Immunization volume 6

Question 1

How much did vaccine serotype invasive pneumococcal disease decrease in children <2 years old in Alberta after introduction of the PCV7 vaccine?

a) 40%
b) 60%
c) 80%
d) 90%

Answer 1

d) 90% reduction in invasive pneumococcal disease (IPD) and 79% reduction in overall invasive pneumococcal disease after PCV7 introduced in Alberta

in older people - aged 65-84: had 92% decline in vaccine serotype IPD and 29% decline in overall IPD
because of herd effect from decreasing NP colonization in young people and consequent infection of older people
PCV7 introduced in 2001 - all provinces by 2006

US study of lots of people: reduction of IPD (serotype) by 100% and non serotype by 76% in <5 year olds

**bottom line, made a huge difference in IPD!

Question 2

Which serotype increased with the introduction of the PCV7 vaccine?

Answer 2

19A - this was not covered by the vaccine and actually increased after the vaccine was introduced.
other non vaccine serotypes also increased (there include 3, 5, 6A, 7F and 22F. In 2007
19A is resistant to lots of antibiotics, in Quebec continues to increase
unclear whether this is directly related to vaccine or to other causes

Question 3

Which of the following is not a consequence of the PCV7 vaccine?

a) decrease in meningitis caused by strep pneumo
b) decrease in meningitis caused by non PCV7 serotype S. pneumo
c) decreased admissions for lobar pneumonia in both children and adults
d) reduction in myringotomy tube placement

Answer 3

b) false - lead to a 78% increase in meningitis caused by non PCV7 serotype S. pneumo (serotype replacement)
a) true - did result in decrease of meningitis by S. pneumo and PCV7 strains of s. pneumo in children

Question 4

Which of the following about PCV13 is false? (based on the NACI recommendations)

a) all healthy children aged 12months - 35 months of age should receive one dose of PCV13
b) children >5 at high risk of IPD should receive one dose of PCV13 (fair evidence)
c) can consider a 3 dose schedule, with the last dose given at 12 months

Answer 4

c) false - insufficient evidence to recommend a 3 dose schedule, for PCV7 can consider 3 dose schedule with last dose at 12 months (but always need 4 doses for people at increased risk of invasive pneumococcal disease). some provinces (including ontario) did 3 doses, need to make sure that the 3rd dose is given early in the second year of life but no earlier

the rest are true
kids >2 with risk should also receive pneumococcal 23 valent vaccine (polysaccharide vaccine)

(in between, there was a PCV10 also)

Question 5

Based on the NACI recommendations, which of the following children aged 36-59 months does not need PCV13?

a) heathy aboriginal children
b) children attending group daycare
c) children at high risk of IPD
d) all of the above need it

Answer 5

d) all of the above in that age group need it(good evidence) and should actually be considered for all kids in this age group (I’m guessing they mean retroactively?)

Question 6

A child is due to have a kidney transplant and just got his MMR vaccine. When is the earliest that you should advise scheduling his surgery?

a) more than 2 weeks
b) more than 4 weeks
c) more than 6 weeks
d) more than 12 weeks

Answer 6

b) 4 weeks

for live vaccines, should wait at least 4 weeks after the vaccine before doing the transplant, for inactivated vaccines, should wait at least 2 weeks

**for live inactivated influenza vaccine - table says to wait at least 2 weeks (not 4 like the other live vaccines), also, can only give to patients who are healthy (so even pre-transplant, should only give to healthy patients)

better to give vaccines before transplant because you will get a better immune response before immunosuppression

Question 7

Which of the following vaccines can be given after transplantation?

a) rotavirus vaccine
b) MMR
c) rabies
d) intranasal influenza virus
e) BCG

Answer 7

c) rabies can be given after immunization

live vaccines are considered relatively contraindicated after transplantation

MMR and varicella - live vaccines, normally given no earlier than 12 months old but can be given as early as 6 months in kids who are awaiting transplantation
in general, these are contraindicated for immunosuppressed transplant patients
Some groups recommend giving measles, mumps and rubella vaccines in select low-risk patients with minimal immunosuppression.
varicella vaccine -most consider it to be contraindicated post transplantation

rotavirus not after transplant
BCG not after transplant

**CAN give HPV after transplant also

Question 8

Name 3 goals in the pre-transplant period for children with upcoming organ transplantation

Answer 8

1. vaccination of the individual
2. vaccination with age appropriate schedules for all household contacts (including seasonal influenza vaccine)
3. identify acute, chronic and latent infections in the recipient and the donor of the organ
4. counsel on how to avoid high risk exposures to infections in the pre-transplant period for the recipient and the donor

to determine specific risks - patient history (including risks associated with tuberculosis exposure, travel, living abroad, household pets, lifestyle and occupation), by the physical examination or by screening tests (Table 2).

