individuals undergoing GU/GI or dental procedures
c) risk of antibiotic adverse effects outweighs the benefits of prophylactic antibiotic therapy except in very high risk situations
d) prophylactic antibiotics for dental procedures are more effective to prevent IE than proper oral health

Answer 6

d)false, in fact, maintaining optimal oral health and hygiene is more important to reduce bacteria and IE, and more important than use of prophylactic antibiotics for dental procedures

overall, since 2007, significant reduction in who needs prophylaxis

the rest of the statements are true

Question 7

What is the risk of mortality from Strep viridans infection of replacement valves?

a) 5%
b) 10%
c) 20%
d) 25%

Answer 7

c) 20% risk from fake valve, 5% from native valve

goal of new recommendations is to target the groups that are highest risk of IE

Question 8

Which of the following groups is not on the new list of people who need IE recommendations?

a) patient with unrepaired acyanotic CHD
b) previous IE
c) prosthetic cardiac valve or prosthetic material used for valve repair
d) cardiac transplant with valvulopathy
e) congenital CHD repaired with prosthetic material within 6 months

Answer 8

a) not cyanotic is not on the list, unprepared cyanotic CHD is on the list, including palliative shunts and conduits
for example, VSD/ASD not on list

who needs prophylaxis:
- unprepared cyanotic heart disease (including with palliative shunts/conduits), repaired congenital heart disease with prosthetic in the first 6 months, previous IE, prosthetic valve or material, congenital heart disease repaired with residual defects, where the incomplete part of the repair inhibits complete healing, cardiac transplant with valvulopathy, rheumatic heart disease with prosthetic used in repair

Question 9

Which of the following patients needs prophylaxis for infective endocarditis?

a) baby with unprepared VSD
b) completely repaired tetralogy of fallout 5 months ago, with prosthetic material
c) teenager with mitral valve prolapse
d) bicuspid aortic valve

Answer 9

b) completely repaired congenital heart disease with prosthetic material within 6 months

the others don’t need:
ASD, VSD, mitral valve prolapse, PDA, previous Kawasaki disease, HOCM, previous coronary heart bypass graft surgery, cardiac pacemakers and defibrillators, bicuspid aortic valves, coarctation of the aorta, calcified aortic stenosis, pulmonary stenosis

prosthetic material - reasonable for 6 months because endothelization takes 6 months (vs prosthetic valve i believe needs prophylaxis lifelong)

Question 10

Which of the following diagnoses is the most common underlying condition that predisposes to infectious endocarditis in the Western world?

a) bicuspid aortic valve
b) cyanotic heart disease
c) mitral valve prolapse
d) rheumatic heart disease

Answer 10

c) mitral valve prolapse predisposes to IE in western world
BUT usually not severe IE and absolute incidence of IE is low - therefore prophylaxis is no longer recommended for this group

rheumatic heart disease - AHA no longer routinely recommends prophylaxis for this group (some centres still do for patients with lots of residual heart disease) - only recommended if prosthetic valves or material are used in valve repair (in certain centres, the Canadian criteria list that if prosthetic material)

Question 11

For patients who require prophylaxis, which of the following dental procedures does require prophylaxis?

a) placement of removable orthodontic appliances
b) placement of orthodontic brackets
c) anaesthetic injections through non infected tissue
d) dental extraction

Answer 11

d) are the precedes that need prophylaxis, the time duration of daily activities is a lot more than for a single dental extraction.
the following are the criteria for prophylaxis: manipulation of gingival tissue, the periapical region of teeth or the perforation of the oral mucosa (ensure that dental extraction falls within this)
losing baby teeth and bleeding from gums or month does not need propylaxis

Question 12

Which of the following is the appropriate 1st line prophylactic antibiotic for a dental procedure?

a) amoxicillin 50 mg/kg x 1 dose 30 -60 minutes before
b) amoxicillin 50 mg/kg x 1 dose 2 days before
c) clindamycin 20 mg/kg x 1 dose 30-60 minutes before
d) cephalexin 50 mg/kg x 1 dose 30-60 minutes before

Answer 12

a) 1st line is amoxicillin 50mg/kg x 1 dose 30-60 min before, adult dose is 2g
unable to take oral med: IV ampicillin 50 mg/kg or cefazolin/ceftriaxone 50 mg/kg
allergy to penicillin/ampicillin: IV cephalexin (1st generation cephalosporin), clindamycin 20 mg/kg or azithromycin/clarithromycin 15 mg/kg
allergy to penicillin/ampicillin and unable to take PO med: IV cefazolin/ceftriaxone or clindamycin

single dose before the procedure
if you forget can give up to 2 hours
if person is showing signs/symptoms of IE, then should take cultures and treat
remember, no cephalosporin in patients who had systemic reaction to penicillin (i.e. angioedema, anaphylaxis, urticaria)

