Infectious disease Flashcards
Name 4 infectious disease emergencies in the returned traveler
Malaria
Typhoid fever
Meningococcemia
Viral hemorrhagic fevers
What investigations do you order in fever in a returned traveler?
CBC with differential
Liver function tests
Blood culture
Malarial smears x3(thick and thin)
Other tests, to be done more selectively:
Serology (EBV, CMV, hepatitis viruses, HIV, dengue, brucellosis, strongyloidiasis…)
CXR
TB skin test
Urine C/S
Stools for C/S, O/P
What are the 5 species of malaria affecting humans
P. faciparum P. vivax P. ovale P. malariae P. knowlesi
What is the incubation period of P.falciprum and P. vivax?
P. falciprum-within 2 months
P.vivax-Can be many months
What are the clinical and laboratory criteria for severe malaria in children?
Clinical: •Prostration (unable to walk/sit up) •Impaired consciousness/coma •Respiratory distress •Multiple convulsions (>2 in 24 hrs) •Shock (SBP< 50mmHg) •Respiratory failure/pulmonary edema/ARDS •Abnormal bleeding/DIC •Jaundice (total bili>45μmol/L) •Haemoglobinuria(macroscopic)
Laboratory:
Hyperparasitemia(>2% in non-immune, >5% in semi-immune)**
Severe anemia (hematocrit<15%; Hgb≤50g/L)
Hypoglycemia (<2.2 mmol/L)
Acidosis (art pH < 7.25 or bicarb< 15 mmol/L)
Renal impairment (Cr > upper limit of normal)
Hyperlactatemia(> 5mmol/L)
How do you diagnose malaria?
3 thick and thin smears
How do you treat malaria?
Mild disease, able to tolerate oral
-Malarone x three days
Severe disease
- IV Artesunate
- Quinine is alternative, but not as effective, more toxic, requires cardiac and serum glucose monitoring
How does typhoid typically present?
Fever without localizing signs
What is the sensitivity of blood cultures for typhoid?
50%
How effective is the typhoid vaccine?
50-70% effective
How do you treat typhoid?
IV ceftriaxone
Cipro resistance is common
What are some considerations for care of children new to Canada?
- Catch up vaccines
- Hearing
- Vision
- Psychosocial:
- -History of persecution, physical and emotional deprivation, cultural dislocation, family breakup etc.
- Cultural and social transition
- School-related issues
- Health care coverage issues
What areas should you focus on physical exam of immigrant child?
- Growth and development
- Signs of undiagnosed chronic illness
- Signs of congenital infections
- Vision and hearing screen
- Dentition
- BCGscar
What is a reasonable preliminary infectous disease workup in an immigrant child?
CBCand differential Liver and renal function tests Serology for HBV, HCV, HIV, syphilis TB skin test Chest x-ray Stool O&P Urinalysis
What is the definition of classic FUO?
- Fever of more than 2 to 3 weeks duration
- Diagnosis uncertain despite appropriate investigations after at least 3 outpatient visits or ≥ 3 days in hospital
What is the differential diagnosis of FUO?
Infectious causes
Rheumatologic/vasculitic causes
Malignancy
Other:
Granulomatousdiseases (IBD, Sarcoidosisetc.)
Hypersensitivity syndromes (drug fever etc.)
Familial (FMF, familial dysautonomiaetc.)
Thalamic dysfunction
Factitious fever
Munchausen syndrome by proxy
What is the infectious disease differential for FUO-localized and systemic?
Localized •Endocarditis •Abscesses •Dental infection •Sinusitis •Mastoiditis •Osteomyelitis •Pyelonephritis •Pneumonia •Sepsis
Systemic
•Viral: EBV, CMV, hepatitis viruses, HIV
- Bacterial: Tuberculosis, brucellosis, yersiniosis, salmonella, cat scratch disease, leptospirosis, tularemia, Lyme disease, chronic meningococcemia
- Rickettsia/chlamydia: Q fever, RMSF, tick typhus, psittacosis
- Fungal: Histoplasmosis, blastomycosis
- Parasitic: Malaria, toxoplasmosis, visceral larva migrans, amebiasis
What are first step investigations for FUO?
CBCwith differential, liver enzymes
ESR/CRP, ANA/RF
Blood cultures
Monospot, EBV, CMVserology
What are some second tier investigations for FUO?
Malaria smears
Tuberculin skin test
Echocardiogram
Imaging (radiographs, radionuclide scans, ultrasound, CT etc.)
Bone marrow aspirate
HIV and other serologies
Investigations for rheumatologic, neoplasticdiseases
What causes of FUO can be associated with pica?
Toxocariaisis
Toxoplasmosis
What two tests would you do in fever in a returning traveler from Nigeria?
Malaria smears (thick and thin) Blood culture (S. typhi, N. meningitidis)
Name 4 vaccine preventable illnesses from Africa
Typhoid fever Meningococcal disease Hepatitis A and B Yellow fever Rabies
What are the two most common differentials for an isolated tender axillary lymph node?
Bartonella
Bacterial adenitis
What is parinaud oculoglandular
syndrome?
- Caused by Bartonella
- Submandibular/preauricular lymphadenopathy and ipsilateral unilateral granulomatous conjunctivitis
What is the most common cause of afebrile chronic lymphadenopathy with no TB/CSD risk factors?
Atypical mycobacterium
What is the differential for acute bilateral cervical LAD?
Respiratory viruses Enteroviruses Adenovirus, EBV CMV
What is the differential for acute unilateral cervical LAD?
S. aureus
S. pyogenes (80%)
What is the infectious differential for chronic bilateral cervical LAD?
HIV
EBV
CMV
Toxoplasmosis
What is the infectious differential for chronic unilateral cervical LAD?
Non-tuberculous mycobacteria M. tuberculosis Bartonella henselae Tularemia, Plague (Y. pestis)
Name 6 clinical presentations associated with cat scratch disease
Lymphadenitis (axillary most common)
Perinaud oculoglandular syndrome
Hepatosplenic bartonellosis (granulomatous disease)
Neuro-retinitis
Encephalopathy
Fever of unknown origin
How do you treat cat scratch disease?
Observation is reasonable
Azithromycin for lymphadenitis (to shorten duration of sx)
Doxycycline + rifampin for neuroretinitis/CNS disease
What is a mnemonic to remember TORCH infections?
C Chicken pox H Hepatitis B, C, E E Enterovirus A AIDS P Parvovirus B19
T Toxoplasmosis O Other (TB, WNV) R Rubella C CMV H HSV E Every other STD S Syphilis
What % of patients with congenital CMV are asymptomatic at birth?
2/3 of those with sequelae are asymptomatic at birth
Name 7 clinical features of congenital CMV
IUGR Hepatosplenomegaly Thrombocytopenia*** Microcephaly Periventricular calcifications*** SNHL*** Chorioretinitis
Others: Strabismus Optic atrophy Microphthalmia Seizures Hyperbilirubinemia Elevated ALT
Name 3 long term sequelae of asymptomatic CMV
Sensorineural hearing loss (7% to 15%)-can be delayed onset
Mental retardation, learning disabilities (3.5%)
Chorioretinitis (2.5%)
Name 3 indications for treatment in congenital CMV
- CNS involvement
- SNHL
- Chorioretinitis
- Case-by-case for “mildly symptomatic” neonates
How do you treat congenital CMV?
