Infectious Disease Flashcards
5-year-old unimmunized boy with H. influenzae meningitis. Has brothers who are 3, 10 and 16 years old, who are also not immunized. Who requires prophylaxis?
No prophylaxis indicated
All household members
All household members and hospital staff
Only the 3-year-old requires prophylaxis
All household members
5 groups eligible for RSV prophylaxis
• Born @ <30 wk GA and <6 months of life at start of season
• HD significant cardiac disease and <12 months of life
• BPD / CLD and <12 months of life, or <24 months if recent O2 needs
• Broader indications:
• Infants in remote communities who would require air transportation for hospitalization born before 36 + 0 weeks’ GA and <6 months of age at the start of RSV season
• Consideration may be given to administering palivizumab during RSV season to term Inuit infants until they reach six months of age
Who should be treated with prophylaxis after Hib exposure?
Chemoprophylaxis Recommended
For all household contacts in the following circumstances:
Household with at least 1 child younger than 4 years who is unimmunized or incompletely immunizedc
Household with a child younger than 12 months who has not completed the primary Hib series
Household with an immunocompromised child, regardless of that child’s Hib immunization status or age
For preschool and child care center contacts when 2 or more cases of Hib invasive disease have occurred within 60 days (see text)
For index patient, if younger than 2 years or member of a household with a susceptible contact and treated with a regimen other than cefotaxime or ceftriaxone, chemoprophylaxis at the end of therapy for invasive infection
Chemoprophylaxis Not Recommended:
For occupants of households with no children younger than 4 years other than the index patient
For occupants of households when all household contacts are immunocompetent, all household contacts 12 through 48 months of age have completed their Hib immunization series, and when household contacts younger than 12 months have completed their primary series of Hib immunizations
For preschool and child care contacts of 1 index case
For pregnant women
Routine vaccination recommended from 2 months til 5 years
Not needed after 5 years unless other health conditions as at decreased risk of invasive disease
3-year-old with otalgia, bulging and erythematous tympanic membrane. Fever for 5 days. Retroauricular swelling with anterior displacement of ear. How would you manage?
PO amox/clav
IV cefotaxime
IV vancomycin
PO azithromycin
IV cefotax
Mastoiditis–needs admission for IV 3rd gen cephalosporin
Strep pneumo most common bacteria.
CT scan of temporal bone to confirm diagnosis and CT head to identify intracranial complications.
Add Vanco if intracranial infection suspected.
What is the BEST agent to use for lice in a geographically resistant area?
Permethrin
Pyrethrin
Lindane
Resultz
Permethrin (Nix)
a. Permethrin—first line (however resistance documented)
b. Pyrethrin—first like (however resistance documented)
c. Lindane—not recommended due to absorption and risk of neurotoxicity and bone marrow suppression
d. Resultz—no resistance, isopropyl myristate 50% and ST-cyclomethicone 50%, approved for >= age 4
A pregnant woman develops varicella 7 days prior to delivery. What do you have to do for the neonate?
1 dose of VZIG IM
Acyclovir
VZIG + acyclovir
No therapy required
No therapy required
What are 3 potential interventions for post-exposure prophylaxis for people exposed to varicella?
Potential interventions for people without evidence of immunity exposed to a person with varicella or herpes zoster include:
(1) varicella vaccine, administered ideally within 3 days but up to 5 days after exposure;
(2) when indicated, Varicella Zoster Immune Globulin; or
(3) if the child cannot be immunized and Varicella Zoster Immune Globulin is not indicated, preemptive oral acyclovir or valacyclovir starting day 7 after exposure.
See photo for VZIG indications for exposed people:
16-year-old girl with nausea/vomiting, lethargy, myalgias. Strawberry tongue, diffuse maculopapular rash, conjunctivitis. BP 74/58, HR 170. What is the most likely organism?
S. aureus
Rickettsia rickettsiae
Borrelia burgdorferi
Neisseria meningitidis
S. aureus
- Superantigen toxin from S. aureus or other bacteria (eg. Group A strep)
- Overstimulates the immune system with nonspecific T cell binding
- Streptococcal TSS is most severe (highest mortality rate)
- Associated with retained tampon, surgical packing
- Skin findings: diffuse macular erythroderma (similar to sunburn) followed by desquamation 1-2 weeks after onset (palms and soles may be affected).