Question 13

Which of the following is the best choice of antibiotic for a child who needs prophylaxis for IE for a dental procedure and has had previous anaphylaxis to penicillin?

a) amoxicillin 50 mg/kg x 1 dose 30 -60 minutes before
b) cefazolin IV 50 mg/kg x 1 dose 30-60 minutes before
c) clindamycin 20 mg/kg x 1 dose 30-60 minutes before
d) cephalexin 50 mg/kg x 1 dose 30-60 minutes before

Answer 13

c) clindamycin (or azithro/claritho)

should avoid cephalosporin in babies who have anaphylaxis to ampicillin

Question 14

Which of the following procedures does not require IE prophylaxis?

a) tonsillectomy
b) adenoidectomy
c) lung biopsy
d) bronchoscopy

Answer 14

d) bronchoscopy does not need prophylaxis
the other procedures are invasive procedures which involve incision and or biopsy of the lung, so they do need prophylaxis for this
if established infection, then need to cover for those organisms as well

Question 15

Which of the following GI/GU situations do not need prophylaxis for IE in at risk patients?

a) elective cystoscopy in a patient with enterococci
b) all procedures
c) high risk patient with established enterococci infection
d) empiric anti-enterococci treatment for patients with non elective urological procedure

Answer 15

b) no longer recommended for all GI/GU procedures (i think only in the special cases below you might consider the antibiotic treatment below)

a) for this high risk patient, should consider antibiotic treatment to eradicate enterococci prior to the procedure
c) for high-risk patients who have an established GI or GU tract infection, or for those who receive antibiotic therapy to prevent wound infection or sepsis associated with a GI or GU tract procedure, the antibiotic regimen should include an agent active against enterococci, such as ampicillin or vancomycin.
d) if non elective procedure, consider adding anti-enterococci treatment to the preoperative regimen

Question 16

Which is the best first line choice for operating on infected skin in a child with risk for infective endocarditis?

a) penicillin
b) vancomycin
c) clindamycin
d) other

Answer 16

a) they say pick a penicillin with anti-staph activity
worry about staph coverage, so best 1st line is penicillin with anti-staph activity (discuss, so like clox??**) or cephalosporin
if allergic to beta lactam, consider vanco or clinda
for MRSA - vancomycin is recommended

Question 17

Which of the following is not one of the top 3 clinical presentations of invasive Group A strep disease?

a) pneumonia
b) necrotizing fascitis
c) bacteremia with no septic focus
d) meningitis

Answer 17

d) is not listed as one of the top 3 most common
invasive GAS disease re-emerged in the 1980s
in Canada 2.7/100000
highest in children and elderly
rate in children

Question 18

Which of the following is false regarding invasive Group A strep in children ?

a) varicella is a significant risk factor
b) when secondary cases happen, they occur usually within 1 week
c) secondary transmission in child care setting is very common
d) a study of household contacts showed that risk of secondarily acquired infection is 20x higher than in the population

Answer 18

c)false, secondary transmission does appear to be rare in settings other than the home

Adults:
group A streptococcal disease among adults include HIV infection, cancer, heart disease, diabetes, lung disease, alcohol abuse, injection drug use and pregnancy-related risk factors.
In children: varicella is a common risk factor
secondary transmission - most happen within 1 week, 20x higher risk
transmission also occurs in hospitals

Question 19

Which of the following is not considered a confirmed case of invasive group A strep infection?

a) asymptomatic patient but growth of GAS (Strep pyogenes) from a normally sterile site
b) growth of GAS from a normally sterile site, hypotension () and renal dysfunction and increased LFTs
d) growth of GAS from a normally sterile site, necrotizing fascitis, gangrene or myositis
e) growth of GAS from a normally sterile site, meningitis

Answer 19

not sure what the deal is with my question making here, but the info I need to know is below
for clinical TSS: need hypotension and 2 of the following: renal dysfunction, liver dysfunction, coagulopathy, ARDS, generalized erythematous rash that may desquamate

invasive group A strep is a reportable disease in provinces, if confirmed, then nationally reportable

Confirmed case:
lab confirmed (aka growth of GAS from a normally sterile site) infection with or without clinical evidence of invasive disease
Clinical evidence of disease:
1. streptococcus TSS which is hypotension (

Question 20

Which of the following is not considered a severe case of invasive group A strep disease that is nationally notifiable ?