Valganciclovir 16 mg/kg/dose bid for 6 months
IV ganciclovir for hospitalized,
severely affected newborns
List 2 toxicities do you need to monitor for when treating CMV
Neutropenia
Nephrotoxicity
Close monitoring of CBC (neutrophil count) & creatinine
Consider interruption of therapy if ANC < 0.5
Consider GCSF if neutropenia is persistent
Name 5 features of congenital syphilis
IUGR
Snuffles (persistent nasal d/c)*
Maculopapular rashes (involving palms & soles)*
Bony changes (Osteitis/perichondritis)*
Pseudoparalysis due to bon pain*
Chorioretinitis
Aseptic meningitis
Others: Prematurity, IUGR, FTT Maculopapular rash followed by desquamation, blistering and crusting Condyloma lata Hepatosplenomegaly Lymphadenopathy Coomb’s negative hemolytic anemia Thrombocytopenia Pseudoparalysis Osteochondritis Diaphyseal periostitis Deminiralization/destruction of proximal tibia metaphysis, osteitis Hydrocephalus Cranial nerve palsies Glaucoma, uveitis
Name 7 late onset manifestations of congenital syphilis
GDD SNHL Saddle nose Hutchinson's teeth Gummas Saber shins Optic atrophy
Others: GDD, hydrocephalus, cranial nerve palsies, seizures, juvenile paresis Eye Interstitial keratitis, healed chorioretinitis, corneal scarring, glaucoma, optic atrophy
Ears
Sensorineural hearing loss
Face
Saddle nose, frontal bossing, protuberant mandible, high arch palate
Teeth
Hutchinson’s teeth, mulberry molars
Skin
Ragades (linear scars), gummas
MSK
Saber shins, clutton joints, Higoumenakis’ sign
How do you interpret the following maternal syphilis serologies:
1) CLIA+ TPPA+ RPR+ (titre >1:16)
2) CLIA+ TPPA+ RPR+ (titre <1:8)
3) CLIA+ TPPA+ RPR-
4) CLIA- TPPA- RPR+
5) CLIA+ TPPA- RPR-
1) Active syphilis, cross reactivity
2) Previously treated syphilis, cross reactivity
3) Late latent syphilis, treated syphilis or early primary syphilis, cross reactivity
4) False positive RPR
5) False positive CLIA
When do you do a FULL evaluation for congenital syphilis in an infant AND treat (Name 6 indications) ?
Infant has signs and symptoms of congenital syphilis
Mother not treated or treatment not adequately documented
Mother treated with non-penicillin regimen
Mother treated within 30 days of child’s birth
Less than 4-fold drop in mothers non-treponemal titer or not assessed or documented
Mother had relapse or re-infection after treatment
Infant RPR 4 fold higher than
maternal RPR
Infant symptomatic
What is a full evaluation for congenital syphilis?
CBC, LFTs
Syphilis serology (Treponemal and non-treponemal)
Skeletal survey-long bones
CSF (WBC count, protein, treponemal and non-treponemal tests)-if positive need to repeat 6 months after tx!
In a mother who was treated for syphilis and has no indications for the full work up, what test do you do?
1) Infant RPR
If Infant RPR nonreactive OR Infant RPR ≤ mothers
and asymptomatic, no further investigations required for now
2) Baseline and monthly assessment for signs or symptoms x 3 mos
3) Serology at 0, 3, 6, 18 months
In a mom with syphilis, name 4 criteria that need to be fulfilled for you to NOT do a full work up and treat her baby?
1) Mom appropriately treated during pregnancy (penicillin ONLY!)
2) >4 fold drop in maternal titres during pregnancy
3) Infant RPR non-reactive OR less than mom’s RPR titre
4) Infant is asymptomatic!
How do you treat congenital syphilis?
IV Penicillin G x 10-14 days
What is the classic triad of congenital toxoplasmosis?
Hydrocephalus/macrocephaly*
Cerebral calcifications*
Chorioretinitis
What percentage of toxoplasmosis is symptomatic at birth?
15% (similar to CMV)
During what trimester(s) is symptomatic congenital toxo acquired?
1st and 2nd
During what trimester is asymptomatic congenital toxo acquired?
3rd
What is the prognosis for congenital toxo that is asymptomatic at birth?
Untreated majority will go on to develop disease (unlike CMV)
What is the most common manifestation of congenital toxo that is asymptomatic at birth?
Chorioretinitis
How do you diagnose congenital toxoplasmosis (name 3 tests)?
Serology (IgG, IgM, IgA) in serum of infant
PCR on CSF, blood and/or urine
Placental pathology
What two findings will you see on CSF in congenital toxo?
Lymphocytic pleocytosis
Elevated CSF protein (often very high)
How do you treat confirmed congenital toxo?
Pyrimethamine + sulfadiazine + leucovorin x12 months
Steroids for eye disease and possibly hydrocephalus
VP shunt for hydrocephalus
What toxicity do you need to monitor for when treating congenital toxo?
Neutropenia
What are the clinical features of congenital VZV?
Microcephaly Cicatricial scars*** Limb hypoplasia*** Microphthalmia GERD
What are the potential sequelae of VZV infection during pregnancy on infants in
a) first/second trimester
b) third trimester
c) perinatal
a) Congenital varicella syndrome
b) Herpes zoster in infancy/childhood
c) disseminated neonatal varicella
How do you manage VZV exposure during pregnancy?
If history of chicken pox/immunized–>do nothing
If no definitive history of chicken pox–>stat varicella serology
If IgG negative-VZIG within 96 hours of exposure
If manifestations of chicken pox-acyclovir
What is a significant VZV exposure in pregnancy?
Household exposure
Face-to-face contact for ≥ 5 minutes
Indoor contact for ≥ 15 minutes
Name 7 clinical features of congenital rubella?
IUGR Blueberry muffin rash Hepatosplenomegaly Cataract*** Bony lucencies***(can be confused with syphilis) Cardiac anomalies (PDA)*** SNHL
Others:
Hemolytic anemia
Thrombocytopenia
At what point in pregnancy are you most at risk of congenital rubella syndrome?
First trimester
After 16 weeks congenital anomalies are uncommon
Name 5 long term features of congenital rubella syndrome
Sensorineural hearing loss Cataract Chorioretinitis Microphthalmia PDA Peripheral pulmonary stenosis Pulmonary valvular stenosis VSD Myocarditis Global developmental delay Language defects Behavioral disorders Seizures
What tests should you do if a pregnant woman is exposed to parvovirus?
1) Parvovirus serology
2) If IgM+, weekly ultrasounds x 12 weeks to look for hydrops
3) If negative, repeat in 2-3 weeks. If IgM- and IgG +, reassure (infection was >60 days ago and hydrous develops 4-6 weeks after infection)
What are the clinical features of parvovirus infection?
Papular-purpuric glove and sock syndrome Arthropathy Transient aplastic crisis Pure RBC aplasia (HIV, transplant) HLH Myocarditis Encephalitis
Name two risk factors for parvovirus infection?
Young school aged children in home
Occupational (teachers of 5-7 year old children, health
care workers)
Name 2 potential sequelae of parvovirus infection during pregnancy?
Fetal loss
Non-immune hydrops fetalis
When during pregnancy is the risk of fetal loss highest in parvovirus infection?
First trimester
What type of virus is Zika?
Flavivirus
How is Zika transmitted
Mosquito
Sexual
What are the clinical manifestations of Zika?
Asymptomatic infection (75-80%)
Clinical illness typified by fever, maculopapular rash,
conjunctivitis and myalgia
When during pregnancy is the highest risk period for Zika?
First & early second trimester
How do you make an antenatal diagnosis of Zika?
Fetal US
Amniotic fluid PCR
How do you make a postnatal diagnosis of Zika?
Zika IgM, dengue IgG and IgM
If either positive PRNT
CSF Zika IgM
PCR on placenta, umbilical cord tissue, serum, urine and CSF
What are the clinical features of congenital Zika?
Severe microcephaly with partially collapsed skull
Thin cerebral cortices
Subcortical calcifications
Macular scarring
Contractures
Which congenital infections are associated with brain calcifications?
CMV-periventricular
Toxo-parenchymal
HIV-basal ganglia
Rarer:
HSV-parenchymal
LCMV-parenchymal
Zika-subcortical
Which congenital infections are associated with microcephaly?
CMV, HSV, Rubella, TOXO, syphilis, VZV
Which congenital infections are associated with macrocephaly?
TOXO, LCMV, syphilis
Which congenital infections are associated with chorioretinitis?
CMV, TOXO, syphilis, rubella
Which congenital infections are associated with SNHL?
CMV, Rubella, syphilis, TOXO
Which congenital infections are associated with microopthalmia?
VZV
Which congenital infections are associated with cataracts?
Rubella (syphilis)
Which congenital infections are associated with pseudoparalysis?
Syphilis
Which congenital infections are associated with optic atrophy?
CMV
Which congenital infections are associated with hydrops?
Parvovirus B19, syphilis, CMV, TOXO
Which congenital infections are associated with HSM?
CMV, HSV, rubella, syphilis, TOXO
Which congenital infections are associated with hemolytic anemia?