- High fever, hypotension
- Strep TSS may progress to nec fasc
- Diagnosis: In addition to hypotension ,at least 2 (Strep TSS) or 3 (staph TSS) organ systems must be affected for diagnosis. Perform bacterial cultures
Neonate with the following rash on their leg (exact picture). Looks well, afebrile with normal blood work (including septic workup and viral studies). Family history of hypopigmentation and dental anomalies. What is the diagnosis?
Incontinentia pigmenti
HSV
Eczema
Incontinentia pigmenti
11 year old girl with elevated ASOT, migrating arthralgia, fevers. She had a normal echo. You treat her with 10 days of antibiotics. How long does she need prophylaxis:
5 years
10 years
Prophylaxis until 18 years of age
No prophylaxis required
10 years
How long should you prophylax to prevent. rheumatic heart disease in person with GAS infection?
What do you prophylax with?
Length of treatment depends on echo findings
1) No carditis: 5 yrs or til 21 yrs of age, whichever is longer
2) Carditis, no valvulitis: 10 yrs or up to 21 yrs whichever is longer
3) Carditis with residual valve lesions: lifetime or up to 40 yrs of age
IM Penicillin q 3-4 weeks (can also do oral but not as practical)
18mo M with a verrucous lesion in his perianal region. He also has warts on his finger. Mom has no history of HPV. How did he get his perianal warts?
Heteroinoculation
Self-inoculation
Sexual abuse
Vertical transmission
self inoculation
4-year-old male with Staph aureus pneumonia, which progressed to lung abscess. He also had a history of pneumonia at 18 months of age. History of impetigo and mouth ulcers. Most likely defect?
B cell
Granulocyte
T cell
Complement
Granulocyte defect: abscesses, mouth ulcers, impetigo
8-week-old infant with cough, conjunctivitis and afebrile. CXR shows bilateral infiltrates. CBC normal apart from some mild eosinophilia. What is the treatment?
PO erythromycin
Amoxicillin
Reassure
Oseltamivir
PO erythromycin
Infants with chlamydial conjunctivitis or pneumonia are treated with oral erythromycin base or ethylsuccinate (50 mg/kg/day in 4 divided doses daily) for 14 days or with azithromycin (20 mg/kg as a single daily dose) for 3 days. Because the efficacy of erythromycin treatment for either disease is approximately 80%, a second course of therapy might be required. Data on the efficacy of azithromycin for ophthalmia neonatorum or pneumonia are limited. Clinical follow-up of infants treated with either drug is recommended to determine whether initial treatment was effective. A diagnosis of C trachomatis infection in an infant should prompt treatment of the mother and her sexual partner(s). Neonates with documented chlamydial infection should be evaluated for possible gonococcal infection. An association between orally administered erythromycin and azithromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported in infants younger than 6 weeks. Infants treated with either of these antimicrobial agents should be followed for signs and symptoms of IHPS.
Treatment of chlamydia in adolescents
For uncomplicated C trachomatis anogenital tract infection in adolescents or adults, oral doxycycline (100 mg, twice daily) for 7 days is recommended (see Table 4.4, p 898). Alternatives include oral azithromycin in a single 1-g dose, or levofloxacin (500 mg orally, once daily) for 7 days.
No test of cure needed, however test for re-infection advised at 3 months
4 month old baby referred because grandfather has cavitary TB. TST negative. What is your best next step?
Repeat TST in 8-10 weeks
Treat with isoniazid and rifampin
Fasting am gastric aspirates x 3
Repeat CXR in 4 months
Repeat TST in 8-10 weeks
(Would also initiate window prophylaxis however window prophylaxis is usually a single drug)
A 9 day-old neonate, born at 32 weeks who presented with a 24 hour history of increasing apneas. His mother was GBS positive and she did not receive prophylactic antibiotics. Blood cultures are positive at 18 hours and are growing gram-positive cocci in clusters. What is the most likely organism?
Staph aureus
GBS
Viridans group strep
Coagulase negative staph
Describe how each organism looks on gram stain and also E. coli on gram stain
CONS
staph aureus: gram positive clusters
GBS: gram positive chains
Viridians group strep: gram positive chains
CONS: gram positive clusters
E. coli: gram negative rods
3 year old boy and his father are having recurrent pinworm infections despite receiving mebendazole three times. His mother and sister are asymptomatic. How should you treat?
One dose of albendazole for dad and brother
Mebendazole with repeat at 14 and 28 days for everyone in the household
One dose of pyrantel for dad and brother
Depending on the version we think… or we’re remembering something wrong?? One of the following:
One dose of albendazole for the entire family
Treatment of the whole household with Pyrantel repeated at 14 and 28 days
Mebendazole at 14 and 28 days for whole house hold.