a) group A strep pneumonia with GAS grown in the BAL sample only
b) meningitis
c) confirmed case resulting in death
d) necrotizing fascitis
e) streptococcal toxic shock syndrome

Answer 20

a)
if grown from BAL and no other aetiology for the pneumonia, should notify public heath and consider invasive for these purposes, however, BAL is not sterile so is not nationally notifiable

Question 21

A patient is diagnosed with group A strep toxic shock syndrome, which of the following close contacts of a confirmed case needs automatic prophylaxis?

a) a child who played with the child 48 hours after antibiotics were started
b) a child who played with a child with group A strep septic arthritis
c) a child in the same preschool as a child with invasive group A strep
d) a child in a home daycare with a child with invasive group A strep

Answer 21

d)all home daycare needs prophylaxis

c) preschool/institution - only need if more than one case in a month or concurrent varicella outbreak
a) window of time is from 7 days of onset of symptoms to within 24 hours of antibiotics

who needs prophylaxis:
1. close contacts of confirmed case who were exposed in the period from 7 days of onset of symptoms and within 24 hours of starting antibiotics; should administer within 24hours of case diagnosis but can be considered up to 7 days after**
alert for symptoms, some variation between provinces
not routinely recommended for non severe bacteremia or septic arthritis (milder disease)
all home daycare

close contacts:
people who spend at last 4 hour per day of 20 hour per week with the case
sexual contacts, kissing, needle sharing, selected contacts in long term care, hospital and child care

Question 22

Which of the following antibiotic regimens is the best 1st line choice for prophylaxis of Group A strep infection?

a) amoxicillin 50 mg/kg/day for 10 days
b) cephalexin 25-50 mg/kg/day for 10 days
c) erythromycin or clarithromycin
d) clindamycin

Answer 22

b)cephalexin - best choice is 1st generation cephalosporin
penicillin not as good at eradicating GAS colonization; alternative is 2nd or 3rd generation cephalosporins

erythro/clarithro alternative for beta lactam allergies - not for pregnant women, need to watch closely since risk of GAS resistant to macrocodes
clindamycin is another alternative for beta lactam allergy

Question 23

Which of the following is not an appropriate treatment for invasive group A strep infection?

a) IVIG for severe TSS in conjunction with antibiotics and supportive care
b) penicillin and clindamycin with supportive care
c) clindamycin mono therapy with supportive care

Answer 23

c)
clindamycin mono therapy is not a good idea
1-2% of GAS are resistant to clindamycin, to date, no resistance to penicillin
penicillin is the best choice - adding clinda because it inhibits protein synthesis (especially when no evidence of toxin mediated disease), has long post antimicrobial effect, not affected by inoculum size
Intravenous immune globulin may be considered in the treatment of streptococcal TSS or severe toxin-mediated disease in the absence of shock. The mechanism of action of intravenous immune globulin is unclear. Suggested regimens include 150 mg/kg to 400 mg/kg per day for five days or a single dose of 1 g/kg to 2 g/kg
The profile of a particular strain includes the identification of the M protein type and T protein, and anti-opacity factor testing for serum opacity-factor-positive GAS
**more info in an infection control document

Question 24

Which of the following age groups is most at risk of hospitalization from influenza?

a) < 6 months
b) <10 years

Answer 24

a) highest hospitalization rate in infants < 6 months of age, hospitalization rate in children < 2years is higher than in those that are older

high risk of adverse influenza outcomes in children < 5 years old; however don’t need antiviral treatment for mild influenza, no matter what age

Question 25

Which of the following patients should be started on oseltamivir therapy?

a) 6 month old with sickle cell disease and mild influenza
b) previously healthy 2 year old with mild influenza symptoms for past 3 days
c) 3 year old with cystic fibrosis and mild influenza symptoms
d) 6 year old previously healthy with mild disease

Answer 25

c) should be started - age >1 year old with risk factor, should get oseltamivir, if don’t respond then inhaled zanamivir
risk factors: illness progressive or complicated, if there are at high risk for severe disease

a) mild disease and risk factor other than age
48 hours usually not worth it; tamiflu only approved for >1 year old** - this kid is too little to get

Question 26

Which of the following is not a risk factor for severe influenza?

a) <18 year old with chronic ASA therapy
b) hypertension
c) metabolic disease
d) first nations children

Answer 26

b) is an exclusion, other cardiac conditions (including congenital and acquired disease, such as CHF and coronary artery disease ) are a risk factor

the other main risk factors

• asthma and other chronic lung disease
• cancer, renal disease, diabetes, immunosuppression, neurological disease, pregnancy, post partum 2 weeks after, obesity, and the others listed