Syphilis
Which congenital infections are associated with blueberry muffin rash?
Rubella, CMV
Which congenital infections are associated with cytopenias?
CMV, TOXO, HSV, syphilis, rubella
Which congenital infections are associated with liver failure?
Enteroviruses, TOXO, HSV
What are the typical manifestations of early onset (<7 days) GBS?
Pneumonia, septicemia, meningitis
What are the typical manifestations of late onset (>7 days) GBS?
Meningitis, osteomyelitis, soft tissue infections, sepsis
What are indications for intrapartum antibiotics?
1) GBS positive
2) Unknown GBS status AND any of the following:
- Previous infant with GBS disease
- GBS bacteriuria during current pregnancy
- Delivery at < 37 weeks gestation
- Membranes ruptured ≥ 18 hours
- Intrapartum fever (>38.0oC)
What are the only two antibiotics that are considered adequate IAP?
Penicillin
Ampicillin
What antibiotics can be used for IAP in a mom who is penicillin allergic?
Mild allergy-cefazolin
Severe allergy-clinda
What are the low risk criteria for febrile infants 29-90 days old?
Previously healthy term infant
Non-toxic clinical appearance
No focal infection (except otitis media)
Peripheral leukocyte count 5.0 – 15.0 x109/L
Absolute band count ≤ 1.5 x109/L
Urine: ≤ 10 WBC per high field (x40)
Stool (if diarrhea): ≤ 5 WBC per high field (x40)
If any of the low risk criteria are NOT met for a febrile infant 29-90 days old, what should you do?
FSWU
- If CSF abnormal: amp+cefotax+vancomycin
- If CSF normal-amp+cefotax
What are the most common bacterial pathogens for 0-28 d infants with fever without source ?
Most common:
GBS, E. coli
Less common
Listeria, S. aureus, GAS, Klebsiella pneumoniae
What are the most common bacterial pathogens for 29-90 d infants with fever without source ?
Most common:
GBS, E. coli
Less common:
S pneumoniae, Neisseria meningitidis, Listeria, S. aureus, GAS
What are the most common bacterial pathogens for 3-36m infants with fever without source ?
Most common:
S pneumoniae
Less common:
S. aureus, GAS, Neisseria meningitidis
What is empiric antibiotic therapy for rule out sepsis
0-28 days
29-90 days
3-36 months
0-28 days
Sepsis- Ampicillin + gentamicin or cefotaxime
Meningitis- Ampicillin + cefotaxime
29-90 days
Sepsis-Ampicillin + cefotaxime
Meningitis-Ampicillin + cefotaxime + vancomycin
3-36 months
Sepsis AND meningitis-Ceftriaxone + vancomycin
What are the three clinical presentations of neonatal HSV?
Mucocutaneous (Skin, eye, mouth) (45%)
Enchephalitis (30%)
Disseminated
When does mucocutaneous neonatal HSV usually present?
Day 10-12 of life
Does clinically silent CNS infection occur with mucocutaneous HSV?
Yes
Dissemination can occur without treatment
When does neonatal HSV encephalitis present?
Day 16-19 of life
How does neonatal HSV encephalitis typically present?
Fever
↓LOC
Seizures
Skin lesions in 2/3 of cases
When does disseminated neonatal HSV typically present?
Day 10-12 of life
What are the clinical features of disseminated neonatal HSV?
Sepsis-like presentation
Multi-organ involvement-elevated LFTs (in 100s)
2/3 have concurrent encephalitis
What investigations should you do for suspected neonatal HSV?
Culture/PCR of vesicle fluid, nasopharynx, eyes, urine, stool, blood, CSF
Do LP even if clinically well (e.g. isolated mucocutaneousdisease)
How do you treat neonatal HSV and for how long?
IV acyclovir 60 mg/kg/day
Isolated mucocutaneous disease: 2 weeks
Disseminated, CNS disease: 3 weeks, then oral acyclovir x 6 months for CNS disease
Name 5 factors determining transmission risk in HSV?
Type of maternal infection & maternal serostatus: First episode primary (57%); first episode non-primary (25%); recurrent (<3%)
NOTE:
First episode primary=Mother has no serum Abs at onset of first episode
First episode non-primary=Mother has a new infection with one HSV type in the presence of Abs to the other type
Membrane rupture >6 hours
Fetal scalp monitor
HSV-1 vs. HSV-2 (31.3% vs. 2.7%)
C/section reduces risk (1.2% vs. 7.7%)
What percentage of whomem who deliver an HSV-infected child have no history of genital herpes?
60-80%
How do you manage asymptomatic infant of mother with active lesions at delivery?
A. First episode; born vaginally or by C/section after membrane rupture
B. First episode; C/section prior to membrane rupture
C. Recurrent episodes
A. First episode; born vaginally or by C/section after membrane rupture
- Empiric acyclovir recommended
- If swabs positive –full workup and treatment
- If swabs negative, complete 10 days of IV acyclovir
B. First episode; C/section prior to membrane rupture
- Empiric acyclovir not recommended
- If swabs positive –full workup and treatment
C. Recurrent episodes
- Empiric acyclovir not recommended
- If swabs positive –full workup and treatment
What bacteria cause AOM?
Streptococcus pneumoniae(25% to 40%)
Non-typeable Haemophilus influenzae (10% to 30%)
Moraxella catarrhalis(5% to 15%)
Other less commonly seen pathogens include group A streptococcus, S. aureus(3% to 5%)
Viruses-20%
What antibiotics are first line for AOM?
Amoxicillin 75-90 mg/kg/day divided BID
Amoxicillin 45-60 mg/kg/day divided TID
What antibiotics are first line for AOM with mild amoxicillin allergy?
Cefprozil30 mg/kg/day divided BID
Cefuroxime30 mg/kg/day divided BID
Ceftriaxone 50 mg/kg IM/IV x 3 doses
What antibiotics are first line for AOM with severe amoxicillin allergy?
Azithromycin
Clarithromycin
Clindamycin
Levofloxacin in select circumstances
What antibiotics do you use for treatment failure?
Amoxicillin-clavulanate45-60 mg/kg/day divided TID (≤35 kg) or 500 mg TID (>35 kg) x 10 days
-For betalactamase producing Hib
Ceftriaxone 50 mg/kg/day for 3 doses
For how long do you treat AOM?
5 days for children ≥2 years
10 days for 6 months-2 years OR perf TM OR recurrent AOM
When can you employ watchful waiting in AOM (children >6 months)?
1) Non-severe illness
- Mild-moderate TM bulge
- Mildly ill, alert, mild otalgia, low grade fever (<39.0oC)
- Responding to antipyretics
2) No underlying conditions of concern
(Immunodeficiency, chronic cardiac or pulmonary disease, anatomic abnormalities of head/neck, history of complicated otitis media, down syndrome)
3) Parents capable of recognizing signs of worsening disease and can readily access medical care
What bacteria cause acute pneumonia?
Most common: Streptococcus pneumoniae Staphylococcus aureus GAS Non-typeable Haemophilus influenzae
Less common: Mycoplasma pneumoniae Chlamydophila pneumoniae Psittacosis (C. psittaci) Coxiellaburnetii(Q fever) Legionella pneumophila
What is empiric antibiotic therapy for uncomplicated community acquired pneumonia?
Well-amoxicillin/ampicillin
Respiratory failure/shock-ceftriaxone +/- vanco
Rapidly progressive multilobar disease or pneumatoceles-ceftriaxone + vanco (for possible MRSA)
What is the rationale for upgrading from ampicillin to cefriaxone for unwell children with community acquired pneumonia?
Ceftriaxone offers better coverage against β-lactamase+ H. influenzae and possibly for S. pneumoniae with high level resistance to penicillin
What bacteria typically causes meningitis?
A. <1 month
B. 1-3 months
C. >3 months
A. <1 month
GBS, GNB (E. Coli), Listeria
B. 1-3 months
Mix of A+C
C. >3 months
S. pneumo, neisseria, non-typeable Hib
How do you treat suspected bacterial meningitis?
A. <1 month
B. 1-3 months
C. >3 months
A. Amp +cefotax
B. Amp+cefotax+vanco
C. Cefotax+vanco
Duration
- S pneumoniae : 10 to 14 days
- Hib: 7 to 10 days
- N meningitidis: 5-7 days.