Question 9

Which of the following statements is false?

a) CMV is one of the most common infections to present in the immediate post-transplant period
b) in the period 1-6 months after organ transplantation, opportunistic infections become more common
c) small bowel transplants carry increased risk of opportunistic infection compared to other transplants
d) children who are doing well 6 months or more after organ transplant are likely to have the same infections as other children

Answer 9

a) false - in the immediate post transplant period, the most common infections are the same as non immunosuppressed patients who have undergone similar procedures (>95%), the remaining 5% are infection that was present in the recipient before transplantation that was exacerbated by surgery, anesthesia and immunosuppressive therapy, or by an infection being transmitted by the allograft.

the rest are true
b) 1-6 months after organ transplantation - opportunistic infections (see next question)
c ) true - because more intense immunosuppression
d) true - kids who are on maintenance immunosuppression and have good allograft function are likely to have the same community acquired infections as heathy children , see question 11 for sicker kids

Question 10

Name 3 organisms that are likely to cause infection 1-6 months after organ transplant

Answer 10

1-6 months after organ transplantation - opportunistic infections

1. viral - CMV, EBV, HHV6, HepB and hepC (can be primary, reinfection with different strain or reactivation)
2. other opportunistic organisms - listeria, aspergillosis, PCP
3. Infection development with these organisms is aided by sustained immunosuppression with or without the immunomodulating effects of viral infections to create a net state of immunosuppression sufficient to increase susceptibility
   - some infections (i.e. small bowel) more likely to have opportunistic infection because the immunosuppression is more intense

Question 11

Name 3 organisms to consider in a child who is presenting with infection >6 months after organ transplant and who is having poor allograft function

Answer 11

Listeria, Cryptococcus, Nocardia, P jirovecii (PCP) - see below

kids who are doing well - same infections as other kids
kids who arent doing well i.e. ‘t, acute or chronic immunosuppression, poor allograft function or a chronic viral infection) :
consider recurrent infections relating to uncorrected mechanical or anatomical problems (eg, implanted foreign material or an obstruction), as well as for opportunistic infections from P jirovecii, L monocytogenes, Cryptococcus neoformans, and Nocardia asteroides, among others.

Question 12

Name 2 viruses that can cause fever without an apparent source of infection in the post-transplant patient

Answer 12

CMV and adenovirus

should do at least CBC and blood culture even if focus identified, if no focus, also do urine. the rest of the management should depend on the patient condition, often need admission
should manage in consult with transplant centre

Question 13

A 12 year old girl just had a kidney transplant one month ago. It is November. Which of the following vaccines should she get first.

a) hepB
b) HPV
c) inactivated influenza vaccine
d) MCV-C

Answer 13

c) inactivated influenza vaccine - should be given starting 1 month after transplant and yearly thereafter
* *in general don’t give vaccines in the first 6-12 months following transplant**

the other vaccines are safe to give after transplant, just don’t give till later
vaccinating household contacts is an important way to prevent infections in the recipient

Question 14

A child 12 months post BM transplant is exposed to a patient with varicella in the hospital. What is the appropriate management?

a) VZIG and varicella vaccine
b) VZIG only
c) varicella vaccine
d) watch and wait for symptoms

Answer 14

b) VZIG only

varicella vaccine is contraindicated in immunosuppressed transplant patients - very important to give it before - get humoral immunity for up to 2 years afterwards (protects in the most critical phase)
need to get VZIG if exposed

Question 15

Which of the following is the most important vaccine to give to a 8 month old boy undergoing a heart transplant?

a) MCV4
b) pneumococcal vaccines - both Prevnar and pneumovax
c) hepatitis B
d) hepatitis A vaccine

Answer 15

b) pneumococcal vaccines - children after organ transplant are at very high risk of invasive pneumococcal disease, particularly patients with heart transplant
- should get the PCV13 with the routine schedule, and then the pneumovax (polysaccharide with 23 valent) at least 8 weeks afterwards

MCV4 - not approved for under 2 years old (should get it if they are over that)
hep B - should get with routine schedule but 2x the dose
hep A- most people say only need if other risks for liver disease (i.e. liver disease, epidemiological factors), (although some say to give to all because drugs are hepatotoxic)

Question 16

What is the appropriate dose of hepB for a grade 7 boy who had a organ transplant 1 year ago?

a) don’t give it
b) regular dose
c) 2x the dose
d) 3x the dose

Answer 16

c) should be given with regular schedule (although remember that in general we don’t give vaccines 6-12 months post transplant) and at 2x the dose

Question 17

Why is it important for transplant recipients to get the HPV vaccine?

Answer 17

increased risk of severe genital warts and HPV related malignancies

Question 18

What are some important counselling points you would tell your patient about who is on immunosuppressive drugs after their transplant?

