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infections Flashcards

1
Q

what is the role of ART

A

Suppress viral replication
Control immune activation
Preserve existing immunity and permitting recovery of lost or dysfunctional immunity.

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2
Q

What is the impact of ART in children

A

Preserves and restores their immunity
Improves growth
Decreased risk for death/ prolong life expectancy
Preserve neurocognitive decline
Reduces infectious disease risk
Preserve vaccine induced responses
Reversal of organ-specific progression to AIDS

The sooner ART is strted the better the outcome

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3
Q

What tests should you do or conditions to exclude before initiating HRT

A

Full clinical assessment: history & examination
* Review all medication and be aware of potential drug interactions
* Nutritional assessment
* Neurodevelopmental screen
* WHO clinical stage of HIV infection
* Screen for TB
* In older children, screen for mental issues including active depression
* Screen for pregnancy (adolescents)
* Symptom screen for sexually transmitted infections (adolescents)
* Confirm HIV test results
* CD4 cell count and percentage
* Hb, if low do FBC and treat accordingly
* Creatinine and eGFR if tenofovir to be used
* Adolescents: Cryptococcal antigen test if CD4 <100 cells/µL; cervical
cancer screen if female; HBsAg

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4
Q

What renel function tests are done for pregnant women before initiating HRT

A

Absolute creatinine level
<85 umol/l

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5
Q

What renal tests should be done for adults and adolescents over 16 years before initiating ART

A

eGFR using MDRD equation
>50

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6
Q

What renal function tests should be done for adolescents at the ages 10-16 before initiating ART

A

eGFR using Counahan Barratt formula
>80

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7
Q

What are the indications for ART

A

All people living with HIV (PLHIV) are eligible for ART regardless of age, CD4 count and clinical stage. For all PLHIV
without contra-indications, ART should be started within 7 days

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8
Q

What are the medical indications to defer ART (Contraindications to ART)

A
  1. TB symptoms
    -Drug susceptible TB (Less than 50 cd4 cells initiate ART within 2 weeks, if more than 50 initiate in 8weeks).
    -Children <5 years, If CD4 count ≤200 cells/µL or <15% - initiate ART within 2 wks of
    starting TB treatment
    If CD4 count >200 cells/µL or >15% - initiate ART 2 – 8 wks of starting TB treatment
    -Drug Resistant TB (Initiate ART after 2 weeks of TB treatment, when pt symptoms improving)
  2. Cryptococcal meningitis
  3. Clinical features of liver disease
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9
Q

What are the prefered 1st line regimens for preterm neonates and neonates <2.3 kg

A

Seek expert advice

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10
Q

what is the preferred 1st line HIV regimens for Birth (≥2.0 kg) – <4 weeks (<3.0 kg)

A

AZT (zidovudine) + 3TC (lamivudine) + NVP (nevarapine)

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11
Q

What is the preferred 1st line HIV tx ≥4 weeks (≥3 kg) – <10 years (<30 kg)

A

ABC (abacavir) + 3TC (lamivudine) + DTG (dolutegravir)

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12
Q

What is the preferred 1st line HIV treatment for children ≥10 years & ≥30 kg

A

TDC (Tenofovir) + 3TC (lamivudine)+ DTG (dolutegravir) (TLD)

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13
Q

What drug interactions occur with Zidovudine

A
  1. Rifampicine decreases the effect of dolutegravir, so increase the dose to 50mg 12hrly
  2. Polyvalent cations (Mg, Fe, Ca, Al, Zn eg Antiacids, sulfate, multivitamin and nutritional supplements) decrease the effect of dolutegravir.
    Soln: Ca and Iron decreases DTG if taken together on an empty stomach, to prevent this, take ca and DTG taken together with food but calcium and iron should be taken 4 hours apart.
    Mg and aluminium containing antiacids decrease DTG regardless of food intake, should be taken min 2hours or 6hours before DTG.
  3. Anticonvulsants: Carbamezapine, Phenobarbatal, Phenytoin decrease DTG concentration
    Avoid and use alternatives: Valproate, Lamotrigine, Levetiracetam, topiramate. Valproate contraindicated in pregnancy
    Double dose of DTG to 50mg 12hrly if alternative anticonvulsant cant be used.
  4. Metformin: DTG increases the effects of metformin
    Max dose 500mg 12hourly
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14
Q

WHen do you monitor fofr TDF-induced nephrotoxocity

A

creatinine at months 3 and 10, thereafter repeate every 12 months

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15
Q

When to monitor for Anaemia and neutropaenia

A

If on AZR, do Fbc and wcc at month 1 and 3, thereafter repeat if clinically indicated