- GBS meningitis: 14 to 21 days
Should you give dexamethasone for bacterial meningitis, and if so when?
YES. Reduces mortality and hearing loss due to HIB and possibly S. pneumoniae
Dexamethasone 0.6 mg/kg/day in 4 divided doses
Should be administered before or within 30 minutes of antibiotics
When do you consider repeat LP at 24-36 hours in bacterial meningitis (name 4 indications)
Failure to improve clinically
Immunocompromised host
S. pneumoniae resistant to penicillin/cephalosporins
Meningitis due to gram negative bacilli
What are the most common bacteria causing purpura fulminans?
N. meningitidis
S. aureus
S. pneumoniae
GAS
What antibiotics do you use for purpura fulminans?
Ceftriaxone + vancomycin
What are the most common bacteria causing toxic shock syndrome?
S. pyogenes, S. aureus
How do you treat TSS?
Cloxacillin (or cefazolin)+ clinda
If TSS due to group A strep-Penicillin + clindamycin±IVIGfor
What are physical exam findings associated with endocarditis?
Osler nodes
Splinter hemorrhage
Janeway lesions
How do you treat skin abscesses after incision and drainage?
A. <1 month
B. 1-3 months
C. >3 months without fever/cellulitis
D. >3 months with cellulitis, no other systemic features
E. Systemic features
A. <1 month
IV antibiotics (with vanco)
PO clindamycin for well babies with no fever, abscesses <1 cm
B. 1-3 months
TMP-SMX
C. >3 months without fever/cellulitis
No antibiotics
UNLESS does not improve after I+D, culture grows anything other than S. aureus
D. >3 months with cellulitis, no other systemic features
TMP-SMX (MRSA coverage) and cephalexin
E. Systemic features
IV antibiotics
What are the typical bacteria causing impetigo?
S. aureus, Group A streptococcus
What empiric antibiotics do you use for impetigo?
PO: Cloxacillin, Cephalexin
topical mupirocin
What are the typical bacteria causing cellulitis?
S. aureus, Group A streptococcus
What empiric antibiotics do you use for cellulitis?
IV: Cloxacillin, Cefazolin
PO: Cloxacillin, Cephalexin
What are the typical bacteria causing pyomyositis?
S. aureus, streptococci
What empiric antibiotics do you use for pyomyositis?
IV: Cefazolin, Cloxacillin
What are the typical bacteria causing necrotizing fasciitis?
Group A streptococcus, S. aureus
What empiric antibiotics do you use for necrotizing fasciitis?
IV: Cloxacillin(or Cefazolin) + clindamycin ±vancomycin
Penicillin +clindamycin if you suspect GAS (e.g. in chicken pox)
What complication of chickenpox would you suspect in a child who develops refusal to weight bear, significant pain, indurated area, bluish hue?
Necrotizing fasciitis
Suspect GAS as underlying cause
List 4 management steps in suspected necrotizing fasciitis?
CBC & blood culture
Urgent surgical consult
IV antibiotics
IVIG
Imaging should not delay surgical intervention
Name 5 complications of chickenpox
General
- Pneumonia
- Hepatitis, pancreatitis, nephritis, orchitis
- Thrombocytopenia
Bacterial infections
-Cellulitis, soft tissue abscess, necrotizing fasciitis
Neurologic
- Cerebellar ataxia
- Encephalitis
- Reye syndrome
- Stroke
- Zoster (including Ramsay Hunt syndrome)
What are some complications of enterovirus?
Meningitis Encephalitis Acute flaccid paralysis Myocarditis Hepatitis
What are some complications of EBV?
Upper airway obstruction (adenopathy) Splenic rupture Encephalitis X-linked lymphoproliferative diseas ITP
What are some complications of influenza?
Otitis media
Secondary bacterial pneumonia
Myositis, Encephalopathy/encephalitis
Reye syndrome
What are some complications of measles?
Otitis media
Secondary bacterial pneumonia
Encephalitis
SSPE
What are some complications of mumps?
Meningitis Encephalitis Orchitis/oophoritis Arthritis Pancreatitis
What are some complications of parvovirus?
Papular-purpuric gloves and socks syndrome
Transient aplastic crisis
Chronic bone marrow failure
Polyarthropathy syndrome
What are three options for obtaining a sterile specimen for diagnosis of UTI?
Catheterization
Suprapubic aspiration
Clean catch
What are antibiotic options for empiric treatment of UTI >2 months?
Majority can be managed with oral antibiotics
Cephalosporin, amoxicillin-clavulanate, TMPSMX
What are indications for IV antibiotics in UTI?
Toxic appearance
<1 month
2-3 months controversial
Unable to retain oral intake (including medications)
Immunocompromisedhost (selectively)
What investigations should be done after first febrile UTI?
Renal and bladder ultrasound for children < 2 years of age
VCUG selectively
What are indications for VCUG
Ultrasound evidence of hydronephrosis, renal scarring or other findings suggestive of high grade vesicoureteralreflux or obstructive uropathy
2nd febrile UTI
What are indications for prophylactic antibiotics for UTI?
Grade 4 or 5 VUR
What antibiotics should you use for prophylaxis for UTI?
TMP SMX
Nitrofurantoin
If child has UTI due to organism resistant to these –consider stopping prophylaxis
What are the most common organisms for dog/cat bite?
Pasteurellamultocida, Streptococci spp., S. aureus, anaerobes, others
What is the best empiric therapy for dog/cat bites?
PO amoxicillin-clavulanate
IV cloxacillin+ penicillin
If not improving, surgical debridement
What are the most common organisms for human bite?
Streptococci, S. aureus, anaerobes, nontypable Haemophilus influenzae, Eikenella corrodens
What is the best empiric therapy for human bite?
PO amoxicillin-clavulanate
IV cloxacillin+ Penicillin
What are the most common organisms for puncture wound of foot WITH sneakers?
Pseudomonas
What is the best empiric therapy for puncture wound of foot WITH sneakers?
Piperacillinor ciprofloxacin ±gentamicin
What are the most common organisms for puncture wood of foot WITHOUT sneakers?
S. aureus
What is the best empiric therapy for puncture wood of foot WITHOUT sneakers?
PO cloxacillinor cephalexin
IV cloxacillinor cefazolin
Name 5 organisms that can cause severe invasive disease in patients with asplenia
S. pneumo (majority of sepsis) HIB Neisseria meningitidis Capnocytophaga canimorsus (dog saliva) Salmonella (reptiles, food, water) Malaria Babesiosis
What are three categories of preventive interventions for children post-splenectomy?
Immunizations
Antibiotic prophylaxis
Education around fevers
What immunizations do asplenic children need?
1) Prevnar13 & 23-valent polysaccharide vaccine
2) Quadrivalent meningococcal vaccine & 4CMenB
3) H. Influenzaetype b
4) Influenza vaccine, annually
5) S. typhivaccine pre-travel
Household contacts need routine vaccines & annual influenza vaccine
What do you use for antibiotic prophylaxis in asplenic patients?
Birth –3 months: amoxicillin-clavulanate (higher risk of E Coli)
≥3 months: Penicillin (amoxicillin alternative)
When are asplenic patients at highest risk of sepsis?
- Younger children
- First year after splenectomy
- Congenital asplenia/functional asplenia>traumatic asplenia
What ticks transmit lyme disease (borrelia burgdorferi)?
Ixodes scapularis
Ixodes pacificus
What are the 3 clinical stages of lyme disease and what are the associated manifestations?
Early localized disease
- Erythema migrans (MOST COMMON)***
- Systemic symptoms (fever, myalgia, headache, arthralgia, neck stiffness)
Early disseminated disease
- Multiple EM lesions
- Meningitis
- Facial nerve palsy (THIRD MOST COMMON)***
- Carditis with heart block
Late disease
- Pauciarticular arthritis (SECOND MOST COMMON)***
- Peripheral neuropathy
- CNS manifestations
How do you diagnose lyme disease?
For erythema migrans:
- DO NOT NEED SEROLOGIES
- Will often be negative in early LD
For all other clinical manifestations:
1) Screening ELISA
2) Confirmatory immunoblot for IgM and IgG
NOTE: ELISA and IgM IB high likelihood of false positive if pretest probability low
When can IgM and IgG be detected in Lyme disease?