Question 27

Which of the following is false of treatment for severe influenza?

a) should start treatment with oseltamivir regardless of duration of symptoms
b) if oseltamivir doesn’t help, zanamivir is the second line treatment
c) zanamivir should be administered via ET tube in intubated patients who are severely ill and not improving with oseltamivir
d) premature infants may have slower clearance of oseltamivir due to decreased renal function

Answer 27

c) false - should be IV in severely ill patients (more effective that inhaled)

zanamivir if getting worse despite oseltamivir, or if sick despite prophylaxis
for severe disease should get treatment even if >48 hours of symptoms

**the rest is in the algorithm

Question 28

Which of the following groups has the majority of RSV hospitalizations?

a) preterm babies
b) healthy term babies
c) children with congenital heart disease
d) aboriginal children

Answer 28

b) heathy term babies
* *this is a tricky question, the majority of hospitalizations are in heathy term babies with no pre-existing risk factors BUT there are higher RATES of hospitalizations in children with congenital heart disease, prematurity

rate of hospitalization is 1-3% of all infants in developed world in the first 12 months of life
in Canada: RSV season starts between November and January and lasts 5 months

Question 29

Studies show all but which of the following?

a) palivizumab is effective at reducing hospitalizations in premature children and with congenital heart disease
b) palivizumab is helps reduce ICU admission and death in children who are premature and with congenital heart disease
c) the severity of RSV is equivalent in hospitalized children whether they received palivizumab or placebo
d) conflicting evidence on whether palivizumab is cost effective

Answer 29

b) false - studies did not have enough power to show the impact on ICU admission and death

the rest are true
evidence on cost effectiveness:
- not cost effective in short term, costs 84000 to prevent one hospitalization
- past studies showed that palivizumab costs less than 50000 per QALY (quality adjustment life year) which is the parameter for cost effective, but these studies had limitations (assumed that it prevents mortality,

Question 30

Which of the following is false based on evidence

a) death during RSV hospitalization occurred in less than 1 percent in high risk children
b) reduced hospitalization from RSV does not affect subsequent risk of asthma
c) past studies that showed a cost of 50 000 per QALY for palivizumab included a population representative of all children with RSV
d) past studies on RSV prophylaxis applied only to children in one Northern community over one season

Answer 30

c) false - only included high risk children with multiple high risk conditions

in terms of cost effectiveness - 84000 to prevent one hospitalization, so not cost effective in the short term; an intervention that costs 50000 per QALY should be considered in Canada, however the studies that showed this had faults (see previous question)

Question 31

What percentage of children with Down syndrome experienced hospitalization from RSV in the first 2 years?

a) 14%
b) 11.9%
c) 9.4%
d) 7.6%

Answer 31

c) 7.6% is the risk of hospitalization in Down syndrome

in children with no other risk factors, 9.4% if preterm, and with CHD and Down’s it is 11.9%

Question 32

Which of the following babies does not quality for prophylaxis with palivizumab under the current guidelines?

a) babies with chronic lung disease of prematurity needing ongoing therapy
b) baby with significant VSD who is 20 months old
c) ex 29 weeker who is 7 months old in November
d) 35 weaker from Nunavut who is 5 months old when the RSV season starts

Answer 32

c) criteria for prophylaxis in Canada:

1. CLD less than

Question 33

Which of the following is incorrect about palivizumab prophyaxis in children GA 32 weeks to 35 weeks and 6 days?

a) all children in this age group should get prophylaxis
b) prophylaxis in this group should be based on AAP or Canadian screening criteria
c) there is currently no policy on this in Canada
d) the last dose of prophylaxis should be given at 3 months chronological age

Answer 33

a) false - no, should be based on the screening criteria
(but this is weak recommendation) should have a panel of experts to determine who in this group should get prophylaxis

AAP screening: only applies until 34 weeks 6 days; uses critter of day care attendance and/or living with at least one child less than five years of age (excluding a twin or triplet), in combination with a chronological age of to predict effect on hospitalization.

last dose should be given at 3 months age, designed to balance cost and benefit and protect children at greatest rid of hospitalization

Question 34

Which of the following carries the greatest weight in the Canadian scoring system to determine who needs RSV prophylaxis?
a) birth weight

Answer 34

d)highest weight is birth month november to january

for children

Question 35

Which of the following children exposed to RSV does not receive pavlizumab?

a) child with CF who is 18 months of age on home O2
b) child with Pierre-Robin sequence who is 3 years old and doing well
c) child who is 22 months old with Down syndrome with recent 2 week hospitalization for pneumonia
d) child who is 20 months old with immunodeficiency

Answer 35

b) does not need - older than 24 months, we only consider for children with older siblings, immunocompromised, prolonged hospitalization for severe pulmonary disease

For children with immunodeficiencies, Down syndrome, cystic fibrosis, upper airway obstruction or a chronic pulmonary disease other than chronic lung disease of prematurity: Palivizumab is not routinely recommended. However, it may be considered for children younger than 24 months of age (because they may not yet have encountered their first RSV infection) who are likely to be exposed to RSV and are on home oxygen, have had a prolonged hospitalization for severe pulmonary disease, or are severely immunocompromised (weak recommendation/no evidence).

