Immunization and Infectious Disease volume 5

Question 1

Which of the following is the most common indication for home IV therapy?

a) cystic fibrosis
b) endocarditis
c) bone and soft tissue infections
d) pneumonia

Answer 1

c) bone and soft tissue
infections are by far the most common indication (95% in one study). bone and soft tissue are the most common of these that qualify for home IV.
may consider for pneumonia if oral not an option and patient doesn’t need other supportive care
CF - many have shown that home iv is beneficial but a few have shown that hospital is better
endocarditis, meningitis, sepsis - may consider home Iv after period of hospitalization
other indications: neonates can be considered if expertise in their iv access is available, TPN including for children in long term care
clotting factors for hemophilia, chemotherapy, therapy for immunodeficiencies, medications for palliative care and anti-­inflammatory mediators

Question 2

Which of the following is the most common complication of home IV therapy?

a) mechanical factors
b) infection
c) adverse reactions to antibiotics
d) metabolic changes and hepatic complications related to TPN

Answer 2

a) mechanical factors
home iv therapy - cost saving, therefore should make sure that it is not being used inappropriately only to achieve this
mechanical factors: IV insertion (eg, correct catheter tip placement or vessel puncture) or later (eg, thrombosis, dislodgement, occlusion or leakage). infection less common
one study: mechanical factors 0.83/1000 catheter days, infections 0.29 and 0.19 (catheter and bloodstream), thrombotic catheter occlusion - 0.23/1000
patients with TPN at home had longer catheter survival and less infection in this study
metabolic and hepatic happen at home and in the hospital with TPN
adverse reactions to antibiotics usually mild

Question 3

Which of the following is false?

a) aminoglycosides and vancomycin must be delivered by special infusion pumps
b) home IV programs should provide 24/h per day support team
c) drugs which are prepared by the pharmacy as unit doses should be stable in the fridge for one week
d) for use with a programmable pump, diluted drug should be stable at room temperature for 1 week

Answer 3

d) false - in fact, for programmable pump, diluted drug should be stable at room temperature for 24 hours
a) true - need a controlled rate of delivery, for all drugs should consider first efficacy and safety (for all drugs) then also need to consider pharmacodynamics and kinetics. for more than one drug, consider drug compatibilities.
b) true - should have 24 hour support, should have a multi-D team available

questions to ask - include risk of clotting, is the patient stable, is the treatment provided at home going to be the same as in hospital
are the patient and hospital equipped for home IV care (distance, money (not always covered) availability of support services, social circumstance, co-existing factors, i.e. drugs), can they learn how to do it

Question 4

Which type of IV access has the lowest infection risk?

a) broviac
b) implanted port
c) PIC catheter
d) peripheral IV

Answer 4

b) implanted port has the lowest infection risk
vascular system is not exposed until the catheter is accessed (according to the chart, I think phlebitis is the main risk with PIV)
useful for intermittent treatment at intervals of days to weeks
port - not good for continuous or daily access - skin breakdown over device, good for intermittent use, minimal effect on patient activities, need GA for insertion

Question 5

Which of the following IV access methods has the longest duration?

a) peripheral IV
b) PIC catheter
c) broviac
d) midline catheter

Answer 5

c) tunnelled access (broviac and hickman) lasts months-years
peripheral IV 1-2 weeks
midline - 2-4 weeks (different from PIC)
PICC - weeks to months
broviac (tunnelled) or port - last months-years
peripheral IV t extravasate and that not likely to get phlebitis;
**more than 2 weeks need CVC

Question 6

Which of the following lines is the best option for blood draws?

a) PICC line
b) peripheral IV
c) tunnelled line (i.e. broviac or hickman)

Answer 6

c) tunnelled access - best for drawing blood

other things to know:
peripheral IV: easy to insert but easy to dislodge, phlebitis common, medication extravasation can lead to tissue breakdown, blockage is common
midline catheter: not commonly used in children
PIC catheter: insertion less invasive than other catheters (usually don’t need GA), not as good to draw blood and may be contraindicated, often dislodged, may need to run something through it constantly
broviac: more stable than PIC, multiple lumens, may need GA for insertion, need weekly heparin and ongoing site and dressing care
home IV for more than 2 weeks of IV therapy

Question 7

Which part of the management plan is not optimal for children receiving home IV therapy?

a) gravity infusion
b) monitoring should include monitoring for complications of the vascular access device
c) see a physician once weekly
d) portable electronic pumps

Answer 7

a) gravity infusion - not a good idea for children, not a consistent rate so can get a quick bolus if too quick or clotting if too slow
portable electronic pumps are the easiest, the caregiver can switch the cassette daily
weekly evaluation - usually if near home IV centre, get evaluated their, if not close then their physician should talk to the IV team weekly
look at the illness and treatment, see if they can switch to oral, look for IV site and functioning of the VAD, compliance, monitoring for drug adverse effects

Question 8

Which of the following statements is false?

a) home IV programs are not all completely funded by the government
b) Home IV therapy for children is cost effective
c) Home IV therapy for children provides improved quality of life and greater satisfaction to patients and families
d) Home IV therapy for children and youth with infections, those needing long-term PN is not as effective and as safe as IV therapy in hospital