IgM can be detected within 2 weeks of infection
IgG rise usually 4-6 after infection
What are oral and IV treatment options for Lyme disease?
Oral:
Doxycycline for children ≥8 years of age
Amoxicillin for children <8 years of age
Cefuroxime
IV:
Ceftriaxone
Penicillin G
How do you remove a tick?
Carefully grasp tick with fine point tweezers as close to your skin as possible
Pull straight out, gently but firmly
Don’t squeeze
Clean the bite area and your hands with soap and water
Don’t put anything on the tick, or try to burn the tick off
What should you do with the tick?
Send to PHL for identification
Do you use chemoprophylaxis is in children with a tick bite?
Yes, if >8 years old
Single dose of doxycycline in high-risk exposure (high endemic region, exudes tick)
When is the peak incidence of West Nile Virus?
Late summer & fall
What are the 3 clinical presentations of WNV?
Asymptomatic infection (~80%)
West Nile fever (~ 20%)
West Nile neurologic disease (≤1%)
What are the neurologic symptoms associated with WNV?
Aseptic meningitis
Encephalitis
Acute flaccid paralysis (poliomyelitis like)
What are 5 strategies to avoid WNV?
Avoid outdoors during times of high mosquito activity (dawn and dusk)
Mosquito repellents (DEET, icaridin)
Long clothing, hat, closed shoes
Screens on windows/doors
Fine mesh netting for cribs, strollers
Limit mosquito breeding by minimizing containers or other objects with standing water (toys, pots etc)
What are the different levels of severity in C. difficile?
1) Mild
- <4 abnormal stools/day
2) Moderate
- ≥4 abnormal stools/day
3) Severe
- Evidence of systemic toxicity (eg, high grade fevers, rigors)
4) Severe complicated
- Evidence of systemic toxicity and severe colitis, including hypotension, shock, peritonitis, ileus or megacolon
How do you treat the following types of C. difficile?
1) Mild
2) First episode mild/moderat, no change with antibiotic stoppage
3) First episode severe
4) First episode severe complicated
5) First recurrence
6) Second recurrence
1) Mild
- Discontinue precipitating antibiotic
- Follow-up
2) First episode mild/moderate, no change with antibiotic stoppage
- PO metronidazole x 10-14 days
3) First episode severe
- po vancomycin x 10-14 days
4) First episode severe complicated
- po vancomycin +IV metronidazole x 10-14 days
5) First recurrence
- Same as above
6) Second recurrence
- vancomycin in tapered or pulsed regimen
List 4 steps for infection control for C. difficile
1) Hand hygiene
2) Identifying and cleaning environmental sources
- Sporicidal agents (chlorine-based, other)
- NOTE: alcohol does not kill spores
3) Contact precautions for duration of symptoms (until 48 hours diarrhea free)
4) Private rooms or cohorting
Who should be screened for STIs?
Females
-All who are sexually active or victims of sexual assault
Males
In presence of risk factors:
-Sexual contact with STI
-Previous STI
-New sexual partner or >2 partners within past year
-Injection drug use or substance abuse
-Unsafe sexual practices (e.g. unprotected sex)
-Anonymous sexual partnering
-Sex worker, survival sex, street involved, homelessness
-Time in detention facility
-Sexual assault or abuse
What tests should be done for an STI screen?
First catch urine NAAT chlamydia and gonorrhea
HIV, HepB, syphilis serology
How do you treat uncomplicated gonorrhea in children >9 years?
Ceftriaxone 250 mg IM OR Cefixime 800 mg po SD
PLUS
Azithromycin1 g SD
How do you treat uncomplicated gonorrhea in children <9 years?
Ceftriaxone 50 mg/kg IM OR Cefixime 8mg/kg BID po x2 doses
PLUS
Azithromycin 20 mg/kg SD
What are the next steps in management of a child born to a mother with untreated gonorrhea?
Well:
Conjunctival cultures
IM Ceftriaxone
Unwell:
Conjunctival, blood and CSF cultures
What are the next steps in management of a child born to a mother with untreated chlamydia?
Routine culture, treatment not recommended
Observe for conjunctivitis, pneumonia
Differential diagnosis for genital lesions
HSV
Cysts or abscesses of the Bartholin glands
Chancroid(Haemophilus ducreyi)
Bechet disease
Trauma
Genital warts
Molluscum contageosum
Syphilis, lymphogranuloma venereum, granuloma inguinale(usually painless)
What is the definition of TB exposure?
Asymptomatic, negative TST, normal CXR
What is the definition of TB infection?
Asymptomatic,normal CXR, but positive TST
What is the definition of TB disease?
Signs and symptoms or radiographic manifestations are apparent
What is the definition of a positive TST?
0-4 mm
•Child under 5 years of age ANDhigh risk of TB infection
≥5mm
•HIV infection (well)
•Close contact with active contagious case (past 2 years)
•Presence of fibronodulardisease on CXR(healed TB)
•Organ transplant
•TNF-αinhibitors
•Other immunosuppressive medications (e.g. corticosteroids –equivalent of ≥15 mg/day for ≥1 month)
•End stage renal disease
≥10mm
•All others
Name 4 reasons for reactive tuberculin skin test
Mycobacterium tuberculosis infection
Non-tuberculous mycobacteria infection
BCG in past
Incorrect technique (measurement)
Name 8 reasons for false negative TST
Incorrect technique Active TB disease Immunodeficiency states Corticosteroids Young age Malnutrition Viral infections (measles, varicella, influenza) Live attenuated vaccines (measles)
What are the advantages of Interferon γ release assays in the diagnosis of TB?
-More specific for M. tuberculosis than TST
(Doesn’t cross react with BCG and most non-tuberculous mycobacteria)
-Does not require follow-up visit in 48-72 hours
What clinical situation are interferon gamma tests most useful?
Diagnosis of LTBI in BCG recipients
What are the disadvantages of Interferon γ release assays in the diagnosis of TB?
- Cross reacts with some NTMB species
- Cannot distinguish LTBI from active TB
- Sensitivity ↓by temporary anergy of acute illness
- Reduced sensitivity in immune compromised individuals (including HIV)
What are risk factors for development of TB disease?
Infants and post-pubertal adolescents
Recently infected (past 2 years)
Immunodeficiency states (PID, HIV, malignancy, organ transplant, immunosuppressive meds, malnutrition)
How do you diagnose pulmonary TB?
TST/IGRA (does not distinguish between latent and active disease)
CXR
Gastric aspirates (3x early morning, before feeding or ambulation)
Microbiology-acid fast staining, culture, DNA probes, PCR
What are three different ways pulmonary TB can appear on chest imaging?
Hilar adenopathy
Ghon complex
Miliary TB
How do you treat LTBI?
INH x 9 months
How do you treat active TB?
INH, RIF, PYR, ETH (4 drugs) x 2 months
INH + RIF to complete course
What supplement should you give for all children with TB disease?
Vitamin D
What are the side effects of INH?
Hepatotoxicity Peripheral neuropathy (interferes withpyridoximemetabolism)
What are the side effects of rifampin?
Hepatotoxicity Hypersensitivity reactions Memory impairment Drug interaction Body fluids turn orange
What are the side effects of pyrazinamide?
Hepatotoxicity
Increased uric acid levels
What are the side effects of ethambutol?
Optic neuropathy (decreased acuity, decreased visual fields, color blindness)
What are the infectious risks associated with blood transfusions?
HIV
1 in 8-12 million
Hepatitis C virus
1 in 5-7 million
Hepatitis B virus
1 in 1.1-1.7 million
HTLV-1/2
1 in 1-1.3 million
What is the leading cause of HIV infection in women?
Heterosexual transmission
In a mother with HIV, what two things do we test for in the infant and when?
PCR(birth, 1, 2 months)
Serology (18 months)
What is the likelihood of vaginal transmission if mom on ART and received IV zidovudine during labour?
<2%
25% if no interventions
Name 5 medical interventions to prevent vertical HIV transmission
1) Triple ART starting in 2ndtrimester (or earlier)
2) IV zidovudine during labor
3) Zidovudine to infant x 6 weeks (or combination ART if mother’s VL elevated)
4) Elective Cesarean section if VL>1000 copies/mL
5) Avoidance of breast feeding
What are the initial management steps in an HIV-exposed infant after birth?