Red book:
Several drugs will treat pinworms (see Drugs for Parasitic Infections, p 949), including over-the-counter pyrantel pamoate and prescription mebendazole and albendazole. Mebendazole and albendazole are significantly more costly than pyrantel pamoate in the United States. Albendazole currently is not approved by the US Food and Drug Administration for treatment of pinworms.
Each medication is recommended to be given in a single dose and repeated in 2 weeks, because these drugs are not completely effective against the egg or developing larvae stages.
Because reinfection is common even when effective therapy is given, treatment of the entire household as a group should be considered. Repeated infections should be treated by the same method as the first infection. Vaginitis is self-limited and does not require separate treatment. “Pulse” treatment with a single dose of mebendazole every 14 days for a period of 16 weeks has been used in refractory cases with multiple recurrences
An unimmunized 3 year-old boy with presents with a 5 day history of low grade fever and has purulent nasal discharge. Culture was positive for H. influenzae. How do you manage?
Amoxicillin
Conservative
Azithromycin
Cephalexin
Amoxicillin
Uptodate:
Most infections caused by H. influenzae are treated empirically. In general, empiric regimens are designed to include an antibiotic that treats H. influenzae. Antibiotics that have activity against H. influenzae include beta-lactams (eg, amoxicillin, amoxicillin-clavulanate, or second- and third-generation cephalosporins), fluoroquinolones, macrolides, and tetracyclines.
Beta-lactams are generally preferred. Amoxicillin-clavulanate is a commonly used empiric treatment option for localized and non-life-threatening infections, such as otitis media, sinusitis, and acute exacerbations of chronic obstructive pulmonary disease. In patients with systemic infections, such as bacteremia or meningitis, ceftriaxone is the treatment of choice. (See ‘Ampicillin resistance’ below.)
A newborn has the following findings: mucocutaneous rash, hepatosplenomegaly, diffuse lymphadenopathy and osteochondritis. Which of the following congenital infections is most likely?
CMV
Syphilis
Rubella
Varicella-zoster
Syphilis
A 35+6 week neonate is born to a mother with fever at time of delivery. Her GBS status was unknown and she did not receive antibiotics. Rupture of membranes was 12 hours. What is the management?
CBC and observe for at least 24 hours if WBC >5
CBC and observe for at least 24 hours if WBC <5
CBC, blood cultures and treat with IV antibiotics for 36 hours
Reassure and discharge home with routine neonatal care
CBC and observe for at least 24 hours if WBC >5
what is considered adequate prophylaxis for GBS infection in neonates?
penicillin or ampicillin given at least 4 hours prior to delivery or cefazolin in penicillin allergic moms
clindamycin or vancomycin can also be used if mom has high-risk penicillin allergy but these are not considered adequate prophylaxis when treating baby
5 Maternal and neonatal risk factors for early onset bacterial sepsis in term infants
1) prolonged rupture of membranes >18 hours
2) maternal temp at time of delivery
3) curent GBS colonization
4) GBS bacturia at any point in pregnancy
5) previous infant with GBS infection
most common organism isolated in septic asplenic patients
strep pneumo isolated in at least 50% of cases
4 organisms other than strep pneumoniae isolated in septic asplenic patients
H. flu type B, Neisseria meningitides, salmonella species, Capnocytophaga from dog and cat bites
what antibiotic should apslenic patients be given after dog bite and what bacteria is it for
Capnocytophaga canimorsus, amox-clav
What extra vaccines should asplenic patients receive?
Pneumococcus: Prevnar-13 (PCV13), Pneumococcal polysaccharide vaccine (PPV23)
Meningococcus: Quadrivalent meningitis vaccine (MCV4) (Men A,C,W,Y).
Hib: All apslenic patients who have never received Hib Immunization or have missed one or more doses should be vaccinated age >= to 5 yrs.
Influenza
Salmonella: S typhi if travelling to developing country
What are 2 antibiotics that can be used for prophylaxis in asplenic patients? what antibiotic can be used if allergy? how long do they need to take them
PenV or Amoxicllin
Clarithromycin if allergic
Prophylaxis for all children <5 yrs of age AND for a minimum of 2 years postsplenectomy
What tropical disease are apslenic patients at increased risk for?