Answer 8

d) false - Home IV therapy for children and youth with infections, those needing long-term PN, and for selected other conditions IS at least as effective and as safe as IV therapy in hospital

the rest of the statements are true

we should work to make home IV more available for parents, more covered, have respite programs for people who need 24 hour infusion (since parents are often doing it). consider for those who need more than 2 weeks of therapy

Question 9

Which of the following serogroups of meningococcus is responsible for most infections with meningococcus?

a) A
b) B
c) C
d) Y
e) W

Answer 9

b) serogroup B is responsible for >50% of cases between 2002-2011, most in preschool age children

Question 10

Which age group is most likely to get infected with serogroup B meningococcus?

a) neonates
b) preschool age children
c) elementary school children
d) adolescents

Answer 10

b) preschool age children is most affected by serogroup B
all provinces have immunization again serogroup C
4CMenB is the new vaccine against serogroup B

Question 11

Which of the following statements is false?

a) 4CMenB, the new vaccine against serogroup B meningitis has very tentative estimates of effectiveness
b) most menB disease in children in the first year of life happens in

Answer 11

d) fever is the only major adverse effect that occurs after this vaccine, usually within 24 hours, however, for 2 month olds may need septic work up and and we can’t say safely that it is due to the immunization in this age group without further work up.

a) true - data is still being determined, degree of effectiveness and how long the protection lasts is being determined
b) true - this is why many not get enough doses to confer protection (although herd immunity may help)
c) true - likely will need boosters

Question 12

What is the number needed to prevent one case with vaccination with 4CmenB (with administering 2,4,6 months)

a) 14000
b) 38000
c) 141000
d) 500000

Answer 12

c) 141000 three doses administered at two, four and six months of age are required for protection, infants younger than six months of age will remain unprotected; therefore, this number increases to more than 141,000 to prevent one case (and 10-20xmore to prevent one death)
The number needed to vaccinate will be lower than these estimates if the vaccine yields a herd effect or covers some non-B strains, or if there are a significant number of culture-negative cases not detected by surveillance.[7] The number will be higher if there is emergence of clones that are not well matched with vaccine strains.[16]

Question 13

Which of the following is not in the high risk group who should be offered 4CMenB vaccination?

a) asplenia
b) more than one episode of invasive meningococcal disease
c) congenital complement, properdin, factor D or primary antibody deficiencies
d) patients taking the complement inhibitor eculizumab
e) HIV patients
f) laboratory personnel who work with serogroup B meningitis
g) patient on eculizimab

Answer 13

e) UNCLEAR whether need to offer to HIV and military, the other groups mentioned are high risk and should be offered the vaccine when available
NACI recommendation (2014) is to give to :
1. high risk
2. close contact of IMD
3. for outbreaks (not part of the schedule yet)
- as the lack of evidence and the range of uncertainty of the underlying assumptions, particularly those concerning the predicted level of strain susceptibility, duration of protection, impact on meningococcal carriage and herd immunity, and potential adverse effects of vaccination at the population level

Question 14

Which of the following substances specifically eliminate infectious pathogenic bacteria?

a) biocides
b) sterilants
c) disinfectant
d) sanitizer

Answer 14

c) disinfectant
(need to remember that biocides, sterilants will also kill bacteria, just more broadly)

Biocides are generally synthetic or semisynthetic molecules that, above certain concentrations and under defined conditions, will kill living cells within specified time intervals. biocides include sterilants, disinfectants and fungicides.

sterilants - destroy all bacterial life
disinfectant - eliminate infectious pathogenic bacteria
sanitizer - reduce microbial contaminants
fungicides destroy fungi on inanimate surfaces that are
pathogenic to humans and animals.

also have mechanical devices that are used to control microorganisms, impregnated devices (i.e. clothes, chopsticks, etc)

Question 15

Which of the following is not well combated by alcohol based hand rubs?

a) bacterial spores
b) rhinovirus
c) adenovirus
d) rotavirus

Answer 15

a) not great for bacterial spores, some non lipophylic (non enveloped) viruses, protozoan oocytes

alcohol based hand rubs - should have concentration of 60-95% alcohol most effective, do have some activity against some non enveloped viruses (rotavirus, adenovirus, rhinovirus, hepatitis A and poliovirus)
**may not be effective against hepA and other non lipophilic viruses depending on the concentration

Question 16

Which of the following is not well combated by chlorhexidine?

a) Gram positive bacteria
b) Mycobacterium tuberculosis
c) Gram negative bacteria
d) Herpes simplex virus

Answer 16

b) mycobacterium TB - only minimal effect; also NOT sporicidal ; less activity against non enveloped viruses (rota, adeno, enter)

chlorhexidine more persistent effect on skin than alcohol
acts by disrupting cytoplasmic membrane
**good for G+, less good for G-, only minimal for mycobacterium TB
enveloped viruses such as HSV, HIV, CMV, influenza and RSV - has in vitro activity; less activity against non enveloped viruses (rota, adeno, entero)
chlorhexidine is found in hand hygiene preparations and antiseptic detergent preparations.