Assess risk of HIV transmission (maternal viral load, CD4 count, ART, mode of delivery)
Assess for potentially associated conditions (syphilis, HepB/C)
Clean well prior to administration of vitamin K
CBC, HIV DNA PCR, viral culture, CD4count
Zidovudine2 mg/kg qid for 6 weeks-start within 8 hours of birth!
When should you give cotrimoxazole prophylaxis in an HIV exposed infant?
Mom has suboptimal virologic control
How can you finalize HIV negative status in exposed infant?
Exclusion of HIV requires 2 separate negative PCR tests taken at 1 month of age or later
How can you finalize diagnosis of HIV infection in exposed infant?
HIV infection confirmed by positive PCRx2 prior to 18 months or reactive serology after 18 months
What are the two most common laboratory abnormalities with AZT?
Macrocytic anemia
Elevated lactate
Name 8 AIDS-defining conditions in chidlren
PJP pneumonia
Lymphoid interstitial pneumonitis
Recurrent bacterial infections
HIV wasting syndrome
HIV encephalopathy
Candida esophagitis
CMV disease
Mycobacterium avium intracellulare infection
Name 11 clinical manifestations of HIV infection in children
Category A (“mild”) symptoms
- Lymphadenopathy, hepatosplenomegaly, parotitis
- Dermatitis
- Recurrent or persistent sinusitis, otitismedia
Category B (“moderate”) symptoms
- Bacterial meningitis, pneumonia, sepsis
- Oropharyngeal candidiasis(non-neonatal)
- Recurrent or chronic diarrhea
- Cardiomyopathy
- Nephropathy
- Complicated chicken pox
- CMV disease (early onset)
- Persistent fever (>1 month)
Well controlled children with HIV are almost immunologically normal. Name two ways they are not.
Increased risk of pneumococcal disease
Vaccine responses not as good as healthy children
What immunizations should be given to children with HIV?
All routine childhood vaccines
Annual influenza vaccine
Polysaccharide pneumococcal vaccine (after Prevnar)
Meningococcal vaccine (Menactra)
What vaccines are contraindicated in HIV?
MMR if severe immune compromise
VZV vaccine if CD4percentage < 25%
BCG & oral polio vaccine contraindicated in developed countries
What is the risk of transmission with needle stick injury for the following viruses if positive source?
Hep B
Hep C
HIV
HepB 2-40%
HepC 3-10%
HIV 0.2-0.5%
What factors affect HIV transmission following needlestick injury?
Community prevalence Needle size Hollow bore Visible blood Depth of penetration Elapsed time
HIV infected source: Disease stage Viral load CD4count Antiretroviral therapy
What tests do you do for needlestick injury and how often?
HBsAg, HBsAb, HBcAb
HIV serology
HCV serology
0, 6 weeks, 3 months, 6 months
What is the schedule for HepB vaccination in needlestick injury?
0, 1, 6 months
What do you do if a patient is fully vaccinated for HepB and get a needlestick injury?
1) HBsAb & HBsAg (STAT)
2) If HBsAb (+) or HBsAg (+)-no treatment, refer to GI if Ag +
3) If HBsAb (−) & HBsAg (−)-HBIg and vaccine
What do you do if a patient is not fully vaccinated for HepB and gets a needlestick injury?
1) HBsAb & HBsAg (STAT)
Administer HBIG & first dose
of vaccine
2) D/C vaccine if HBsAg+ or HBsAb+
List 5 management priorities in daycare bite wounds
1) Local wound care (allow to bleed freely***, soap and water)
2) Tetanus immunization if needed
3) Prophylactic antibiotics if moderate/severe tissue damage, deep puncture, more than superficial injury to face/hand/foot/genitalia
4) HIV post-exposure prophylaxis if one kid is HIV infected and there is exchange of blood
What to do when unknown HepB status child bites another unknown HepB status child AND there is break in skin?
Vaccinate both
No testing
What to do when HBV carrier child bites a non-immune child AND there is break in skin?
For bitten child:
HBIg
HB vaccine
Follow up testing (HepB serology at 6 months)
What to do when a non-immune child bites HBV carrier AND there is break in skin?
For biting child:
HBIg
HB vaccine
Follow up testing (HepB serology at 6 months)
What to do when unknown HepB status child bites non-immune child AND there is break in skin?
For bitten child:
HB vaccine
What to do when non-immune child bites child with unknown HepB status AND there is break in skin?
For biting child:
HB vaccine
What is a general contraindication to any vaccine?
Prior history of anaphylaxis to vaccine or vaccine component (egg allergy is ok-can be observed in office after vaccine administration)
What is a contraindication to live vaccines?
Severe immune deficiency
What are contraindications to influenza vaccine?
-History of Guilain Barre within 6 weeks of influenza vaccine in past
What are contraindications to live attenuated influenza vaccine?
Immune compromising conditions
Severe asthma (oral steroid; high dose inhaled steroids; active wheezing; medically attended wheezing in preceding 7 days)
Chronic ASA therapy
Pregnancy
What vaccines are contraindicated in patients with active TB?
MMR
VZV
What are contraindications for rotavirus vaccine?
Hypersensitivity
History of intussusception
Immunocompromisedinfants (especially SCID)
> = 8 months of age
What is the period of infectiousness of meningococcal meningitis?
7 days prior to symptom onset until 24 hours after start of effective therapy
Do you give chemoprophylaxis for meningococcal meningitis to contacts that are immunized?
YES
During what time period of contact with an index case would you consider chemoprophylaxis for meningococcal meningitis?
Up to 10 days after last contact with index case
What are indications for chemoprophyalxis AND vaccination in close contacts for meningococcal meningitis?
Household contact
Persons who share sleeping arrangement with index case
Childcare and preschool contact
Direct exposure to index secretions (kissing etc)
HCW who have intensive unprotected exposure
Seated next to index case during flight >8 hours
Name 3 options for chemoprophylaxis for meningococcal meningitis
Rifampin (5 mg/kg [max 600 mg] bid x2 days)
Ceftriaxone single dose IM (adult -250 mg; 125 mg <12 years)
Ciprofloxacin (adults 500 mg single dose)
What are the three types of meningococcal vaccines and what do they protect against?
Meningococcal C conjugate vaccine (Menjugate, Meningitec, NeisVac-C)
-Serogroup C
Quadrivalent conjugate vaccine (Menactra, Menveo)
-Serogroup A, Y, W-135
Multicomponentmeningococcal B vaccine (4CMenB)
-Serogroup B
What are the indications for MenC vaccine?
Administer at 12 months of age to healthy children
Close contacts of known group C disease
What are the indications for quadrivalent meningoccal vaccine?
Menveo recommended for children < 2 years of age at increased risk of disease
All adolescents should be offered a booster dose beginning at 12 years of age
Close contact of serogroups A, Y, W-135
Who is at increased risk of invasive meningococcal disease?
Asplenia
Primary antibody deficiencies
Complement, properdinor factor D deficiency
Acquired complement deficiency (Eculizumab)
Travelers to areas where meningococcal risk is high
(e.g. sub-SaharanAfrica, Saudi Arabia during Haj)
Laboratory personnel with exposure to meningococcus
The military
What are the indications for multicomponent meningococcal B vaccine (4CMenB)?
Recommended for children 2 months or older if:
-Increased risk of invasive meningococcal disease
(asplenia, complement deficiency, eculizumab therapy)
-Close contacts of invasive group B disease case
-Outbreak control
What are the indications for HPV vaccine?
All girls and boys 9-26 years of age and older regardless of sexual activity
What is Gardasil?
Recombinant vaccine for the prevention of cervical cancer and condylomata
Which HPV serotypes does Gardasil protect against?
Covers HPV types 6, 11, 16, 18
What does HPV 6, 11 cause?
90% of anogenital warts
Recurrent respiratory papillomatosis
What does HPV 16, 18 cause?
70% of squamous cell and adenocarcinomas
86% of adenocarcinomas of the cervix
Cancers of penis, anus, vulva and vagina
What is the dosing regimen for Gardasil?
3 dose schedule-0, 2, 6 months
Who can get 2 dose schedule (0, 6 months) for Gardasil?