Malaria
Note: sickle cell protective against malaria, other aplsenic patients at risk for malaria
what antibiotic should be used in febrile asplenic patients?
Ceftriaxone +/- Vanco to treat strep pneumoniae
Nephrotic syndrome. Fever, ascites, abdominal distension. A peritoneal tap is done. What is the most likely organism?
Streptococcus pneumoniae
Escherichia coli
Enterococcus faecalis
Bacteroides fragilis
Strep pneumo
Gram negative bacteria also associated with many cases
A 3-year-old child has a history of a Streptococcus pneumoniae pneumonia and several episodes of otitis media. He has also had a previous infection with Giardia lamblia. What will give you the diagnosis?
Lymphocyte count
CH50
Respiratory oxidative burst
IgM, IgG, IgE and IgA levels
Immunoglobulin levels as giardia, strep pneumonia, and otitis media fit with B cell disorder
CH50–complement disorder
Respiratory oxidative burst–phagocyte defect
Lymphocyte count–T cell defect
How does chronic granulomatous disease/phagocyte defect present and what test do you use to diagnose?
Normal cell counts but inability of phagocytes to kill bacteria
Get recurrent abscesses throughout the body:
-cellulitis
-osteomyelitis
-gum abscesses
-GI/colitis
-upper and lower respiratory infections
Use respiratory oxidative burst to diagnose
2 month old male admitted with RSV bronchiolitis. He has moderate work of breathing and diffuse crackles and wheeze with decreased air entry at the right upper lung field on exam. He sats at 96% on 0.5L O2 and drops to 84% on room air. He is afebrile and feeding well. What is your management?
CXR
Supportive
Humidified high flow O2
Short-acting beta agonist
Supportive (CPS guideline and AAP no good evidence for HFNC)
A 4-year-old girl with fever, diffuse lymphadenopathy and hepatosplenomegaly. She has ulceration of her tonsils and oral mucosa. Her WBC is 25, Hg 100 and platelets 30.
Acute lymphoblastic leukemia
Lymphoma
EBV
Systemic JIA
Answer: Acute lymphoblastic leukemia—2 cell lines down, high WBC can be seen, overall very unwell
Lymphoma—usually large lymph node, less sick
EBV—usually asx in young
Systemic JIA—usually have high WBC, and high platelets (low or normal platelets should prompt evaluation for other diagnosis such as malignancy as per up to date, may have mild anemia. Overall sJIA is diagnosis of exclusion).
A 7 year old male with known hereditary spherocytosis presents with lethargy. His hemoglobin dropped from 100 to 40 and his retics are 1%. What is most likely to be responsible for this?
EBV
Parvovirus B-19
Coxsackie
***
Parvovirus B19
trigger of aplastic anemia (red cell aplasia), bone marrow freezes, no more production of retics and causes profound anemia
A 12 year old female with sickle cell anemia is going on a trip to South Asia. For which pathogens does her underlying disease put her at biggest risk?
Dengue
Typhoid fever
Hepatitis A
Tuberculosis
Typhoid fever–>Salmonella
A 3 year old male with 1 week of sore throat and cough. 4 days ago he started azithromycin, amoxicillin and tylenol. He now presents with the following rash.
What is the most likely cause?
Amoxicillin
Azithromycin / Tylenol?
Mycoplasma
HSV
(picture of crusty rash on lips, face, legs)
Mycoplasma—Mycoplasma pneumonia induced rash and mucositis (MIRM)—severe mucositis and rash preceded by prodome of cough, fever, malaise approx. one week prior to onset of their symptoms
Can also get rash if you give amoxicillin to a patient with EBV but it is diffuse maculopapular rash. Develops a few days after amoxicillin. Can develop into erythroderma.
Kid with resp symptoms, SpO2 92% on RA. CXR shows LLL consolidation. What do you treat with?
IV Ceftriaxone
IV Ampicillin
IV Vanco
IV C***
IV ampicillin
Once child with AO/SA has responded to IV antibiotics, which PO antibiotic should you switch them to?
Cephalexin (kingella resistant to Cloxacillin)
Cloxacillin if susceptive MSSA (however tastes bad)
Clinda, TMP-SMX, or linezolid if MRSA
A (child age) ***-year-old female presents with 3 days of pain at the distal tibia. CRP and ESR are elevated. MRI with gad confirmed osteomyelitis. What do you treat with?