Question 17

Which of the following is not well covered by triclosan, which is found in many soaps and other consumer products?

a) Gram positive bacteria
b) Gram negative bacteria
c) Mycobacteria
d) filamentous fungi
e) Candida

Answer 17

d) filamentous fungi - limited activity
better for gram positive than gram negative
some activity against mycobacteria and candida
like chlorhexidine, effect on skin is more persistent than alcohol

ammonia compounds are another type of compound - mainly bacteristatic and fungastatic , are microbicidal at high concentrations. most common example is benzalkonium chlorides
active against lipophilic (aka enveloped) viruses (such as RSV, etc, see list above)

dilute bleech - should be used to clean up bodily fluids
kleenex with antiviral - no proof that works, thought that hand washing might be better

Question 18

Which of the following is the best agent to use to clean up spills of bodily fluids?

a) diluted bleach
b) alcohol
c) soap and water
d) other

Answer 18

a) diluted bleach is the best for bodily fluid spills

alcohol based hand washes - good for when soap and water not available
antibacterial dishwashing - not proven whether they work in real world settings
overall CPS says soap and water hand washing is generally the best for the home

Question 19

Which of the following is false?

a) there is not definitive evidence that biocides contribute to antimicrobial resistance
b) it is possible that excessive antimicrobial use may predispose children to allergies and asthma
c) cutting boards that are impregnated with antimicrobial agents are recommended in the kitchen
d) toys which are frequently placed in a childs mouth should be cleaned with detergent and water, rinsed before giving to another child
e) carpets in infant areas should be cleaned every month

Answer 19

c) false - cutting boards and counters with antimicrobial agents are not recommended for the kitchen, if you get chicken etc on a surface that cannot go to the sink, should use a reliable commercial kitchen disinfectant
a) true no definitive evidence, but some possibility of cross resistance with common antibiotics, therefore needs further study

for viral infections 15-20second hand wash or alcohol based scrub should do
disinfection of surfaces should be done with household bleach based cleaners
carpet - infant areas, every month, every 3 months in other areas and when soiled
alcohol, bleach or peroxidase-based agents are preferred because they dissipate readily and are less likely to exert prolonged antimicrobial pressure. Agents such as triclosan, chlorhexidine and quaternary ammonium compounds exert more prolonged antimicrobial pressure.

Question 20

Which of the following groups does not have poor sensitivity of for the TST test?

a) very young children
b) previous BCG vaccine
c) infants younger than 3 months
d) immunocompromised people
e) active or disseminated TB infection

Answer 20

b) previous BCG vaccine leads to poor specificity (i.e. false positives) , other things with poor specificity include previous BCG vaccine, or infection with non environmental tuberculosis, further hampered by poor standardization, inter- and intra-observer variability, and the need for a return visit for interpretation.
the other groups with poor sensitivity (i.e. lots of false negatives)
very young, infants

Question 21

Which of the following is not a common cause of false positive Tuberculin skin tests?

a) infants <3months
b) previous BCG vaccine
c) environmental non tuberculosis mycobacteria

Answer 21

a) false - infants t rule this out (opposite)

It can be influenced by many factors such as malnutrition, concurrent viral and parasitic infections, and concurrent medical conditions and diseases

causes of poor specificity (False positive) is previous BCG vaccine and envionrmental non TB mycobacteria

further hampered by poor standardization, inter- and intra-observer variability, and the need for a return visit for interpretation.

Question 22

Which of the following patients is not target for a TB screening skin test?

a) children with suspected active TB
b) children with risk factors of progression to disease from infection
c) children travelling or residing for >3 months in areas with a high incidence of TB
d) contacts of patients with latent TB
e) children who arrive in Canada from countries with high TB incidence within the last 2 years

Answer 22

d) false - it is for contacts of patients with active TB

the rest are indications
for those travelling to areas - those with contacts with local population

**a bit confused about the active TB indication, I thought we did gastric aspirates for those (discuss) maybe we do TST first

Question 23

Which of the following is true of interferon gamma release assay?

a) works well in young children
b) more specific in low prevalence settings such as Canada
c) more subjective to interpretation
d) need multiple visits

Answer 23

b) true - the antigens are present in M tuberculosis, not in BCG, or in several environmental NTM strains, overall more specific (less false positives) correlate better with gradients of exposure to infectious source cases than the TST when used in low prevalence settings

the rest are false
a) don’t use in kids less than 5 , AAP says not to use in this age group, lack of published data about utility with these groups; T spot is listed as for >10 year old
c) false - less subjective to interpretation
d) false - can do in single visit and rapid turn around time
interferon gamma release assay - measure the in vitro production of interferon gamma by sensitized lymphocytes
2009 American Academy of Pediatrics Red Book IGRAs cannot be recommended routinely for use in children younger than 5 years of age or for immunocompromised children of any age because of a lack of published data about their utility with these groups

Question 24

There is a school outbreak at a elementary school in Toronto of TB. Which of the following is not a correct method and timing of testing for close contacts ?