Otherwise healthy children 9-14 years of age
What pathogen accounts for most admissions for gastroenteritis and most gastroenteritis <2 years of age?
Rotavirus
How effective is the rotavirus vaccine?
Decreases incidence of gastroenteritis by 70-80%
Decreases severity by 85-95% (reduces admissions)
When should rotavirus vaccine be given?
Between 6-14 weeks of life
SHOULD NOT be given >8 months of age
Who should get the flu vaccine?
All children >6 months of age
In what groups of children in influenza vaccine particularly recommended?
Children 6-59 months of age
Chronic respiratory, cardiac, renal, metabolic conditions
Immune compromising conditions
Hemoglobinopathies
Children and adolescents on long-term with salicylates
Children and adolescents with underlying neurological disorders
Children who are household contacts of individuals at high risk
All pregnant women, adults over 65 years, aboriginal peoples, chronic care facility residents
People capable of transmitting influenza to those at risk
What form of the inactivated influenza vaccine is recommended for children?
Quadrivalent
What is the dose of inactivated influenza vaccine?
Two doses 0.5 mL 4 weeks apart in children 6 months to 9 years of age first year of receipt
Single dose in all others
In what age group is live attenated influenza vaccine authorized?
> =2 years of age
How many after receiving antivirals can you get the live flu vaccine?
48 hours
If you get an antiviral within 2 weeks of getting the live flu vaccine, when should you give a second dose of vaccine?
48 hours after stopping antiviral
Who should get antibiotics for pertussis and what is the purpose?
Treatment of child indicated to reduce spread; wont impact duration of cough
Household contacts should also get antibiotics
What are 4 nationwide strategies to reduce pertussis?
Universal vaccination of children
Universal vaccination of teenagers and adults
Invest in more immunogenic vaccines
Post-exposure immunization
Education of public
How long after IVIg do you need to wait before giving MMR or varicella vaccines?
Recommended interval depends on IVIG dose
300-400 mg/kg=8 months
1 g/kg=10 months
2 grams/kg=11 months***
Which vaccines have reduced efficacy after IVIg?
MMR and varicella
Not other live vaccines or inactivated vaccines
What are the indications for Hepatitis A prophylaxis with JUST vaccine?
All individuals within 2 weeks of exposure in those ≥6 months of age
What are the indications for Hep A prophylaxis with JUST immunoglobulin?
Infants <6 months
Vaccine contraindications
What are the indications for HepA prophylaxis with BOTH vaccine and Ig?
Immunocompromised
What should you do for a newborn born to mom with unknown HepB status?
- Send maternal HBsAgSTAT
- If result available within 12 hours of birth can await result, if (+) give HBV vaccine and HBIG, if (-) no intervention
If mom HepBsAg positive, what time frame do you have to give HepB vaccine and Ig?
Vaccine should be given within 12 hours of birth (provides 90% of protection)
Ig should also be given within 12 hours, but can be given up to 7 days after birth. Efficacy signficantly decreased after 48 hours
What is the HepB vaccine schedule for exposed newborns?
0, 1, 6 months
When should infant HepB serologies be done after administering the full vaccine series?
4 weeks after
Usually at 9-12 months of age
If HBsAg-, HBsAb -, reimmunize
Who should get the 4 dose schedule of HepB vaccine (0, 1, 2, 6 months)
Infants <2.0 Kg at birth
What does the following HepB serology mean: HBeAg−, HBcAg−, HBsAg−
HBeAb−, HBcAb−, HBsAb+
Immunized, uninfected
What does the following HepB serology mean: HBeAg+, HBcAg+, HBsAg+
HBeAb−, HBcAb+, HBsAb−, IgMHBcAb+
Acute infection
What does the following HepB serology mean: HBeAg−, HBsAg+
HBeAb+, HBcAb+, HBsAb−
Healthy carrier
What does the following HepB serology mean: HBeAg+, HBsAg+
HBeAb−, HBcAb+, HBsAb−
Chronic infection
What does the following HepB serology mean: HBeAg−, HBcAg−, HBsAg−
HBeAb+/−, HBcAb+, HBsAb+
Past infection
What is the risk of transmission of maternal HCV ?
5%
What factors increase the risk of maternal HCV transmission?
HIV co-infection, higher HCV viral load, elevated ALT, cirrhosis
Is elective C/S recommended for mothers with HCV?
No
What and when do you test an infant exposed to HCV?
HCV serology at 12 to 18 months
PCR can be done between 3-6 months of age, but not essential (to relieve anxiety)
Name 5 indications for VZIg (within 10 days of exposure)?
Immunocompromised children without history of varicella or varicella immunization
Susceptible pregnant women
Newborn infant whose mother had onset of chicken pox within 5 days before delivery or within 48 hours of delivery
Hospitalized premature infant (≥28 weeks gestation) whose mother lacks a reliable history of chicken pox or serologic evidence of protection against varicella
Hospitalized premature infant (< 28 weeks gestation or birth weight ≤1000 gram) regardless of maternal history of varicella or varicella-zoster virus serostatus
What things would you do on an infant born to mom with varicella prior to delivery?
- Test for presence of IgG(serology)
- VZIg if rash within 7 days before delivery or 2 days after
- Treat with acyclovir IV if develops chickenpox
What three infection control precautions should you take in mom with varicella?
Mom should be in negative pressure isolation if still has active lesions
Baby should be isolated with mom (incubation period 7-21 days post-exposure)
Non-immune family members should not come to the hospital (incubation period)
What are 5 things you would do to manage a dog bite?
Clean, irrigate (saline) &debride
X-ray if concerned about fracture
Wound closure –controversial; hand wounds often left open
Antibiotic prophylaxis (amoxicillin-clavulanatefor 5 days)
Rabies immune globulin into wound
Initiate rabies vaccination series (5 doses)
Notify public health
Advise elevation of the hand first 48 to 72 hours
What are the indications for rabies prophylaxis (RIG and vaccine)?
Direct contact with bat+ bite, scratch, or saliva exposure into a wound or mucous membrane cannot be ruled out
Unprovoked dog, cat, ferret, skunk, fox, coyote, raccoon, other carnivores bite
Healthy dog, cat, ferret-observe x 10 days and if signs of rabies, initiate prophylaxis
What are the management steps in a possible rabies exposure?
Notify public health
Handling of animal
- Domestic animal can be observed 10 days for signs of rabies; if develop –animal euthanatized and tested
- If wild animal –euthanize and test immediately
Rabies immune globulin
- 20 IU/kg; as much as possible should be infiltrated into wound
- Remainder can be given IM
Rabies vaccine (Human diploid cell vaccine) -Four (or five) doses of vaccine days 1, 3, 7, 14, (28)
How should rabies immunoglobulin be given?
Infiltrated into wound, remainder should be given IM
How many doses of rabies vaccine are given?
Usually 4 or 5 doses
What is the recommended post-exposure prophylaxis for Hib type B?
Rifampin x 4 days
What is the recommended post-exposure prophylaxis for N. meningitidis?
Rifampin x 2 days
What is the definition of invasive GAS and what is the recommended chemoprophylaxis for close contacts of invasive GAS?
Invasive GAS=
Strep TSS
Soft tissue necrosis (NF, myositis, gangrene)
Meningitis
Cephalexin x 10 days
What is the recommended post-exposure prophylaxis for B. pertussis?
Azithromycin x 5 days
Erythromycin x 14 days
What is the recommended post-exposure prophylaxis for measles?
IG within 6 days of exposure
MMR within 72 hours
What is the recommended post-exposure prophylaxis for rubella?
Generally none
IG may be considered in pregnancy if termination not an option
MMR within 72 hours
What are the indications for palivizumab?
Children < 12 months of age with CLD of prematurity who require ongoing medical therapy at the start of the RSV season
Children < 12 months of age with hemodynamically significant heart disease
Infants without CLD born at < 30 weeks gestation if they are < 6 months of age at the start of the RSV season
Consider in infants who live in remote communities and born at < 36 weeks gestation if < 6 months of age at the start of the RSV season
Consider in full-term Inuit infants < 6 months of age at onset of RSV season living in remote communities with persistently high rates of RSV hospitalization
May be considered in children < 24 months of age who are on home oxygen, have had a prolonged hospitalization for severe pulmonary disease or are severely immunocompromised
Name 4 infectious contraindications to breastfeeding
HIV
HTLV-1/2
Active HSV lesions on breast (until crusted)
Active TB (until after 2 weeks of treatment in mom)
Untreated brucellosis
By what rate does palivizumab decrease admissions related to RSV?