Answer 18

Besides providing information on the risks of immunosuppressive drugs (Table 4) [23] and their interactions with common antimicrobials (Table 5), clinicians need to counsel young transplant patients about infection risks associated with food and drinking water, pets and other animals, swimming and other water sports, fungal spores (eg, from gardening, farm buildings, construction sites, excavations, caves, marijuana and tobacco), mosquito bites, travel and sexual behaviour, as appropriate.[19]

Question 19

How do you treat a patient with positive strongyloides serology who is for transplant?

a) no treatment
b) ivermectin
c) mebendazole

Answer 19

b) ivermectin
only get strongyloides if patient has lived in endemic area
big long list of serologies to get

Question 20

A pre transplant 10 month old is positive for CMV IgG. What is your next step?

a) ask team about treatment
b) repeat in 1 months
c) do urine CMV
d) none of the above

Answer 20

c) do urine CMV
can get maternal antibodies until 18 months old
will influence post transplant management

another special one - heart kids should test for toxoplasma , will influence management

Question 21

Which of the following prophylaxis regimens post organ transplant is incorrect?

a) all recipients - TMP/SMx for 6-12 months
b) seropositive for HSV - treat with acyclovir x 3 months
c) liver transplant - nystatin up to 4 weeks
d) heart transplant with toxoplasma +ve - voriconazole x 2 months
e) CMV - 3 months IV ganciclovir
f) candida - up to 4 months of fluconazole/nystatin/ampho B depending on RFs for high risk patients
g) aspergillus in heart/lung recipients - voriconazole/itraconazole , ampho B if high risk factors
g) ALL organ recipients - PJP prophylaxis with septra

Answer 21

d) false - heart transplant with toxoplasma positive - Pyrimethamine/sulfadiazine for D+R- patients
TMP-SMX of some value for R+ patients for 6 months

the rest are true
look at the chart

**this table has a whole crew of stuff

remember that all the organ recipients should get PJP prophylaxis with septra Typically six to 12 months, or if receiving steroids or if CD4

Question 22

Which of the following drugs is likely to cause gingival hyperplasia and hirsutism?

a) azathioprine
b) tacrolimus
c) cyclosporine A
d) rituximab

Answer 22

c) cyclosporine A (aka neoral) is a calcineurin inhibitor Hirsutism, gingival hyperplasia, nephrotoxicity, hypertension

the others:
tacrolimus (also a calcineurin inhibitor, aka prograf, advagraf) : tremor, dose-dependent neuropathy, nephrotoxicity, hypertension, hyperglycemia

azathioprine is a anti-proliferative agent (inhibits DNA synthesis) (aka imuran) causes leukopenia, anemia, thrombocytopenia

rituximab - mAB - most likely effects are infusion related Infusion related reactions (eg, fever, chills, hypotension), angioedema, pancytopenia

Question 23

Which of the following drugs is most likely to cause apthous ulcers as a side effect?

a) tacrolimus
b) sirolimus
c) basilixumab
d) cellcept (aka MMF)

Answer 23

b) sirolimus aka rapamycin (which is a mTOR inhibitor, the other in this class is afinitor) : causes Delayed wound healing, aphthous ulcers, hyperlipidemia, bone marrow suppression, pneumonitis

Question 24

Which of the following drugs is most likely to cause a neuropathy when used in high doses?

a) tacrolimus
b) sirolimus
c) cyclosporine A
d) cellcept (aka MMF)

Answer 24

a) tacrolimus (which is a calcineurin inhibitor ) : side effects: tremors, dose dependant neuropathy, nephrotoxicity, hypertension, hypertension, hyperglycaemia

overall, classes of meds include:

Question 25

Which of the following drugs does not increase the level of immunosuppressant drugs? a) rifampin b) erythromycin c) ciprofloxacin d) fluconazole e) indinavir

Answer 25

a) rifampin actually decreases the level (i.e. is a inducer of immunosuppressants), the other drugs that decrease the levels are caspofungin(non CYP mediated with tacolimus only) and Nevirapine/Efavirenz the other drugs that increase them include antibiotics: Azithromycin, Clarithromycin, Erythromycin, Metronidazole, Levofloxacin Ciprofloxacin anti fungals: Fluconazole, Ketoconazole, Itraconazole, Voriconazole (Caspofungin AUC (exposure) increased with cyclosporine Micafungin less likely to affect levels than caspofungin Ketoconazole and itraconazole > fluconazole and voriconazole) Anti-virals: Indinavir, Nelfinavir, Ritonavir, Lopinavir, Amprenavir, Saquinavir these are cytochrome p450 drugs used in transplantation cyclosporine A, sirolimus, tacrolimus and everolimus

Question 26

Which of the following drugs is most likely to impair the function of immunosuppressants (i.e. increase the levels of the immunosuppressants)? a) erythromycin b) clarithromycin c) azithromycin d) amoxiillin

Answer 26

a) interaction with erythromycin>clarithromycin>azithromycin>beta lactams which are safe The above drug interactions do not preclude use of these antimicrobial agents. However, strategies to manage and monitor interactions/drug levels should be discussed with the transplant team before initiation