Remarks. This recommendation should be expanded to include more children with pulmonary disease if evidence becomes available that avoidance or delay of the initial RSV hospitalization impacts long-term pulmonary function
don’t get lifelong immunity, but subsequent infections are likely to be more mild
almost all children have RSV by age 2

Question 36

Which of the following is the main adverse side effect of pavlizumab?

a) vomiting
b) diarrhea
c) seizure
d) anaphylaxis

Answer 36

d) anaphylaxis is the rare but only serious adverse effect recognized
it is expensive 5600$ for 5 doses, administered every 30 days during RSV season
a humanized murine monoclonal immunoglobulin G-1 directed against an epitope on the F glycoprotein of RSV, produced by recombinant DNA technology, and consists of 95% human and 5% murine amino acid sequences. It does not interfere with the response to routine immunizations.

Question 37

Which of the following bugs is not known to survive for a long time on surfaces?

a) MRSA
b) rotavirus
c) respiratory viruses such as RSV
d) Haemophilus influenzae B

Answer 37

d) Haemophilus influenza B - transmitted by droplet, but does not survive long on objects, other bacteria that are similarly fragile nclude Neisseia meningitis and Bordatella pertussis

rotavirus, respiratory viruses known to survive on inanimate objects
C. diff and MRSA has been documented to
influenza, parainfluenza, rhinovirus, adenovirus and SARS coronavirus survive long enough to be picked up on hands of patient or personel therefore these need drop and contact.

there are all droplet precautions for these organisms - masks (help prevent contact with mouth/eyes), eye shields, gloves also reduced infection (suggests that contact is an important form of transmission

Question 38

Which of the following organisms does not need airborne precautions?

a) smallpox
b) Enterovirus
c) varicella
d) measles
e) tuberculosis

Answer 38

b) enterovirus not airborne, the others are not
SARS coronavirus - mainly droplet and contact but some argue that some airborne transmission in certain cases (intubation, bronchoscopy) may be possible

airborne precautions: infectious particles survive in aerosols of small desiccated droplets from the respiratory tract or from skin squames which remain suspended in the air and are dispersed over large distances by air currents.
control needs negative pressure room or with air filters that remove particles before re-circulation
need N95 mask for these

Question 39

Which of the following is not part of droplet precautions?

a) special ventilation
b) surgical or procedure masks for people within 2 meters of the patient
c) masks with face shields
d) transmission by large droplets which are inhaled by or deposited mucous membranes of nearby individuals

Answer 39

a) don’t need special ventilation because the droplets don’t stay suspended in air, they settle on surfaces nearby
face/eye shields shown to reduce RSV infection
organisms that need droplet precautions include:
eg, Haemophilus influenzae type b, Neisseria meningitidis and Bordetella pertussis) are very fragile and do not survive in the environment or on hands.

Other organisms such as RSV, influenza, parainfluenza, rhinovirus, adenovirus and SARS coronavirus survive long enough on surfaces to be picked up on hands of patients or personnel. need droplet and contact for these

Question 40

Which of the following patients with TB is not considered contagious?

a) untreated cavitary pulmonary disease
b) laryngeal disease
c) latent TB infection
d) smear positive sputum
e) disseminated congenital infection

Answer 40

c) latent TB is not (double check this), the other forms are listed as contagious via airborne route in CPS Statement
also extensive lung involvement is listed

Question 41

Which of the following precautions is paired incorrectly?

a) hepatitis A - 7 days after onset contact precautions
b) mumps - 9 days after onset of swelling droplet precautions
c) rubella - 5 days after onset of rash, droplet precautions
d) measles - to 4 days after onset of rash airborne precautions