a) TB skin test 8-12 weeks after most recent exposure contact
b) TB skin test 8-12 weeks after initial contact
c) TB skin test and IGRA 8-12 weeks after most recent exposure
d) IGRA only 8-12 weeks after most recent exposure

Answer 24

b) for high risk contacts, should do TST +/- iGRA 8-12 weeks after MOST recent exposures. NOT after initial contact
also

if both TST and IGRA are used, then blood should be drawn for IGRA on or before the day when the TST is read

agreement between IGRA and TST is between 65-95%
IGRA may not be as good at diagnosis of TB in young children or immunocompromised children

IGRAs should be used as a supplementary diagnostic aid, to help support the diagnosis of active TB. should NOT be used in isolation to confirm active disease. should try to get microbiological confirmation. negative IGRA doesn’t rule OUT active TB (especially in young children but not in anyone)

may be useful in low prevalence setting , such as school outbreak, where there are false positive TST from BCG or non tuberculosis mycobacterium

Question 25

A healthy, non immigrant 14 year old has a positive TB skin test (done for volunteer requirements) . The IGRA is negative. Which is the appropriate course of action?

a) start the patient on isoniazid treatment
b) confirm that the patient doesn’t have TB and let them go volunteer
c) discuss the case with ID specialists

Answer 25

c) any decision not to offer chemoprophylaxis based on a negative IGRA should be discussed with and ID specialist

if the IGRA is positive, should consider for treatment of latent TB

never use IGRA alone to diagnose TB

Question 26

Which of the following groups should not be routinely screened for TB?

a) all immigrant children
b) teenager who recently travelled to China who has HIV infection
c) 12 year old with chronic renal failure on hemodialysis who is returning from a trip to India

Answer 26

should not routinely screen all immigrant children, but is recommended for foreign born travellers and children that have risk factors for reactivation of TB

Immigrant children who should be targeted for LTBI screening include those younger than 15 years of age who have lived in a country with high TB incidence and have immigrated within the past two years, and children with risk factors for progression to disease, as outlined in Table 3.

is this just for immigrants?

Question 27

Which of the following patients is not high risk for development of active TB?

a) silicosis
b) transplantations (related to immunosuppressive therapy)
c) recent TB infection (past two years)
d) treatment with glucocoricoids

Answer 27

d) treatment with glucocorticoids is considered increased risk not high risk

high risk: AIDS/HIV/silicosis, transplantation, chronic renal failure on hemodialysis, recent TB infection (past 2 years), carcinoma of the head and neck, abnormal chest X ray - fibronodular disease (higher risk than granuloma which is considered increased risk not high risk)

Question 28

Which of the following is not considered increased risk for development of active TB?

a) TNF alpha inhibitors
b) diabetes mellitus
c) overweight
d) cigarette smoking

Answer 28

c) in fact underweight is considered increased risk (BMI<20 kg/m2)

other which are increased risk: glucocorticoid treatment, TNFalpha inhibitors, diabetes, young age (0-4 years ) when infected, cigarette smoking, abnormal CXR (granuloma)

Question 29

What is the risk of vertical transmission of syphillis in a mother with latent syphillis?

a) 70%
b) 40%
c) 20%
d) 100%

Answer 29

b) risk of transmission with early latent syphillis is 40% - since risk of reactivation

untreated primary or secondary syphillis - 70-100%
late latent syphilis - <10%
staging of maternal syphillis is complex - not discussed in the statement

Question 30

At which point in pregnancy are most infants with congenital syphillis infected?

a) 1st trimester
b) at delivery
c) after 4th month of gestation
d) 3rd trimester

Answer 30

c) most are infected in utero after 4th month of gestation
infection can occur as early as 9 weeks or by contact with active lesion at delivery

should have routine maternal syphillis testing at first prenatal visit, followed by counselling and therapy if needed for Reactive test

Question 31

Which of the following regarding syphillis screening is false?

a) high risk women should be rescreened at 28-32 weeks and at delivery
b) if a cause is not known for a hydropic or stillborn baby, the mother should be screened for syphillis post partum
c) a healthy newborn born to a mother who did not get screening in pregnancy needs routine care and discharge
d) all of the above statements are true

Answer 31

c) false - if they didn’t get screened during pregnancy, the maternal serology must be drawn and follow up arranged prior to discharge

the rest are true

high risk includes women from areas with lots of syphillis and in areas having outbreaks of syphillis

incidence of syphillis increasing - 10x between 1997 and 2000, congenital from 2-10 nationally, likely lots of cases that went unrecognized (asymptomatic or not considered on ddx)

Question 32

Name 4 causes of false positive syphillis tests in Canada

Answer 32

1. collagen vascular disease
2. pregnancy
3. IV drug use
4. lyme disease

false positive ( in the table) is positive RPR but negative treponemal tests

Question 33

Which of the following patients does not have syphillis?

a) RPR reactive, TP-PA non reactive, FTA-ABS non reactive
b) RPR non reactive, TP-PA non reactive, FTA-ABS reactive
c) RPR reactive, TP-PA reactive, FTA-ABS reactive
d) RPR non reactive, TP-PA reactive, FTA-ABS reactive