Question 27

Which of the following is least likely to happen as a consequence of blood transfusion in Canada? a) TRALI b) anaphylactic reaction c) infection d) all are equally likely to occur

Answer 27

c) infection the others are more likely to occur although risk of infection can never be reduced to 0 overall in kids - benefits>risks, crucial step in enhancing safety (because lots of the adverse events are due to human error); should try to minimize the risk of transfusion

Question 28

Which of the following blood products can you use a solvent/detergent method to reduce pathogens? a) RBC b) platelets c) plasma

Answer 28

c) has been approved since 2012 for plasma only unfortunately can't use for RBC or platelets heat can't be used for RBC or platelets either careful aseptic technique procedures for collection and infusion;[10][11] the diversion of the first 40 mL of blood collected into a diversion pouch [12] (ie, not used for transfusion); donor screening by serological and other tests, including bacterial detection in platelets [13] (Table 1); viral inactivation procedures used in manufacturing plasma-derived products and leukocyte reduction

Question 29

Which of the following is all Canadian donor blood not tested for? a) HIV b) CMV c) HTLV d) Hep B e) Syphillis

Answer 29

``` b) CMV antibody only tested in select units Trypanosoma cruzi (agent for Chagas’ disease) antibody on at-risk donors ``` for CMV there are leukocyte reduction techniques that reduce the transmission of white cell associated viruses such as CMV the blood is tested for the others, also tested for HepC for WNV, in Canada nucleic acid testing hear round, in quebec, only in travellers and during the summer bacterial culture on platelets specific tests: HIV antibody or PCR; HTLV - antibody; syphillis will be treponemal test/HepC antibody or PCR

Question 30

Which of the following agents is not inactivated by solvent/detergent? a) parvovirus B19 b) CMV c) hepB d) HIV e) WNV

Answer 30

a) parvovirus B19 is not inactivated by solvent/detergent, it is inactivated by heat; hepA is also not inactivated by solvent/detergent but is inactivated by heat; enterovirus is not inactivated by solvent/detergent inactivated by solvent/detergent: CMV, hepB, hepC, HIV, WNV inactivated by heat: those above, plus hepA and parvovirus B19

Question 31

What is one disadvantage of ultrafiltration of blood products?

Answer 31

removal of macromolecules such as factor VIII (advantage is that it removes even small viruses)

Question 32

Which of the following viruses is not removed by leukocyte depletion of blood products? a) HTLV I b) CMV c) HTLV II d) hepB

Answer 32

d) hepB non WBC associated viruses are not removed by leukocyte depletion, the other viruses are WBC associated (i.e. they hang with the WBCs)

Question 33

True or False - Factor VIII and IX in Canada carry the same infectious risks as blood products

Answer 33

false - in Canada they are recombinant products and therefore do not carry the same risks as a blood product

Question 34

Why are platelets at higher risk of bacterial contamination than RBCs?

Answer 34

stored at room temperature (22+/-4 C0 which supports bacterial multiplication Initial aliquot diversion and bacterial detection have decreased the risk significantly,[13] as has the automated culture of platelet components, but bacterial contamination of platelet concentrates remains a concern.[16] The risk of bacterial contamination of frozen components, such as fresh frozen plasma and cryoprecipitates, is much lower because the usual microbes (Table 4) are killed by freezing and other storage conditions plasma contamination from water used to thaw the products used to be a major issue, but now with microwave and other thawing techniques, less of an issue

Question 35

True or false - plasma has a lower risk of infection than cryoprecipitate

Answer 35

true - risk of contamination from plasma and blood is similar, higher than for plasma HTLV and CMV are cell associated viruses, don't need to screen plasma for HTLV; generally CMV is removed by the manufacturing process and because it is cell associated, it is less likely to be found in plasma **on the chart, cryoprecipitate highest risk of virus infection pre inactivation (since this is all the factors, although in Canada we usually use recombinant factors)

Question 36

What is the most common adverse transfusion related event in Canada? a) anaphylaxis b) hypotensive reaction c) transfusion related circulatory overload d) transfusion related acute lung injury

Answer 36

c) TACO - 46.2% of serious adverse events anaphylaxis 15.9% hypotensive reaction 11.9% TRALI 8.1% +/- 1.9% rate of bacterial contamination very low only 1:292775 units transfused overal rate of adverse events increased in the most recent evaluation, but most likely because of more reporting of TACO, regardless of severity

Question 37

Which organism is associated with blood transfusion acute infection from pRBC transfusion? a) staph aureus b) Yersinia enterocolitis c) E. coli d) Enterococci

Answer 37

b) Yersinia, gram negative organisms including pseudomonas are associated with pRBC blood transfusion associated infections: pRBC: yersinia, gram negative incl pseudomonas whole blood: gram negative incl pseudomonas platelets: skin bugs (staph epi, strep), salmonella, serratia, clostridium,enterococci, e coli plasma: staph aureus and pseudomonas