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16
Q

when to monitor for dislipidemia

A

Total cholesterol and TGs at month 3, if above acceptable, do fasting cholesterol and TGs
If acceptable, obtain expert advice

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17
Q

When to monitor viral load and response to treatment after initiating ART

A

Routine monitoring at 3 and 10 months thereafter if virally suppressed, every 12 months

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18
Q

What is virally suppressed

A

<50 copies/mL = undetectable
(suppressed VL)

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19
Q

What could potentially cause a high VL in a pt on ART

A
  1. Adherence
  2. Bugs (infections)
  3. inCorrect ART dosage
  4. Drug Interactions
  5. rEsistence (if >2yrs on tx)
  6. poor absorption
  7. incorrect dosing
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20
Q

What are some of the factors that affect adherence to ART

A

– Inadequate counselling and education of caregivers
– Caregiver factors: non-disclosure to family, physical illness, depression, untreated affective disorders, substance abuse,
change of caregiver
– The more complex the antiretroviral regimen the less adherent:
number of tablets, frequency of administration, processing such
as crushing, mixing, dissolving & measuring.
– Side effects: patients may discontinue medication to avoid side effects

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21
Q

How to maintain good adherence to ART

A

(think of causes of poor adherence)

. Education / counselling
* Give patients feedback
* Support groups & treatment clubs
* Simplify medication
* Link medication to daily activities, educate caregivers about
consistency
* Manage side effects
* Provide tools: pill boxes, reminder calls

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22
Q

Which drugs are used for drug susceptible TB in SA and what effects do they have

A

Isoniazid (high early bactericidal activity, kills actively dividing bacteria)
Rifampicin (major sterilizing agent)
Pyrazinamide (kills dormant or slow dividing bacilli)
Ethambutol (efficacy against actively replicating bacilli)
Ethionamide (high CSF penetration)

23
Q

Which TB treatment do you give to HIV negative children with minimal PTB

A

Intensive phase: 2HRZ (Isoniazide, Rifampicin, Pyrazinamide)
Continuation phase: 4HR

24
Q

Which TB treatment do you give to HIV negative children with extensive PTB or severe forms of extrapulmonary TB

A

intensive phase: 2HRZE
Continuation phase: 4HR

25
Q

What TB tx do you give to HIV infected children (with all forms of EPTB except TBM or miliary TB)

A

Intensive phase 2HRZE
Continuation phase: 4-7 HR

26
Q

What TB tx do you give to all children (with TBM and miliary TB

A

Intensive: 2HRZEt
continuation: 4-7 HRZEth (NB Ethionimide has high CSF penetration)

27
Q

what is multi-drug resistant TB

A

resistance to both INH and RIF
with/without resistance to other anti-TB drugs

28
Q

What is Extensive drug-resistent TB (XDR-TB)

A

resistance to rifampicin
(and may also be resistant to isoniazid), and that is also resistant to at
least one fluoroquinolone (levofloxacin or moxifloxacin) and at least one
additional Group A drug, either BDQ or LZD

29
Q

How to diagnose drug-resistant TB in paeds

A
  1. Culture-unconfirmed TB with a drug-resistant TB contact
    – TB treatment regimen is based on the susceptibility of the isolate causing TB in the household/close contact

2* Rifampicin resistance identified by Xpert MTB/RIF Ultra

3* TB isolates cultured from children:
– Hain line probe assay screening for INH & RIF resistance
– If INH & RIF resistance detected on the LPA, DR-TB reflex
testing will be don

30
Q

Define Pre-extensively drug-resistant TB (pre-XDR-TB)

A

resistance to
rifampicin (and may be resistant to isoniazid), and that is also resistant
to fluoroquinolones

31
Q

What is IRIS

A

unmasking of new TB disease
Paradoxical worsening of established disease

32
Q

Discuss the manifestations of IRIS

A

– Swinging fever
– New/worsening lymphadenitis
– New/worsening pulmonary infiltrates, respiratory
failure
– New/worsening pleuritis, pericarditis, ascites
– Intracranial tuberculomas, TBM
– Disseminated skin lesions
– Hepatosplenomegaly, soft tissue abscesses

33
Q

How do we treat IRIS

A

– Expectant
– Glucocorticosteroids

34
Q

How is BCG administered in SA

A

BCG is injected on the upper right arm at the insertion of the deltoid muscle.
The dose is 0.05 ml administered with a special BCG syringe, at birth.