Answer 33

a) false positive result

how the tests work: 2 types
non treponemal (includes the rapid plasma reagin RPR) and the VDRL (used in Canada for CSF) 
treponemal test - looks for treponemal specific antibodies including fluorescent treponemal antibody absorption, Treponema pall­idum particle agglutination, microhemagglutination for T pall­idum, enzyme immunoassay (EIA) and line-blot immunoassay, such as INNO-LIA (Innogenetics, Belgium), with interpreta­tion as shown in Tables 1 and 2.

the others

b) Primary syphilis with compatible history/clinical findings
c) all reactive- means syphillis any stage OR old treated syphillis OR in persons from endemic countries, yaws (eg, Caribbean), pinta (eg, Central America) or bejel OR Lyme disease
d) RPR NR, treponemal are reactive : Usually treated syphilis OR early infection (early primary syphilis) OR late latent/tertiary syphilis OR in persons from endemic countries, yaws (eg, Caribbean), pinta (eg, Central America) or bejel OR Lyme disease

Question 34

What is the name of the organism that causes syphillis?

Answer 34

treponema pallidum

Question 35

Which of the following tests which is used as an initial screen has the highest sensitivity and specificity?

a) rapid plasma reagen (RPR)
b) syphillis enzyme immunoassay (EIA)
c) venereal disease laboratory (VDRL)
d) syphillis INNO-LIA

Answer 35

b) syphillis EIA - which is a treponemal test

most provinces use RPR for initial screen
**some have started using syphillis EIA because it is more sensitive and specific
however even if EIA is positive need to do the RPR because need it for staging of disease and to follow the disease
confirmed treponemal tests are fairly specific for syphillis, but can occur with other treponemal diseases (see list above for case positive causes) †Serology is typically repeated two to four weeks after the initial test to observe the rise in the rapid plasma reagin (RPR) tire to detect enzyme immunoassay (EIA)/confirmatory test conversion

Question 36

True or false : treponemal tests remain reactive for life

Answer 36

true
the RPR
The treponemal test usually remains reactive for life unless treatment was administered very early in the infection; there­fore, a decrease in the RPR(NON treponemal test) titre must be monitored.

The expected RPR titre decline with adequate therapy is a four­fold drop (eg, from 1:32 dilutions to 1:8 dilutions) at six months, an eightfold drop at 12 months and a 16-fold drop at 24 months with primary syphilis; an eightfold drop at six months and a 16-fold drop at 12 months with secondary syphilis; and a fourfold drop at 12 months with early latent syphilis [1]. The RPR may eventually revert to nonreactive after treatment or remain at a low steady level (serofast).
if worried about re-infection should keep monitoring the RPR

Question 37

A baby is born to a mother with positive RPR and treponemal test, who did not get any treatment during pregnancy. the baby is well. What is the appropriate management?

a) monitor for symptoms at baseline and monthly for 3 months and if they develop, investigate for congenital syphillis
b) monitor for symptoms at baseline and monthly for 3 months , perform serology for syphillis at 0,3,6 and 18 months, don’t give any treatment
c) monitor for symptoms at baseline and monthly for 3 months , perform serology for syphillis at 0,3,6 and 18 months, do long bone radiographs, CBC, CSF for VDRL and treat for congenital syphillis
d) none of the above

Answer 37

c)is the answer
for all the details see table
essentially, untreated syphillis - monitor for symptoms at baseline and monthly for 3 months, monitor serology at 0,3,6,and 18 months (RPR and treponemal test each time, with clinical assessment), Long-bone radiographs, complete blood cell count and differential, and sampling of CSF for cell count and differential, glucose, protein and VDRL, with a low threshold for doing ophthalmological and audiological assessments and treat for congenital syphillis

If maternal RPR titres did not decline as described above, if follow-up titres were not obtained or if maternal reinfection is a possibility, infants should be considered to be at risk for congenital syphilis.

Question 38

A baby is found to have positive RPR and Treponemal test at 6 months of age. What is the appropriate management?

Answer 38

can get false negative of RPR and TT before 6 months, this is why we need to repeat them at recommended interval by 6 months. if both are negative at 6 months, can omit the 12 month and 18 month tests.

Long-bone radiographs, complete blood cell count and differential, and sampling of CSF for cell count and differential, glucose, protein and VDRL, with a low threshold for doing ophthalmological and audiological assessments and treat for congenital syphillis, repeating of serology depends on the timing of last assessment

Question 39

A mother was treated for latent syphillis during her pregnancy with an adequate fall in her titres. What is the appropriate management?