Answer 41

c) rubella - 7 days after onset of rash

the types of precaution are listed correctly
a) viral hepatitis - until viral infection ruled out, 7 days after onset of illness if hep A

c) duration of illness if immunocompromised

Question 42

How long should a non immune contact during incubation period with each of the following illnesses be kept under precautions (matching question)
a) rubella
b) varicella
c) measles
d) mumps
i) 7 days after first day of exposure to 21 days after last day of exposure
ii) From 10 days after the first day of exposure to 26 days after the last day of exposure
III) From 8 days after the first day of exposure to 21 days after the last day of exposure; to 28 days if given varicella zoster immune globulin
iv) From 5 days after the first day of exposure to 21 days after the last day of exposure

Answer 42

rubella: i) 7 days after first day of exposure to 21 days after last day of exposure
varicella: iii) From 8 days after the first day of exposure to 21 days after the last day of exposure; to 28 days if given varicella zoster immune globulin
measles: iv) From 5 days after the first day of exposure to 21 days after the last day of exposure
mumps: ii) From 10 days after the first day of exposure to 26 days after the last day of exposure

varicella and measles are airborne
mumps and rubella are droplet

Question 43

which of the following precautions period is matched incorrectly

a) pertussis - droplets until 5 days of antibiotics received
b) viral meningitis - droplet after 48 hours of antivirals
c) impetigo - contact until 24 hours of antibiotic received
d) zoster - airborne and contact until crusted over or zoster ruled out

Answer 43

b) false - CONTACT for duration of illness

**most things are duration of illness
most bacterial infection - after 24 hours of antibiotics

others - scabies - until initial therapy applied
zoster is the same as varicella (except that now the CPS statement doesn’t say the crusted over thing anymore so a bit confusing)

skin infection - contact until drainage done or lesions healed
see more detailed list for others

Question 44

How long should a well ventilated room (at 6 air exchanges per hour) be left vacant after a patient with TB (any patient) or non immune patient for measles or varicella has entered in order to air it out?

a) 50 minutes
b) 60 minutes
c) 70 minutes
d) 80 minutes

Answer 44

c) 70 minutes ventilation - 6 air exchanges per hour
other things to know infected children - directly into exam room, same with immunocompromised
plush toys are harder to clean, and more infected than plastic - even if cloth/plush toys ran through washing machine still contaminated, bleach helps
separate infection times for well visits and infected children
don’t need gloves for vaccines , antiseptic - 70% alcohol
avoid multi dose medication vials if possible - need to be very careful to maintain sterility if using them
h

Question 45

Which of the following employees should be restricted from the office?

a) influenza
b) gastroenteritis
c) conjunctivitis
d) herpetic whitlow
e) zoster

Answer 45

a) influenzae should be restricted from the office until symptoms resolve

No direct patient care for the others listed: gastro, conjunctivitis, herpetic whitlow, zoster, hep A, herpes simplex (for newborns and immunocompromised if lesions not covered), scabies, staph, group A strep (until 24 hour Abx)
(zoster no direct patient care if not covered, if covered, from immunocompromised people including pregnant women)
No office for: measles, mumps, rubella, pertussis, varicella , active pulmonary TB

**note super long statement, should look at original lists when studying (infection control in paediatric office)

Question 46

Which of the following is not a likely consequence of harmonized immunization schedule across Canada?

a) bulk purchases leading to better rates
b) less missed vaccines for children who move to a province with a different immunization schedule
c) education for both health care providers and patients focused on only one schedule
d) prevent individual provinces from enhancing their immunization schedule with new vaccines

Answer 46

d) would not cause this, they could still start vaccines that are not individually recommended by NACI

offers equal access to immunization for all children
other countries including britain, australia and US have a harmonized schedule across the country
ational Advisory Committee on Immunization (NACI) regularly and systematically reviews the evidence for effectiveness and safety for new and old vaccines, and sets a ‘minimum’ recommended schedule [, but provinces don’t always implement everything at the same time
one of the arguments is that health is a provincial responsibility, however the current act doesn’t talk about all health, only hospitals, so this wouldn’t change that

Question 47

How many neonates are asymptomatic carriers of C. difficult?

a) 15-63%
b) 3-33%
c) up to 8.3%
d) <2%

Answer 47

a) 15-63% of neonates are asymptomatic carriers

infants and children are much more likely to be asymptomatic carriers of C diff than adults
3-33% for <2 years old
up to 8.3% for children older than 2 years
spread by fecal oral route - in hospitals, from touching surfaces with C. diff
spore forming bacteria
Infants and young children rarely develop symptoms, possibly because of immature surface receptors for these microbes, and because they are protected by maternal antibodies acquired transplacentally or in breast milk.[5]

Question 48

Which is the estimated incubation period for C. diff?