35
Q

What are the contraindications of BCG

A
  1. Children over 12 months of age not for BCG
  2. Children with symptoms of HIV infection
  3. HIV-exposed newborns who are well enough to be discharged should
    be given BCG
  4. If HIV-exposed newborns are sick the birth PCR should be checked, and BCG administered if the PCR result is negative
  5. If mother has TB and is on Anti TB drugs, child should be given TB preventive treatment and BCG only after TB treatment has been completed
36
Q

What are the complications of BCG

A

Local BCG disease- papular eruption, ulceration
2. Regional BCG disease- Ipsilateral lymphadenitis, suppuration, fistulation
3. Distant/ disseminated BCG disease- lymphadenitis, pulmonary disease, BCG osteitis, dissemination

  1. BCG Iris - 3months of starting ART
  2. Erythema nodusum
  3. Lupus vulgaris
  4. Uveitis
37
Q

Who should be given TB Preveventive tx

A

All adult, adolescent and child contacts in whom TB disease has been ruled out

38
Q

what Preventive tx do you give to drug susceptible TB contact after TB exposure
(NB HIV + and HIV neg)

A

HIV-negative children: Daily isoniazid plus rifampicin for 3 months using the
NDoH dosing recommendations
HIV-infected children: Daily isoniazid for 6 months

39
Q

What TB preventive tx do you give to Isoniazid monoresistant TB contact

A

Rifampicin 10-15 mg/kg/day per os for 4 months

40
Q

What TB preventive tx do you give to Rifampicin monoresistant TB contact

A

Isoniazid 10 mg/kg/day per os for 6
months

41
Q

What TB preventive tx do you give to MDR-TB TB contact

A

▪ Isoniazid 15-20 mg/kg/day plus ethambutol 20-25 mg/kg/day plus
levofloxacin 15-20 mg/kg/day per os for 6 months
▪ Levofloxacin 15-20 mg/kg/day per os for 6 months (likely to be
recommended in the near future)

42
Q

What TB preventive tx do you give to xDR-TB TB contact

A

▪ Isoniazid 15-20 mg/kg/day per os for 6 months
▪ Regular follow-up for two years
▪ Ensure household infection control practices are observed
▪ Children who develop active infection should be referred

43
Q

How effective is TB preventive treatment

A

Provisional finding ex TB-CHAMP
study:
Levofloxacin preventive treatment
reduced risk of MDR-TB by 56%

44
Q

How to prevent meningitis

A

The general stuff: hygiene, tx infections otitis media, head injury etc

Vaccines (bacterial)
Pneumococcal vaccine for over 2months old
Meningococcal vaccines for 11-12 years
H.Influenza type b virus from 2months

45
Q

Symptoms and signs of meningitis

A

Fever
Vomiting
Headache
Photophobia
Poor feeding
Hugh pitched cry
Lethargic
Neck stiffness
Bulging fontanelle in babies
Purple-red splotchy rash

Severe
Convulsions
Confusion
Hallucinations
Staggering or swaying when walking
Loss of consciousness

46
Q

Which organisms cause meningitis

A

Neonates
Bacterial: Group B strep, Listeria, EColi

In 1year or older
Viruses: CMV, herpes simplex virus, enterovirus
Bacteria: Neisseria meningitis, strep pneumonia, haemophilia influenza
Fungal: cryptococcus
TB
Parasites: toxoplasmosis?

Adults: strep pneumonia, Elderly: listeria

In older
Virus: Polio, enteroviruses

47
Q

Complications of meningitis

A

Sepsis/shock
Hearing loss
Brain damage: intellectual disabilities
Long term seizures
Hydrocephalus

Other short term: SIADH presenting as Hyponatremia, cerebral oedema, brain abscesses, secondary infections eg pneumonia, pericarditis

48
Q

Treatment of meningitis according to the causative organism

A

Strep pneumonia: IV Penicillin or IV ceftriaxone, if resistant IV Vancomycin
H. Influenza: IV ceftriaxone
Nisseria meningitis: Ciprofloxacin oral single dose or ceftriaxone IM single dose, or IV Penicillin for 7d

49
Q

What type of meningitis do you get petechia or purpura and hypothermia

A

Meningococcal

50
Q

Contraindications to Lp

A

Infection at site
Signs of raised ICP
Bleeding disorders
Congenital anomalies of lower spine (meningomyelocele)
Extremely ill infant

51
Q

Drug Tx for raised ICP

A

Mannitol 0.25-1.5 g/kg in children <12

52
Q

What is the normal CSF glucose

A

2.5mmol/l, it is about 2/3 of serum glucose

If lowered, consider bacterial meningitis

53
Q

Treatment of TB meningitis

A

Rifampicin 20mg/kg PO as single dose
Isoniazide 40mg/kg PO as single dose
Pyrazinamide 40mg/kg PO single dose
Ethionamide 20mg/kg PO as single dose

Tx is a 6month regimen

Paeds (24 decks)

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