Answer 39

monitor clinicaly at regular intervals (monthly for the first 3 months), serology (RPR and TT) at 0,3,6,and 18 months (along with clinical assessment) , don’t need treatment or other investigations

Question 40

When does early congenital syphillis present?

a) 0-1 month
b) 0-6 months
c) 0-18 months
d) 0-2 years

Answer 40

d) early congenital syphillis - defined as syphillis diagnosed up to 2 years of age
most are asymptomatic at birth so diagnosis relies on positive lab or radiographic findings

As a gen­eral guide, infant RPR titres will decline by three months of age and be nonreactive by six months of age in the absence of congenital syphilis. The expected course of treponemal test results, such as EIA, is less clear, but passive antibodies from other infections usually clear by 12 months of age and always clear by 18 months of age. In addition to the investi­gations mentioned in Table 4, any skin lesions, nasal dis­charge, placental lesions or the umbilical cord can be examined for treponemes using darkfield microscopy or dir­ect fluorescent treponemal antibody test after consultation with the local laboratory. Molecular assays, such as polymer­ase chain reaction, may be available as a research or adjunctive diagnostic tool.

Question 41

Which of the following is not a common feature of congenital syphillis?

a) stillbirth
b) chorioretinitis
c) snuffles/rhinitis
d) thrombocytopenia

Answer 41

b) chorioretinitis ia rare finding, other rare findings include meningitis, chorioretinitis, nephritic syndrome and paroxysmal cold hemoglobinuria

Question 42

Which of the following signs is unlikely to present in the newborn period?

a) Hutchinson teeth
b) neurosyphillis
c) rash
d) rhinitis
e) osteochondritis

Answer 42

a) Hutchinson teeth - screwdriver shaped teeth upper central and lateral incisors

MSK findings: Osteochondritis or perichondritis, seen initially radiographically (25% of cases) and later as pseudoparalysis, which can be confused with child abuse as there are both bony and of tissue limb changes. Later develop frontal bossing, poorly developed maxillas, saddle nose, winged scapulas and sabre shins

Recurrent arthropathy and painless knee effusions (Clutton’s joints) occur after two years of age

stillbirth/hydrops/spontaneous abortion

• rash - within 1st 8 weeks
• hepatosplenomegaly - 1st 8 weeks
• neurosyphillis - at birth or delayed
• osteochondritis
• hematological - at birth or delayed - anemia/thrombocytopenia
• in older kids:
• interstitial keratitis - 2-20 year old
• Hutchison’s teeth - permanent teeth
• Mulburry molars - 13-19 months
• 8th nerve deafness (sensorineural) - 10-40 years
• *see chart for more details on the findings

Question 43

A child has VDRL positive in the CNS. What does this mean?

Answer 43

positive VDRL is diagnostic of neurosyphillis, although not super sensitive so if negative cannot totally rule it out
normal CSF blood counts - range from 5-20 x106; CSF protein ranges from 0.45g/L to 1.0g/L
CSF FTA-ABS lacks specificity, so it should not be routinely per­formed; a negative FTA-ABS is helpful in ruling out the diagnosis of neurosyphilis.
if woman was incubating syphillis at the time of delivery, could be negative test for both mom and baby, so if symptoms of syphillis, need to test for it

Question 44

Which of the following is the appropriate treatment for syphillis in a 3 week old?

a) benzathine penicillin 50000 units/kg every 8 hours
b) penG 50 000 units/kg every 12 hours
c) penG 50 000 units/kg every 6 hours

Answer 44

a) is the answer

benzathine penicillin G IV 10 day course
50 0000 units/kg every:
for children 4 weeks every 6 hours

Some experts recommend administration of a single dose or three weekly doses of this product to newborns who have no evi­dence of congenital syphilis but were born to women adequately treated for syphilis during pregnancy or to women treated for late latent syphilis during or following pregnancy. NOT a good idea unless great follow up because most of these kids are not infected and theoretically could lead to a temporary decline in RPR titres.

common error is to give benzyl penicillin (pen G) instead of benzathine penicillin ; benzathine penicillin’s better because it is converted to penG in the body, allows a low concentration of penG over time

Question 45

Which of the following is the appropriate finding in adequately treated congenital syphillis?

a) drop by 4x in RPR
b) absence of treponemal antibodies by 18 months
c) persistent CSF abnormalities

Answer 45

a) drop in 4x in RPR is the best answer

absence of treponemal antibodies - if never had congenital syphillis, or if treated very very early for congenital infection
if persistent CSF abnormalities (should be checking every 6 months) may need a second course

Question 46

Which of the following statements is false?

a) urinalysis and urine culture should be obtained from children 3 year old with symptoms of UTI should have urinalysis and culture done
c) prepubertal girls presenting with dysuria and red vulva most likely have UTI and should be treated as such
d) infants with fever >39 for >48 hours with no other source are likely to have a UTI
e) UTI can occur in bronchiolitis but it is probably that most positive urine culture in children

Answer 46

c) false - this presentation can occur commonly with irritants including bubble bath and other exposures; should not treat as UTI (this is often done incorrectly)

for chilren > 3 years should use symptoms to decide who to request urinalysis and culture for
dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence are symptoms of UTI in this age group

Question 47

Which of the following girls has a less than 1% chance of UTI?

a) 8 month old, white, temperature >39 for 2 days, absence of another source of infection
b) 10 month old, black, temperature >39 for 1 day, absence of another source of infection
c) 13 month old, white, temperature >39 for 1 day, absence of another source of infection
d) 13 month old, black, temperature >39 for 1 day, URTI symptoms