IV cloxacillin
IV cefazolin
IV clindamycin
IV ertapenem (lol this probably wasn’t the antibiotic)
Answer: IV cefazolin. If MSSA is identified can subsequently narrow to cloxacillin or continue cefazolin; however K kingae is resistant to clox.
As per CPS statement:
Can treat with first-generation cephalosporin as most cases due to MSSA or Kingella kingae
K kingae is resistant to clinda, Vanco, and Cloxacillin
If unvaccinated and in area of invasive H flu should broaden to cefuroxime (2nd gen)
what generation cephalosporin is cefazolin?
1st
what generation cephalosporin is cephalexin?
1st
what generation cephalosporin is cefoxitin?
2nd
what generation cephalosporin is Cefprozil?
2nd
what generation cephalosporin is Cefuroxime?
2nd
what generation cephalosporin is Cefaclor?
2nd
what generation cephalosporin is cefotaxime?
3rd
what generation cephalosporin is ceftazidime?
3rd
what generation cephalosporin is cefixime?
3rd
what generation cephalosporin is Cefepime?
4th
How long should you treat uncomplicated osteomyelitis with antibiotics? what about if hip is involved?
3-4 weeks
4-6 weeks if hip involved
what is the time difference between acute and chronic osteomyelitis?
chronic: present for >1 month
How does bacteria get into the blood stream to cause acute osteomyelitis and septic arthritis?
mucus membranes, upper respiratory tract
what bacteria cause bone and joint infections? (4)
What about if unimmunized?
Staph aureus (most common overall), Kingella kingae (most common in children <4 yrs), strep pneumo, strep pyogenes
Kingella esp common in infants
H. flu in unvaccinated
Clinical presentation of transient synovitis of the hip
Usual age 4-10 yrs
Hip pain and new limping
Low grade fever <38.5
Can usually weight bear but may not
History of URTI in preceding 2 weeks
Non toxic appearance
Gradually improves over several days
Responds well to NSAIDs
How to differentiate lyme mono arthritis from septic arthritis
lyme much less painful than SA
Usually no recent fever
Baker’s cyst may be present
Often still willing to weight bear
CRP is <40
Clinical presentation of chronic recurrent multifocal osteomyelitis (CRMO)
Insidious onset of bone pain
Lesions affect metaphysis and epiphysis
May have low grade fever and malaise
pain often worse at night
Diagnosis based on relapsing disease course
Lesions often involve unusual sites such as clavicle, jaw, or scapula
May be intense sclerosis with healing on radiographs
On physical exam, may have local tenderness with some warmth and swelling, but sometimes no objective signs
1/3 may have low grade fever, malaise, weight loss
May have palmoplantar pustulosis, psoriasis, or other dermatologic conditions
How to differentiate boney pain from hematologic malignancy from osteomyelitis/septic arthritis
Prominent systemic complaints in heme malignancy
Child may have reluctance to walk or have metaphyseal licences and periosteal reactions as with acute OM.
On exam, no localized pain to palpation but may have joint swelling and evidence of mild synovitis on joint exam
May have mild fever
Differentiating bone neoplastic lesion from osteomyelitis
Typically occurs in the diaphysis or in flat bones
typically more gradual onset
Pain often worse at night
Differentiating JIA from Septic arthritis
Gradual onset
Oligoarthritic or polyarthritic
More likely to be symmetric with extra-articular symptoms
Often symptoms less severe compared with bacterial SA.
May have contracture.
Usually fewer WBC in joint fluid compared with SA
Differentiating SLE from septic arthritis
constitutional symptoms
cutaneous symptoms
milder arthritis
heme abnormalities: leukopenia and anemia (in sJIA leukocytosis and elevated platelets, mild anemia)
abnormal urinalysis
differentiating reactive arthritis from SA
oligoarthritis of larger joints, usually 2-3 weeks after preceeding infection of GI or urogenital tract
may also have occur and urinary symptoms
arthritis is more subacute and less severe compared with bacterial SA
Reactive arthritis vs transient synovitis of the hip
Reactive arthritis: usually 2-3 weeks after GI or urogenital infection, but may happen concurrently with infection, elevated ESR or CRP, may have enthesitis
Transient synovitis of the hip: usually URTI 2 weeks prior, low grade fever, well appearing, CRP <20
Clinical presentation of post streptococcal reactive arthritis
acute onset of symmetric or asymmetric arthritis
usually polyarticular and non-migratory and can be persistent or recurrent (in ARF, migratory joint involvement)
usually 3-14 days after preceding strep infection
may have extra articular manifestations ex. vasculitis, glomerulonephritis
what use does X-ray, ultrasound, and MRI with gadolinium enhanced have in workup of ostemyeltisis/SA?