Question 38

How long can you store platelets? a) 5 days b) 40 days c) 24 hours d) none of the above

Answer 38

a) 5 days at room temperature 20-24 C plasma: store frozen, once thawed can keep at 1-6 C for 24 horus pRBCs and whole blood - 1-6 C for 25-42 days

Question 39

What is the risk of getting HIV from a blood product in Canada?

Answer 39

1:8-12 million (in comparaison, hit by lightening is 1/3 million)

Question 40

Which of the following infections has the highest risk in Canada from blood products ? a) HIV b) hepB c) hepC d) syphillis

Answer 40

b) hep B risk is 1/1.1-1.7 million HIV is 1/8-12 million hepC 1/5-7 million syphillis is 1/100 million others: HTLV 1-1-1.3 million; no cases of west nile virus bacterial infection Apheresis platelets: 1 in 105,000 Platelet pools: 1 in 47,000 (**pretty high in comparison) **in comparison risk of infections from plasma is pretty darn close to 0 (when compared to blood)

Question 41

What is the risk of getting parvovirus B 19 from a blood transfusion in Canada?

Answer 41

1/5000 to 1/20000 **so reasonably high see table for other rare organisms that I didn't bother focusing on **but based on this table we don't test our blood for parvovirus B19

Question 42

Which of the following is not a TNF alpha antagonist? a) certolizumab b) etarnacept c) infliximab d) toclizumab e) golimumab

Answer 42

d) toclizumab is a IL-6 receptor antagonist the others are TNF alpha antagonists adalimumab (aka Humira) is also a TNF alpha antagonists the other similar sounding drugs that are different: Canakinumab: binds Il1 alpha receptors Ustekinumab: IL-12 and IL-23 antagonism natalizumab: Blocks integrin association with vascular receptors limiting adhesion and transmigration of leukocytes abatacept: Binds to CD80 and CD86 on antigen-presenting cells, and therefore blocks production of TNF-α, IL-2 and interferon-γ how biological response modifiers work: either antibodies to the pro inflammatory cytokines or proteins that target their receptors to block the pro inflammatory cytokine effect and decrease inflammation . administer either IV or SC q weekly, q2 weeks, monthly or bimonthly. often derived from antibodies (see the complete list, they are not all here)

Question 43

Name 3 biological response modifiers that target IL-1?

Answer 43

1. Canakinumab - Binds to IL-1 ß receptor and prevents interaction of cell surface receptors 2. Anakinra - binds the IL-1 alpha receptor 3. rilonacept - Binds to IL-1 α and ß and prevents interaction of cell surface receptors

Question 44

Infection with which of the following organisms is not significantly increased with biological response modifier therapy? a) TB b) fungi c) strep pneumo

Answer 44

c) strep pneumo not believed to be increased In the populations studied thus far, there does not appear to be a significant increased risk of infections with more common bacterial pathogens, such as S. pneumoniae. may increase other mycobacterium (non TB), may also increase fungi including histoplasma, blastomyces, coccidiodes; intracellular bacteria such as listeria; consider reactivation of strongyloides in patients from endemic areas role in lots of infections is unknown (in EBV, unclear if can lead to reactivation, increase lymphoma??); effect in pregnancy and lactation unknown increases risk of TB and fungi even compared to standard immunosuppression, risk of reactivation TB not well studied but probably similar to that of treatment pathophys: compromises the T cell mediated response which is needed for intracellular pathogens, granulomas and cell mediated response. can also get reactivation of existing infections that have been dormant

Question 45

True or false- the risk of infection is inversely related to the duration of therapy with biological response modifiers and stops once the medication is stopped

Answer 45

false - the risk is related to the length of treatment - longer treatment is more immunosuppression The risk of infection appears to be related to the length of therapy. Owing to the long half-life of some drugs (ranging from three to 24 days), the increased risk of infection may persist for weeks and possibly months after discontinuing the drug unknown effect on fetus/in lactation

Question 46

A child has a TST done before starting a biological response modifier for RA. It is 6 mm. What do you do? a) nothing b) CXR, start isoniazid and start the biological response modifier right away c) CXR, if negative no treatment and start the biological response modifier d) none of the above

Answer 46

d) none of the above what you should do : positive test is >5 mm, so if high suspicion of latent TB, start isoniazid (expert opinion) for 9 month course and don't start the BRM until one month after the isoniazid has been started also do a good epidemiological history IGRAs are also a good option in immunosuppressed (better sensitivity in immunosuppresed) remember can only use in kids 5 or older **if patient looks like they have TB, should talk to ID specialist also and they should see the kid to help manage

Question 47

Name 4 things to test for before starting a patient on a biological response modifier