Answer 47

d) is the answer

predictive rule for girls 39 C for 2 days or more, no other source of infection

if there is 1 or less of these features, then the risk of UTI is

Question 48

True or false? It is common for boys to have their first UTI after age 3

Answer 48

false - it is uncommon for boys to have their first UTI after age 3 in the absence of urinary tract instrumentation

Question 49

True or false? perineal cleansing is necessary to obtain a clean midstream urine

Answer 49

false - may not be necessary, since the first few drops of urine should wash away any bacteria contaminating

Question 50

What is the contamination rate of bag samples for urine?

a) 30%
b) 40%
c) 50%
d) 60%

Answer 50

d) 60 % (63% to be exact) of bag samples are contaminated
so cultures from bag are not appropriate
can use bag to do initial urinalysis and then move on to catheter or suprapubic aspirate after that

for toilet trained children - should do a midstream urine
one way for girls is to have them sit backwards on the toilet (spreads the labia)

Question 51

Which of the following tests is the most specific for diagnosis of UTI?

a) bacteria on microscopy
b) nitrite
c) leukocyte esterase
d) bacteria on microscopy

Answer 51

b) nitrite is the most specific (98%) but not very sensitive (53%) - i.e. if it is positive can be pretty certain that the patient has a UTI, if negative, cannot rule it out

how nitrites are made - certain organisms convert nitrate to nitrite (gram negative bacteria do this) however not all organisms (including gram positive organisms) do not

the other tests:
leukocyte esterase - measures pyuria - can be negative when low concentration of leukocytes
WBC in microscopy - sensitive measure of inflammation caused by UTI
different values - most Canadian labs >5 WBC/high power field is considered pyuria, however more sensitive indicator should be >10WBC/microliter in uncentrifuged sample

Question 52

Name reasons why a patient may have UTI despite negative nitrite

Answer 52

1. short time of the urine in the bladder

2. organisms which doesn’t metabolize nitrate (including all gram positive organisms)

Question 53

True or false - febrile UTIs should result in pyuria

Answer 53

true - it has been argued that febrile UTIs should result in pyuria, however common teaching is that absence of pyuria should not exclude UTI as the diagnosis

According to published literature, a child with a negative urine dipstick for nitrites and leukocyte esterase and no pyuria or bacteruria on microscopic examination has a <1% chance of having a UTI

Question 54

Which of the following statements is false?

a) a negative urine bag culture rules out UTI
b) a single dose of antibiotic can sterilize urine
c) definitions of colony count should be strictly used to make diagnoses
d) for non toilet trained children only catheter or SPA are considered reliable methods of urine collection

Answer 54

c) false - the colony counts are operational and not absolute in rare circumstances low colony counts can be indicative of UTI

the rest of the statements are true
a) positive bag urine culture is not useful, although negative can rule out UTI
must do urine collection before antibiotics because a single dose can sterilize the urine

Question 55

Which of the following is least likely to cause a UTI in a previously healthy child not on antibiotics?

a) enterococcus
b) E. coli
c) Klebsiella
d) Enterobacter

Answer 55

a) enterococcus - it is controversial whether enterococcus is likely to cause a UTI in previously healthy child with no antibiotics
the common UTI organisms are: E. coli, Klebsiella pneumonia, Enterobacter species, Citrobacter, Serratia
in adolescent females only: Staphylococcus saphrophyticus
mixed growth or other organisms suggests contamination

Question 56

Which of the following colony counts does not suggest UTI infection?

a) clean catch (midstream) with CFU/L 10^8 (aka CFU/mL 10^5)
b) catheter sample with CFU/L 5x10^7 (aka CFU/ml 10^4)
c) clean catch (midstream) with CFU/L 10^7 (aka CFU/ml 10^4)
d) suprapubic aspirate CFU/L 10^6 (aka CFU/mL 10^3)

Answer 56

c) clean catch(midstream) with CFU/L 10^7

the criteria (minimum colony count) for UTI for different sample types:

clean catch - CFU>10^8 or more; mixed growth usually contamination
catheter sample (remember, needs to be cleaner) - CFU >10^7 or more; mixed growth suggests contamination; specimens from indwelling catheters are less reliable
suprapubic aspirate - any growth is considered a UTI

Question 57

Which of the following is the appropriate monitoring for a stable 4 month old child with febrile UTI who is on gentamycin x 2 days ?

a) blood cultures, renal function
b) no additional investigations
c) renal function only
d) blood culture only

Answer 57

c) renal function

don’t need to do blood cultures unless hemodynamically unstable
**renal function if complicated UTI (see next questions) or if on gentamycin >48 hours or more

Question 58

True or false? The risk of renal damage from acute pyelonephritis in children with normal kidneys is significant.