X-ray: may be normal as abnormalities often develop up to 21 days after infection, however used to exclude other causes such as neoplasms and fractures. Can see joint effusions on Xray in SA.
Ultrasound: fluid collection in subperiosteal areas and soft tissues, or excess fluid in joint space, may be able to characterize if fluid is reactive or not
MRI: most sensitive and specific, bone marrow edema is earliest finding of AO. Can determine if fluid in SA is inflammatory
An infant was IUGR and has sensorineural hearing loss and urine positive urine for CMV. What do you do for management?
Ganciclovir for 2 weeks
Valganciclovir for 4 weeks
Valganciclovir for 6 months
No treatment
Valganciclovir for 6 months
CPS statement: “Expert opinions differ regarding treatment of infected infants with isolated SNHL. Definitive recommendations await results of ongoing trial, but existing observational data suggest benefit “
5 month female with a febrile UTI (positive nitrates and >50 WBC and many bacteria) with in and out catheter. Treated with PO Cefixime and improves. Back to baseline, well and afebrile. Culture results available after 3 days, grew E. coli >10^8 resistant to amoxicillin, cephalosporins, and TMP-SMX. Only sensitive for ciprofloxacin and gentamicin. What do you do?
Admit for IV gentamicin
Repeat urinalysis and culture
PO ciprofloxacin
PO nitrofurantoin
Repeat urinalysis and culture
Incidence of cCMV
0.5-1% of live births in NA and Europe, 6% of live births in developing countries
clinical features of symptomatic cMV at birth (6)
microcephaly
IUGR
hepatosplenomegaly
petechial rash
jaundice
seizures
physical exam findings cCMV
General: SGA, microcephaly, jaundice, hydrops
Skin: petechiae
Resp: pneumonitis
Abdo: HSM
CNS: seizures, poor suck, hypotonia, lethargy
hearing
Eye: chorioretinitis, optic atrophy, microphthalmia, retinal scars, strabismus, cortical visual impairment
Lab abnormalities in cCMV
low platelets, other cell line suppression may occur (thrombocytopenia and anemia also seen in congenital syphillis)
transaminitis (elevated ALT)
Hyperbilirubinemia: increased conjugated
spinal fluid abnormalities: pleocytosis, elevated protein, positive CMV PCR
Head imaging findings in cCMV
periventricular calcifications, cysts etc
within what time frame should you test symptomatic infants body fluids for cCMV?
within 21 days of life
after 21 days may be perinatal or post natal infection
how to test for cCMV?
‘Gold standard’ test: Urine CMV PCR/shell vial before 21 days postnatal age
Other positive tests before 3 days postnatal age: CMV PCR on a) newborn DBS, b) saliva PCR, if confirmed by urine or other*
*Blood or CSF are not recommended as routine tests, but if positive before 3 weeks post-birth, would confirm cCMV.
Not antibody tests as these might represent maternal transplacental antibodies
What are the indications for infant testing for cCMV?
1)Antenatal Indicators of risk:
a) Maternal CMV infection
b) Fetal ultrasound with findings suggestive of cCMV
c) Placental pathology consistent with CMV infection
2) Other indicators of potential risk:
HIV exposure
Primary immunodeficiency
3) Features consistent with symptomatic cCMV
4) A failed newborn hearing screen or confirmed SNHL
What workup should be done when cCMV has been confirmed?
1) Blood: CBC, differential; Bilirubin; ALT, AST‡
±CSF if done as part of workup for seizures/sepsis, request CMV PCR testing
2) Imaging:
HUS unless there are neurological concerns, then MRI†
If HUS is abnormal, follow with MRI†
3) Hearing evaluation
4) Ophthalmological evaluation
How are infants with cCMV classified?
Confirmed (positive gold standard test BEFORE 3 weeks OR newborn DBS-positive) vs. Probable (positive gold standard test AFTER 3 weeks PLUS CMV-specific features)
3 subclasses under CONFIRMED cases:
1) Asymptomatic +/- SNHL
-no clinical or lab abnormalities
2) Mildly symptomatic +/- SNHL
-1 to 2 isolated, transient, mild features of cCMV WITHOUT Chorioretinitis or CNS involvement (ex. mild transaminitis or thrombocytopenia)
3) Moderate to severely symptomatic +/- SNHL
Who should be treated for cCMV? (3)
Who does not need treatment?