a) 24 hours
b) 2-3 days
c) 5 days
d) 7 days

Answer 48

b) estimated incubation estimated to be 2-3 days from exposure to onset
most adults have history of exposure to antibiotics or anti neoplastic agents
almost all antibiotics have been associated with C. diff (I believe clinda is the classic example)
2 toxins of C. diffToxin A can disrupt neuronal function and cause the aberrant release of calcium.[1][2][5] Toxin B exerts its effect on leukocytes by altering the chemotaxis of neutrophils, the activation of macrophages and mast cells, and the induction of inflammatory mediator release.[1][2][5] The end result of toxin activity in the intestine is fluid secretion, mucosal damage and interstitial inflammation.[1][2][5]

Question 49

Which of the following is not associated with increased risk of C difficile infection in children?

a) exposure to multiple antibiotic classes
b) chemotherapy
c) younger age
d) duration of hospital stay
e) immunosuppression
f) tube feeding

Answer 49

c) false, intact older age is an increased risk factor for paediatric CDI

the other factors are associated with increased risk

a) almost all abx have been associated with C diff, including those for surgical prophylaxis. decisions to use certain antibiotics (risk benefit) should be based on presence of resistant strains to the particular antibiotic
b) chemotherapy: antimicrobial properties of chemotherapeutic agents, the effects of immunosuppression and neutropenia, and changes in the gut mucosa. other imunosuppression - include IBD, common co-morbid diagnosis
e) HIV - 4fold increase in newly infected, hypogammaglobulinemia
f) manipulation of the GI tract (including tube feeding), GI surgery

PPIs - some studies suggest increased risk, others say it is because often patients with other risk factors are on PPIs, one study showed H2 blockers lead to less colonization by C. diff

Question 50

Which of the following is false about the NAP1 strain of C difficile?

a) related to severe disease in adults
b) widely distributed worldwide, including in Canada
c) relationship between age and disease severity in children with this strain is unknown
d) susceptible to fluoroquinolones

Answer 50

d) false - in fact resistant to fluoroquinolones

new strain
variation in toxin genes
outbreaks and severe disease in adults
relationship between age and disease severity with this strain is unknown
recent reports have contraindicated the belief that C. diff is less bad in young babies/children - perhaps this is due to this new strain that is emerging (but not proven)

Question 51

Which of the following is the most common manifestation of C. difficile in children?

a) watery diarrhea
b) bloody diarrhea
c) psedomembranous colitis
d) toxic megacolon

Answer 51

a) watery diarrhea is the most common manifestation of C. diff in children
case definition is watery diarrhea and either a stool test that is positive for C. diff OR a colonoscopy that shows pseudomembranous colitis
Because the toxins produced by C difficile can cause intestinal cell water secretion, watery diarrhea may result. However, because the organism is found so frequently in asymptomatic children, it is difficult to prove that C difficile is the cause of this syndrome, which is often mild.
severe disease - includes fever/rigors/systemic toxicity, can include ileum, toxic megacolon(most severe manifestation), peritonitis
C difficile-associated colitis should be considered in any patient who is receiving or who has received antibiotics within the previous 12 weeks, and who has the following signs: bloody diarrhea with or without systemic toxicity, fever and abdominal pain.
C difficile-associated diarrhea should be considered in immunocompromised patients who are receiving or have received antibiotics or chemotherapy within the previous 12 weeks, and who have any diarrheal illness (either watery or bloody).
in previusly heathy chilren, diarrhea unlikely to be from C. diff, should not routinely test

Question 52

Which of the following children is not at increased risk of complications from C. diff infection?

a) Hirschprung disease
b) IBD
c) asthmatics
d) neutropenic cancer patients and those after stem cell transplant

Answer 52

c) asthmatics not on the list, the others are

in general severe/fatal disease are rare in children

Question 53

Which of the following is accurate of how C. diff laboratory testing?

a) bacterial culture is the gold standard for diagnosis
b) run the sample on all stool provided
c) sensitivity is low
d) Enzyme Immunoasssay for glutamate dehydrogenase, toxin A and B and cell cytotoxic assay are commonly used, with C. diff PCR being used increasingly frequently

Answer 53

d) true - bacterial culture is too slow with turnaround time
EIA toxin testing main method until recently but is not that sensitive, and cytotoxin assays are expensive and need lots of work. One strategy is 2 steps with a) EIA for GDH then the toxin EIA or (preferably) a cell cytotoxin assay to confirm diagnosis. PCR is promising/used more and more, rapid, sensitive and specific.

a) false - not practical for C. diff testing, because of slow turnaround time

b) false - should only run if diarrhea stool, or if ileus from C. diff is suspected
children can be asymptomatic hosts of toxin producing strains
c) false - sensitivity is 95% (if negative can rule it out) but specificity is poor (since lots of kids are asymptomatic carriers of C. diff)