Answer 47

1. make sure all vaccines up to date,give any live vaccines at least 4 weeks before starting treatment and inactivated 2 weeks before to allow for good immune response ; 2. do a TB skin test or blood based assay 3. do a CXR 4. ensure family members are vaccinated - varicella and influenza , varicella if lesions at sites keep it covered 5. perform baseline serologies as needed based on clinical/exposure history (Histoplasma, Toxoplasma and other intracellular pathogens)if unknown about exposure to varicella and measles, do these serologies 5. counsel regarding exposures (i.e. food, pets/animals/soils, caves (fungal spores), spelunking and histoplasma -**spelunking is cave exploration) and travel to areas with fungi and TB. avoid undercooked foods/deli meats (listeria, todo), avoid litter (toxo), kittens (bartonella), reptiles (salmonella), pet bites (pasteurella)

Question 48

What is one area where there is cocciodoides?

Answer 48

SW US

Question 49

A patient is on high steroids for their IBD .They need to get there dTAP vaccine prior to starting BRM. What do you do? a) give them the dTAP and then start them on treatment b) don't give them the dTAP and start treatment c) give them the dTAP and start BRM 2 weeks later d) give them the DTAP and start BRM 4 weeks later

Answer 49

d) give them the DTAP and start BRM 4 weeks later in general, want to give the vaccines before if possible, will have better response for inactivated vaccines, at least 2 weeks before; HOEWVER, if they are on steroids, wait 4 weeks till starting for live vaccines - wait 4 weeks, shouldn't give live vaccines to immunosuppressed (specific role in BRM not well studied) if possible, children aged

Question 50

When can the skin testing for TB be not be done? a) same day as MMR vaccine b) 2 weeks after MMR vaccine c) 4 weeks after MMR vaccine d) 6 weeks after MMR vaccine

Answer 50

b) can't be done 2 weeks after, since MMR can temporarily decrease the reactivity of the TST either do it the same day or 4-6 weeks after

Question 51

Name the two major side effects of amphotericin B?

Answer 51

1) nephrotoxicity - including hypokalemia 2) infusion related events (fever, chills, rigours) new lipid based formulations are less nephrotoxic than conventional formulations (i.e. ambisome and albicet) however, they are more expensive (see table for deets) The lipid-based products are usually recommended in patients who are refractory to or intolerant of amphotericin B deoxycholate

Question 52

Which of the following statements is false about fluconazole ? a) fluconazole is low lipophilic and has limited protein binding b) fluconazole has significant hepatotoxicity c) fluconazole has good activity against aspergillus and other molds d) fluconazole is an inducer of cytochrome P450 e) more active against candida albicans than other candidal strains f) fluconazole has higher concentrations in the urine than in the blood

Answer 52

c) false - has no activity against aspergillus and other moulds true - readily penetrates tissues because of low lipophilic nature and limited protein binding, approximately 90% bioavailable 10-20x more concentrated in urine than blood more active against candida albicans than other strains, for prophylaxis, used in allogenic stem cell transplant patients, its role in neonates for prophylaxis is being investigated **see the rest of the charts, there are lots of random details in them

Question 53

Which of the following is the best treatment of invasive pulmonary aspergilosis in older children and adults? a) itraconazole b) voriconazole c) fluconazole

Answer 53

b) voriconazole - the preferred treatment for invasive pulmonary aspergillosis in older children and adults itraconazole - used for prophylaxis for candida and aspergillus (i.e. stem cell transplant)It is often used for prophylaxis in lung transplant recipients who are colonized by Aspergillus [20]. The drug is also used selectively in severe Aspergillus infections or as step-down therapy. **fluconazole - DOES NOT work agains aspergillus Adverse events include skin rash, visual abnormalities, (photophobia and blurred vision) photosensitivity reactions and elevated hepatic transaminase or serum bilirubin levels

Question 54

Please pair the main side effect with the medication listed (may have more than 1 pairing) fluconazole itraconazole voriconazole ``` hepatotoxicity GI disturbance skin rash photosensitivity visual abnormalities ```

Answer 54

fluconazole - main SE is rare but serious hepatotoicity, induces cytochrome P450 itraconazole - GI side effects and hepatotoxicity voriconazole - 1. skin rash, visual abnormalities, photosensitivity, increased LFTs - all reversible 2. also, should avoid the IV form in patients with renal failure because they might have toxic effects from the solvent vehicle the other azoles - paediatric experience is lacking

Question 55

Which of the following is the best option for a patient with impaired renal function a) caspofungin b) voriconazole

Answer 55