CNS disease
Chorioretinitis
Severe single or multi-organ disease
SNHL–debated but treatment has shown improvement
No treatment if mild disease (transient or minor abnormalities in one or two organ systems with no CNS involvement)
What is the recommended treatment for cCMV?
Antiviral treatment should commence in first month of life and be administered for 6 months
Valganciclovir (16 mg/kg/dose by mouth, twice per day, for 6 months)
IGanciclovir (6 mg/kg/dose IV twice per day) may be used for the first 2 to 6 weeks before transitioning to valganciclovir for very sick neonates
What does follow-up entail for cCMV patients? (monitoring and services)
Monitoring on treatment:
CBC/differential weekly x 1 month; every 2 weeks x 2 months then monthly x 3 months
AST, ALT, urea, creatinine monthly x 6 months
Follow-up
Audiology: Frequent tests in the first 2 to 3 years, then yearly until school age.
Testing frequency is determined by audiology based on results from previous testing.
Ophthalmology: Evaluate as soon as possible after cCMV is confirmed. Follow-up testing is based on initial findings.
Neurodevelopmental follow-up: Child should be followed closely in the first 2 years. Frequency of follow-up in first 2 years and thereafter should be determined by neurological concerns and initial assessment.
Dental: Enamel hypoplasia
Vestibular dysfunction: OT
list 2 1st gen cephalosporins, 3 2nd gen, 4 3rd gen and 1 4th gen and say if they’re PO or IV or both
1st:
Cefazolin–IV (think osteoinfections)
Cephalexin–IV or PO
2nd:
Cefoxitin–IV (think PUD)
Cefprozil–PO (think what Dr. Moore likes for AOM)
Cefuroxime–PO or IV
3rd:
Ceftriaxone
Cefotaxime
Cefixime
Ceftazidine
4th:
Cefepime
Mom is anti-HCV positive and + Hep C PCR positive. Baby is now 6 months old. Baby Anti Hep C antibody negative. What investigation do you do now?
If neg at 6 months, too early but will always be neg, reassure
If positive at 6 months, too early may be mom’s antibodies so repeat
A-Hep C PCR
B-Retest Hep C antibody at 12-18 months
C- no further investigations
No further investigations
If neg at 6 months, will always be neg, reassure
If positive at 6 months, too early may be mom’s antibodies so repeat
Rheumatic fever with no chorea and no carditis
No prophylaxis
Prophylaxis for 5 years
Prophylaxis for 10 years
Prophylaxis for life
prophylaxis for 5 yrs
4 year old who has had high fevers at home, 2 days later he developed a rash on the face. He was diagnosed with fifth disease (it said that). What do you recommend about returning to daycare:
a) Can not return until Rash resolves
b) Can not return until fever resolves
c) Must wait 7 days from onset of symptoms
d) Keeping him away from school will be un-effective as once the diagnosis is made
keeping away from school is ineffective
Canada public health:
Exclusion not required since no longer infectious once rash appears. However, children who are febrile should be excluded until fever free and able to participate in regular programs. Infected children with sickle cell or other forms of chronic anemia and pregnant staff are advised to consult with their health care professional
A 6 year old girl presents with 3 weeks of vulvar discomfort and intermittent wetness and yellow staining of her underpants. She appears well. On examination she has redness of the medial surface of the labia majora extending to the perineum with yellow vaginal discharge. What is the most appropriate management?
Oral amoxicillin - GAS
Topical clotrimazole
Oral mebendazole
Greater attention to hygiene
oral amox –GAS
Adolescent. 3 days worsening pain + fever. Illustration of bilateral tonsils with white exudate. She has posterior cervical lymphadenopathy
Penicillin
Acyclovir
Supportive
Supportive–mononucleosis
Strep throat has anterior cervical lymphadenopathy
Repeat. Child with mastoiditis on ceftriaxone. He becomes lethargic, what do you do next:
MRI/MRV
Add vancomycin
Myringotomy tubes
MRI/MRV
Assess for sinus venous thrombosis
acute AOM with complications CPS statement
Who qualifies for home RSV prophylaxis.
a. 2mo with cystic fibrosis
b. 4 mo ex 31+6 wk without chronic lung disease
c. 9 mo ex 33+6 wk with chronic lung disease requiring home O2
d. Born 30-32 weeks
9 month ex 33 wk infant with chronic lung disease requiring home O2
What are the current recommendations for HPV Vaccine for 15 year old boy
A- 2 doses; now and 6 months later
B- 3 doses; now, then at 1, and 6 months
C- No vaccine
D- Wait until he is sexually active
3 doses, now then at 1, 6 months
Government of Canada:
HPV4 or 6 vaccines should be administered at 0,2,6 months in people >=15 yrs
For kids age 9-14, can do 2 or 3 dose schedule
5-year-old girl recently immigrated from East Africa comes into ER. She is febrile >39 C and has a decreased level of consciousness. She’s jaundiced with hepatomegaly. Which investigation is most likely to give you her diagnosis?