Answer 58

false - the risk of renal damage from acute pyelonetphritis in children with normal kidneys is very low, the need for IV antibiotics has been questioned

Question 59

True or false?oral therapy and IV antibiotics are equally effective in otherwise healthy, nontoxic, children with UTI

Answer 59

true -
Cochrane review - IV antibiotics for 10-14 days and IV for 3 days followed by oral for 10 days are equally effective , with respect to fever and renal damage
no significant difference between IV Abx x 2 weeks vs. IV then PO for 7-14 days
based on this, most people recommend oral antibiotics for febrile UTIs in nontoxic children with no known structural urological abnormality, assuming they are likely to receive and tolerate every dose
**more controversial for babies age 2-3 months, some people recommend initial IV for these babies (and this statement doesn’t talk about babies <2 months since need to think about sepsis)

Question 60

Which of the following is the appropriate treatment for cystitis in a teenager

a) IV antibiotics x 5 days
b) IV antibiotics x 3 days then PO for 10 days
c) PO antibiotics for 10 days
d) PO antibiotics for 2-4 days

Answer 60

d) cystitis - UTI without a fever, presents in post puberty with dysuria and frequency, treatment should be 2-4 day course of oral antibiotics based on local susceptibility of E. coli

for UTI in general:

should pick the antibiotic based on local susceptibility
cefixime (3rd generation cephalosporin) is a good oral choice in most areas
should pick narrowest spectrum
for IV, lots of people use gent (with or without ampicillin), some choose 3rd generation cephalosporin because less nephrotoxic
modify to narrowest spectrum possible when the susceptibilities are available, don’t need to switch outpatients as long as the bacteria is sensitive to the treatment they are on
for UTI - treatment is 7-10 days

Question 61

Which of the following is not a sign of a complicated UTI?

a) poor urine flow
b) hemodynamically unstable
c) increased creatinine
d) bladder or abdominal mass
e) fever not improving in 24 hours

Answer 61

e) fever not improving in 48 hours (i.e. trending downward) and not clinically improving at all in 24 hours are signs of complicated UTI

the others are all signs of complicated UTI
should treat with IV antibiotics until improving clearly
RBUS should be done to look for abscess or obstruction

Question 62

What is the appropriate imaging/testing modality for a 1 year old presenting with her first febrile UTI?

a) VCUG
b) renal bladder US
c) DMSA scan
d) none of the above

Answer 62

b) renal bladder US
before used to recommend VCUG but this is no longer the case.
children <2 year old with 1st febrile UTI should have US done
goals of the imaging: confirm that the child had pyelonephritis and to identify whether severe vesicoureteral reflux (VUR) or structural anomalies of kidney, ureter or bladder that predispose to infection are present; cystitis do not need imaging (i.e. the older kids)

Question 63

True or false? antibiotic prophylaxis should be given to children with febrile UTI who are awaiting the results of their imaging

Answer 63

false - no longer routinely need the antibiotic prophylaxis in these children

Question 64

Which grade of vesicoureteric reflux generally leads to hydronephrosis on US?

a) I
b) II
c) III
d) IV

Answer 64

d) grade IV and V reflux leads to hydronephrosis on US
**less good at diagnosing lower grades of reflux, but lots of experts say this is less important since most low grade VUR resolves spontaneously
It is controversial whether there is a need to obtain a RBUS if a high-quality ultrasound reported by an expert can be documented to have shown a normal fetal urinary tract late in pregnancy

Question 65

Which grade of vesicoureteric reflux needs antibiotic prophylaxis?
a)I
b)
II
c)III
d) IV

Answer 65

d) only IV and V need prophylaxis; I-III no longer need prophylaxis, so no longer need routine VCUG after first UTI since it wouldn’t change the management to detect these lower grades of reflux (and IV and V reflux should still be detected by US)

for grade IV and V reflux, should discuss with paediatric urology or nephrology to see if their needs to be an urgent consult and to guide further management

Question 66

Which of the following infants does not need to have a VCUG done?

a) 18 month old with 2nd febrile UTI
b) 15 month old with hydronephrosis on US
c) 12 month old with obstruction
d) 9 month old with 1st febrile UTI and normal US

Answer 66

d) does not need

the indications for VCUG are :

1. selective renal abnormalities and obstruction on US
2. 2nd febrile UTI in child

Question 67

True or false?

VCUG should be delayed until antibiotics for UTI treatment are completed

Answer 67

false - no evidence that needs to happen

it is controversial whether child should be on antibiotic prophylaxis for VCUG

Question 68

Name 3 risks of a VCUG?

Answer 68

1. radiation
2. risk of introducing a UTI
3. uncomfortable for the child
4. expensive

Question 69

Name 2 diagnosis that can be picked up on VCUG?

Answer 69

1. vesicoureteric reflux

2. posterior urethral valves (male anatomy)

Question 70

Which is the best test to use to assess a 18 month old boy who has their first febrile UTI and hydronephrosis on ultrasound?

a) DMSA scan
b) VCUG
c) nuclear cystogram

Answer 70

b) VCUG
while nuclear cystogram delivers less radiation, it is less readily available and bad at looking at the male anatomy** - however, it is reasonable to consider as the initial test in girls and as follow up in both genders (since less radiation)
DMSA scan - lots of radiation, used to diagnose pyelonephritis, and identify renal scars. should be used only when the diagnosis of UTIs or renal scarring is in question
children with UTI should have their parents advised that they should be evaluate for UTI early in the course whenever they have a fever