a) caspofungin - good for invasive candidiasis and aspergilosis, in some centres it is the drug of choice for treatment in febrile neutropenic with impaired renal function. caspofungin causes anemia, LVR problems, rash, headache, fever, GI symptoms the echinochins, target the fungal cell wall (beta glucan) voriconazole has renal toxicity, caspofungin does not caspofunging is dosed by BSA not weight micafungin - some paediatric studies, may be good post stem cell transplant

Question 56

Name one case where one needs to treat with combination anti fungal therapy

Answer 56

cryptococcal meningitis - convincing that combination therapy is better than one drug only; other circumstances where combo therapy might be considered: 1. central nervous system fungal infections 2. disease with incomplete response to initial therapy, notably where optimal dosing is compromised by toxicity; 3. empirical therapy of severe disease presumed to be due to organisms that are known to have distinct fungal susceptibility profiles (ie, a different drug is needed for each likely pathogen) 4. initial therapy of selected cases of invasive pulmonary aspergillosis, particularly for diseases in close proximity to major mediastinal blood vessels. for CNS infection with candida and or cryptococcus - do amphB with flucytosine

Question 57

Which of the following drugs is not good to treat cryptococcus? a) ampho B b) voriconazole c) fluconazole d) caspofungin

Answer 57

d) caspofungin - the echinocanins don't cover cryptococcus (see chart)

Question 58

What is the most common reported STI in Canada?

Answer 58

Chlamydia | most in women 15-24 and men 20-29

Question 59

how many infants born to mo's with untreated chlamydia get the infection?

Answer 59

50% of the time for vaginally delivered infants, only rarely for C section babies Sexual abuse should be considered in pre-pubertal children

Question 60

when suspecting sexual abuse, what type of samples should you send?

Answer 60

NAAT cultures also for medico-legal purposes

Question 61

is it likely to get gonorrhoea from household fomites

Answer 61

no, very unlikely | should consider when there is infection after the neonatal period

Question 62

Which age group has the most gonorrhoea?

Answer 62

men aged 20-29 | rates increasing among men who have sex with men

Question 63

which age group has gonorrhoea been increasing in the most?

Answer 63

in women between 15-19 years of age

Question 64

who is more likely to have symptoms with gonorrhoea, men or women?

Answer 64

men more likely to have symptoms, women more likely to be asymptomatic so female cases tend to be asymptomatic can get both gonorrhoea and chlamydia more and more gonococcal resistance

Question 65

Who is the most commonly affected by syphilis?

Answer 65

MSM 30-39 years old, sex workers and their clients people who have gotten infected elsewhere in the world many cities have "hot spots" for syphillis

Question 66

Which groups are most likely to be infected by HIV?

Answer 66

rates across Canada vary the rates increased from 2000-2008, then decreased 1. MSM 2. heterosexual contact 3. injection drug users (variation in rates in different groups across the counter)

Question 67

when should you screen teens for STIs?

Answer 67

at any visit! since they don't come very often

Question 68

Which adolescents should be screened for STIs?

Answer 68

1. Females: all who are sexually active or victims of sexual abuse or assault 2. in males: if their history suggests sexual contact with person with a known STI, previous STI, patient of an STI clinic previously, new sexual partner or >2 sexual partners within the past year, injection drug use or other substance use (especially if associated with sexual activity); unsafe sexual practices, kinky sex, random sex, sex workers, survival sex, street involvement or homelessness, detention facility, sexual assault or abuse (....so isn't this essentially everyone also).

Question 69

true or false - rectal and pharyngeal gonococcal infections usually have symptoms?

Answer 69

false - often asymptomatic | should ensure to find all the patient's sexual contacts, test and treat them appropriately

Question 70

How often should you screen females for chlamydia

Answer 70

at least annually for all sexaully active females <25 years old; males with risk factors should be screened

Question 71

After treating a kid with chlamydia, when should you re-screen them for an STI?

Answer 71

6 months after if the risk persists

Question 72

What is the most sensitive and specific test for chlamydia trachomatis

Answer 72

NAAT can use first catch void urine, vaginal(including self-collected), endocervical or urethral specimens are all suitable for NAAT testing

Question 73

what is better for chlamydia NAAT, first catch or midstream?

Answer 73

midstream likely adequate but first catch is better

Question 74

Is serological testing an appropriate way to screen for chlamydia?

Answer 74

nope, lots of cross reactivity and hard to interpret | if no risk factors, should do a urine screening specimen

Question 75

a ten year old is diagnosed with chlamydia, you have treated them, do you need to test them again?

Answer 75

yes, should do test of cure with NAAT 3-4 weeks after completing therapy for prepubertal individuals (as well as the people specified below)

Question 76

a fifteen year old is diagnosed with chlamydia, you have treated them, do you need to test them again?

Answer 76