A-Blood smear - thick and thin smears
B-Blood culture
C-Brain MRI
D-Hgb electrophoresis
thick and thin smear
C Diff treated with PO Flagyl. Now recurred with 5> stool and positive toxins (2 months later), c diff positive. What to do?
A- Observe
B- PO Flagyl
C- PO Vanco
D- IV flagyl, PO vanco
PO flagyl
Relapse does not mean drug resistance. After first recurrence repeat regimen used for initial treatment. For second recurrence use Vanco.
For severe disease treat with PO Vanco.
For mild, discontinue precipitating antibiotics, follow-up, no abx.
Moderate disease treat with flagyl.
Tubo-ovarian abscess on seen US 3 days ago. No mention of vitals. What is the next step?
IM Cetriaxone x 1 and Doxycycline PO x 2 weeks
Admit and start IV Clindamycin and Gent (might have just said IV Clinda and Gent)
Surgery referral
Single dose Cefixime and Azithro
?IV antibiotics
Tuboovarian abscess = PID (gold standard = surgical identification)
Ceftriazone 250 mg IM x 1 plus doxy 100mg PO BID x 14 days + metronidazole 500mg PO BID x 14 day for anaerobes (IV treatment cefoxitin 2g q6h, doxy 100mg PO/IV q12h, flagyl)
Can happen with IUD placement (within 21 days), dont have to remove but at least 2 doses Abx before removal
Hospitalizations: pregnant, appe cant be excluded, not responding or tolerating PO, severe illness, tubo-ovarian abscess, consider in youth/teens/HIV infection
Red book:
The decision to hospitalize adolescent or young adult females with acute PID should be based on the provider’s judgment and whether the patient meets any of the following suggested criteria:
Surgical emergencies (eg, appendicitis) cannot be excluded;
Tubo-ovarian abscess;
Pregnancy;
Severe illness, nausea and vomiting, or high fever;
Unable to follow or tolerate an outpatient oral regimen;
No clinical response to oral antimicrobial therapy.
Patient with shock, rash and injected conjunctiva, strawberry tongue, hypotensive, diffuse erythematous macular rash. What is the most likely causative organism?
A- Staph Aureus
B- Rickettsia
C- Neisseiria
D- Borrelia Burgdorferi
s aureus
Mother IVDU. No prenatal care. Delivered and baby discharged. Mother cultures came back positive for gonorrhea but negative for chlamydia. Baby received eye erythromycin. What to do?
A- IV CTX x7d
B- No need since got erythromycin
C- IM CTX x1
IM CTX x 1?
Child with lymphadenitis, history of pneumonia and umbilical cellulitis. Most likely dx?
CGD
Selective IgA def
HIV
CVID
CGD?
what is the gold standard test for diagnosing GAS pharyngitis?
bacterial culture of tonsils and posterior pharynx
When should you confirm a negative strep rapid antigen detection test with a culture?
when there is a high burden setting because sensitivity of test is only 86%
Why should ASOT not be used to diagnose GAS pharyngitis?
doesn’t distinguish GAS carriage from infection
within what time frame should you treat GAS pharyngitis?
within 9 days of symptom onset to prevent ARF and suppurative complications
what are 2 antibiotics you can use to treat GAS pharyngitis and how many days should you treat for?
10 days
PenV (however no suspension available)
Amoxicillin (can be dosed once daily)
(for patients with difficulty with adherence can treat with 1 dose of IM PenG)
what should you treat with in a penicillin allergic patient who has GAS pharyngitis?
non-anaphylactic reaction: oral amoxicillin challenge or cephalexin
type 1 hypersensitivity: clindamycin, azithromycin, clarithromycin
Who should you consider treating for GAS pharyngitis before positive culture results come back?
Northern/indigenous children >=3 yrs old with sore throat when centor criteria is >=3