Question 54

A 4 year old previously heathy girl presents with 3 episodes daily of watery diarrhea after receiving clindamycin for a GAS infection. She is otherwise well. Her stool is positive for C. diff. What is your next step in management plan?

a) treat with metronidazole PO 30 mg/kg/day in 4 divided doses for 10-14 days
b) treat with vancomycin PO 40 mg/kg/day in 4 divided doses for 10-14 days
c) d/c antibiotics and follow closely
d) treat with vancomycin IV 40 mg/kg/day in 4 divided doses for 10-14 days

Answer 54

c) d/c antibiotics and follow closely, this is describing a mild infection. because so many children are colonized with C. diff difficult to conclusively attribute C. diff as the cause. Even if decide to treat as C. diff, should recognize that there may be another pathogen associated.
in all cases of antibiotic associated diarrhea, the offending agent should be discontinued. if can’t stop the antibiotic, pick one that is less associated with C. diff

the others:
moderate infection or mild infection not improving after stopping antibiotics: metronidazole x 10-14 days
initial severe infection - vancomycin PO 40 mg/kg/day x 10-14 days
mild - watery or bloody

Question 55

A 4 year old with IBD presents with constant watery diarrhea, high fever, chills, and hypotension. Her stool is positive for C. diff. What is your antibiotic choice as part of the management plan?

a) vancomycin IV 40 mg/kg/day in 4 divided doses for 10-14 days PLUS metronidazole IV 30 mg/kg/day in 4 divided doses for 10-14 days
b) vancomycin PO/NG 40 mg/kg/day in 4 divided doses for 10-14 days PLUS metronidazole IV 30 mg/kg/day in 4 divided doses for 10-14 days
c) vancomycin IV 40 mg/kg/day in 4 divided doses for 10-14 days PLUS metronidazole IV 30 mg/kg/day in 4 divided doses for 10-14 days
d) vancomycin PO/NG 40 mg/kg/day in 4 divided doses for 10-14 days

Answer 55

b) is the answer for complicated C. diff infection
(means diarrhea, C. diff, systemic toxicity (severe) PLUS evidence of severe colitis (such as for complicated hypotension, ileus, toxic megacolon, peritonitis/shock)
for complete ileum, consider rectal vancomycin in addition)
vancomycin PO/NG 40 mg/kg/day in 4 divided doses for 10-14 days PLUS metronidazole IV 30 mg/kg/day in 4 divided doses for 10-14 days (vanco is PO, flagyl is IV)

vanco on its own is for severe infection but has to be PO - has no effect on C diff when given IV

**for first recurrence - same regimen as used originally (does not imply resistance) for second or more recurrence, pulsed vanco treatment

Question 56

Which of the following methods of C. diff prevention is not accurate?

a) wash hands with alcohol based solutions
b) contact precautions until 48 hours with no diarrhea
c) remove environmental sources of C. diff and clean with sporicidal agents
d) use private rooms or cohorting
e) antimicrobial stewardship

Answer 56

a) alcohol doesn’t kill C. diff

the rest are true
no value to retesting the stool - should base the precautions on clinical symptoms since stool can stay positive for C. diff long after the symptoms have abated

antimicrobial stewardship - key step to reduce CDI risk
upcoming studies- probiotics MAY be beneficial in prevention, no evidence for treatment of C. diff, but may help with relapses

Question 57

Which of the following statements regarding probiotics and C. diff is false?

a) may be beneficial in prevention
b) can be used for treatment of C. diff
c) may help with relapses of C. diff
d) S. boulardii has been associated with fungemia in immunocompromised patients and patients with central venous lines

Answer 57

b) no evidence that it can be used for treatment for C. diff

the rest are true
S. boulardii is a probiotic
other upcoming options for recurrent disease:
- rifaximin

Other agents to treat C. diff which are upcoming: teicoplanin, which is likely to be as effective as vancomycin,[67] bacitracin and fusidic acid.
fidaxomicin - may be better for NAP1 (some adult studies) but still experimental

Question 58

how to remember the live vaccines?
BCG
OPV
Yellow fever
S
Live
O
Varicella
E
Typhoid
H
E
C
R
Intranasal influenza
Measles/Mumps
Epidemic Typhus

Answer 58

there are the live vaccines

Question 59

Who should not get zanamivir?

Answer 59

patients with asthma or COPD - can cause bronchospasm
anamivir is a dry powder, not an aerosol, and should not be administered using nebulizers, ventilators or other devices typically used for administering medications in aerosolized solutions.