``` only if 1. compliance uncertain 2. alternative treatment used 3. re-exposure likely 4. pregnancy and again its 3-4 weeks ```

Question 77

What is the best way to screen asymptomatic individuals for gonorrhoea?

Answer 77

first catch urine for NAAT | pharyngeal samples if history of oral sex and rectal samples if receptive anal intercourse

Question 78

When should you use you use culture instead of NAAT for the detection of gonorrhoea?

Answer 78

(especially important since increasing resistance of gonorrhoea) 1. sexual abuse of children 2. sexual assault with treatment failure 3. PID 4. symptomatic MSM 5. infection overseas or with recognized antimicrobial resistance

Question 79

true or false, NAAT is validated for pharyngeal infections?

Answer 79

false - validated for urine, urethreal and cervial samples can also detect rectal and oropharyngeal infections but are not in Canada used of this propose also remember that NAAT will not tell you antibiotic susceptibility **also NAAT has not been validated for children <12 years old and for medico-legal specimens

Question 80

Who needs test of cure for gonorrhoea?

Answer 80

1. second-line or alternative treatment 2. antimicrobial resistance 3. compliance is uncertain 4. high re-exposure risk 5. adolescent is pregnant 6. previous treatment failure 7. pharyngeal or rectal infection 8. prepubertal child 9. signs/symptoms post treatment

Question 81

10 year old with gonorrhoea, when/how to do test of cure

Answer 81

3-4 days after with culture or | NAAT-2-3 weeks post treatment

Question 82

treated a teenager with lots of random sex with gonorrhoea, when should you repeat screening for gonorrhoea

Answer 82

6 months after with NAAT (same as chlamydia)

Question 83

true or false, can get false-negative RPR in early syphlis?

Answer 83

true, you can enzyme immunoassays may provide a more sensitive screening test for syphilis if EIA is positive, then second test is required

Question 84

when do do follow up testing in syphilis : | usual diagnostic test is syphiilis when lesions, EIA is more sensitive than nontreponemal tests

Answer 84

1. primary, secondary, early latent infection: repeat follow after treating at 1,3,6 and 12 months after treatment of infectious cases 2. late latent infection: 12 and 24 months in late latent causes michelle says primary 1st 4 weeks after - get chancre - painless secondary 2 months - get generalized disease, rashes, fever, LN tertiary - brain and heart latent syphillis - at any point the body can suppress syphillis (becomes latent syphillis) - can occur after any of the stages, asymptomatic latent is early or late early: if acquired within the previous year; late : if acquired with unknown duration treatment: primary or secondary single dose of benathin penicillin if neuro - then IV for 14 days if latent - need penicillin once/week x 3 weeks

Question 85

what is the initial screening test for HIV?

Answer 85

serum EIA is the initial screening test western blot is then the confirmatory test EIA can take up to 6 months with older tests (but can be detected at 3 weeks with newest EIA test)

Question 86

19 year old with symptoms of cervicitis, what to send?

Answer 86

1. vaginal or cervical swab for gram stain, gonorrhea culture and chlamydia (NAAT or culture) 2. swab of cervial lesions for HSV if present 3. vaginal swab for wet-mount

Question 87

Symptoms of vaginitis? what to send

Answer 87

pooled secretions if present if no secretions, swab the vaginal wall to prepare a smear wet mount and gram stain for diagnosis of vulvovaginitis, candidiasis, bacterial vaginosis and trichomonad

Question 88

treatment of gonorrhoea anogenital infections

Answer 88

``` 1st choice (for both 9 year old) : ceftriaxone + azithro or cefixime + azithro Alternative treatment: spectinomycin plus azithromycin (in >9 year old can do 1 or 2 grams of azithromycin) ```

Question 89

treatment of gonorrhoea pharyngeal infection

Answer 89

1st choice: ceftriaxone plus azithromycin | Altertnative: cefixime plus azithromycin (doses a bit different per age but not going to remember this)

Question 90

why is azithromycin preferred over doxycycline for treatment of gonorrhoea?

Answer 90

lots of resistant gonorrhoea also poor compliance with longer course, and contraindicated in breastfeeding women and children <9 year old azithromycin is preferred

Question 91

what is the risk of using a macrolide in a neonate?

Answer 91

hypertrophic pyloric stenosis **they do say to use ceftriaxone in neonates for treatment, but I thought we didn't normally do this because of bill displacement - discuss

Question 92

Name some ways to do primary prevention of STIs?

Answer 92

vaccination against hepatitis B and HPV, condom use and behavioural changes

Question 93

secondary prevention of STIs:

Answer 93

1. partner notification | 2. treatment and screening for STIs in asymptomatic young adults

Question 94

you have diagnosed an STI, what are some important manager steps

Answer 94

1. provide education and amangement strategies for the partners of individuals with STIS for infection control and patient well-being 2. reportable diseases - need to report it 3. directly observed therapy can help with compliance in teens 4. check for other STIs including HIV (since have common risk factors)

Question 95

Lyme disease testing

Answer 95

ELISA is IGM - have lots of false positive (i.e. with lupus) | then second step is Western Blot - tells you what type of IgM - much more specific with lyme

Question 96

if lyme arthritis fails treatment

Answer 96

1. NSAIDS 2. hydroxyquine 3. synovectomy switch to IV

Question 97

fluconazole vs voriconazole

Answer 97

fluconazole - good for candida and crypto voriconazole - for aspergillosis ampho B - for febrile neutropenic