50%
What part of RSV is palivizumab directed against?
Humanized murine monoclonal immunoglobulin G-1 directed against an epitope on the F glycoprotein of RSV
Should palivizumab be continued after natural RSV infection has occurred?
NO-Continuation of monthly palivizumab is not recommended for children hospitalized with breakthrough RSV infection
Which intervention will result in the best form of infection control for RSV?
Isolate everyone with respiratory symptoms
What do you if you have diarrhea on your hands?
Wash with regular soap and water
What infections require airborne precautions?
Varicella
Measles
TB
Smallpox
What infections require droplet/contact?
RSV Influenza Rhinovirus Coronavirus Parainfluenza
What infections require droplet precautions?
S. pneumoniae
N. meningitiditis
S. pyogenes
Pertussis
What infection require contact precautions?
Diarrhea
ARO
VRE
MRSA
When can children with impetigo return to daycare?
24 hours after treatment initiated
When can children with strep pharyngitis return to daycare?
24 hours after treatment initiated
When can children with pertussis return to daycare?
5 full days after treatment initiated
When can children with E. Coli 0157:H7 return to daycare?
Resolution of diarrhea & stool culture negative x2
When can children with shigella return to daycare?
Resolution of diarrhea ≥24 hrs ±neg stool cultures
When can children with non-typhi salmonella return to daycare?
Until resolution of diarrhea
When can children with C. difficile return to daycare?
Until resolution of diarrhea
When can children with typhoid fever return to daycare?
Resolution of symptoms & negative stool cultures x3
When can children with HepA return to daycare?
Until 1 week after onset of illness or jaundice
When can children with chickenpox return to daycare?
Whenever
When can children with mumps return to daycare?
Until 5 days after parotid gland swelling
When can children with measles return to daycare?
Until 4 days after onset of rash
When can children with scabies return to daycare?
Until after treatment given
Do children with lice and varicella need to be exlcuded from daycare?
NO
Name 4 methods to practice antimicrobial stewardship
Use clinical judgement (accurate diagnosis, investigate judiciously)
Treat infection, not contamination/colonization
Assessment of antibiotic allergy
Know local antibiogram
Select narrowest spectrum antibiotic needed
Optimize dosing to obtain maximal benefit
- e.g. high dose Q24H for aminoglycosides, rather than traditional Q8H
- e.g. BID for AOM, TID for pneumonia
Use the shortest recommended course of therapy for uncomplicated infections
Do not change or prolong antibiotics uneccessarily
Promote vaccination
What are causes of facial nerve palsy in children?
Idiopathic (incl. HSV) Otitis media Lyme disease VZV (Ramsay Hunt syndrome) Cholesteatoma Facial nerve schwannoma Vestiular schwannoma Meningioma
How do you treat bell’s palsy (excluding Ramsay Hunt syndrome)?
Corticosteroids
What are the typical clinical features of Ramsay Hunt syndrome?
Reactivation herpes zoster in geniculate ganglion
Facial nerve LMN palsy
Ear pain
Vesicles on ipsilateral face, ear, ear canal
Deafness
Vertigo
How do you treat Ramsay Hunt syndrome?
Antiviral and steroids
Name 4 high risk groups for severe influenza infection
Children 6-59 months of age
Children with chronic health conditions
- Cardiovascular, liver, renal, metabolic disease
- Neurologic or neurodevelopmental conditions
- Anemia or hemoglobinopathy
- Malignancy and other immune compromising conditions
Children and adolescents on chronic ASAt herapy
Pregnancy
Aboriginal peoples
What are indications for oseltamivir?
- Moderate/severe, progressive influenza
- Patients 1-4 years with mild influenza within 48 hours
- Patients >1 year with mild influenza and risk factors
When do you give zanamavir in the treatment of influenza?
Moderate/severe influenza with no response to oseltamivir or previous oseltamivir prophylaxis
What EBV serology results would you get in acute EBV infection
Monospot + VCA IgM + EA IgG + VCA IgG + EBNA IgG -
What EBV serology results would you get in past EBV infection?
Monospot - VCA IgM - EA IgG - VCA IgG + EBNA IgG +
What is the interaction between clarithromycin and cyclosporine?
Clarithromycin reduces cytochrome P4503A activity leading to reduced
cyclosporin clearance
What 2 infections can mimic terminal ileitis (especially think about in children with exposure to farm animals)?
Yersinia enterocolitica
TB
What antibiotic do you use to treat sinusitis?
Amoxicillin
What are effective regimens for treating lice?
Permethrin1% (Nix) (>2 months)
Pyrethrin (R+C shampoo) (>2 months)
50% isoprophyl myrisate (ResultzR) (>4 years)
Why do we not use lindane to treat lice?
Lindanehas slow killing time, more resistance
and more toxicity
What antibiotics do you empirically use for pulmonary exacerbation in cystic fibrosis?
Ceftazidime and tobramycin
What interventions should you immediately do for suspected HSV keratitis?
Swab for HSV PCR
IV acyclovir
Optho consult
What are cardiac indications for endocarditis prophylaxis?
Prosthetic valve or prosthetic material in valve repair
Prior infective endocarditis
Unrepaired cyanotic CHD
Completely repaired CHD with prosthetic material during first 6 months after procedure
Repaired CHD with residual defects adjacent to prosthetic material
Cardiac valvulopathy in heart transplant patients
What are procedure indications for endocarditis prophylaxis?
Dental procedures that involve:
- Manipulation of gingival tissue
- Manipulation of periapical region of teeth
- Perforation of oral mucosa
Invasive procedures of the respiratory tract that involve incision or biopsy of mucosa
Prophylaxis no longer recommended routinely for GI or GU procedures
What conditions can be associated with erythema nodosum?
Group A streptococcus M. pneumoniae M. tuberculosis B. henselae Yersinia Sarcoidosis Bechet’s disease Malignancy IBD
What children are at high risk of invasive streptococcal disease?
Chronic CSF leak Congenital immune deficiencies Cochlear implants Asplenia Chronic neurologic conditions Sickle cell disease and other hemoglobinopathies Chronic renal disease HIV infection Chronic liver disease Immunosuppressivetherapy Chronic cardiacdisease Malignancy Chronic respiratory disease(excluding asthma) Solid organ transplant Poorly controlled diabetes mellitus Hematopoieticstem cell transplant
What empiric antibiotics do you use for orbital cellulitis?
IV cloxacillin+ ceftriaxone±metronidazoleor clindamycin
What organisms is most responsible for bacterial tracheitis?
S. aureus, mixed organisms
What organisms are most responsible for epiglottitis?
Hib
S. aureus
What is the differential for recurrent fevers?
Recurrent viral infections True infections with immune deficiency Chronic non-infectious (e..g autoimmune) Cyclic neutropenia Periodic fever syndromes
Should you do a full septic work up, HSV OCR lesion scraping, and start IV acyclovir for mucocutaneous HSV?
YES
Until what age could a baby develop neonatal HSV?
6 weeks
When should you do surface swabs in mom with active HSV lesions at delivery?
24 hours
Mouth, conjunctiva, nasopharynx, anus
How do you treat children <2 years of age who are exposed to pulmonary TB and have negative TST/CXR?
INH x 3 months, recheck TST, if negative can stop INH
If >2 years, can observe (age 2-5 is controversial)
What vaccines should you give a previously unimmunized child >7 years?
TdAP IPV
MMR
NO Hib over 7 years
Name 4 conditions that HPV vaccine prevents
Genital warts
Cervical cancer
Anorectal cancer
Penile cancer
What is most likely serology pattern in fully immunized 9 month old infant born to mom with HepBsAg positive?
HepBcAb+, HepBsAb+ (cAb from mom)
Spot diagnosis: http://accessmedicine.mhmedical.com/data/books/1843/cmdt17_ch35_f008.png
Cutaneous larva migrans
Spot diagnosis: https://www.atsu.edu/faculty/chamberlain/images/koplik_spots2.jpg
Koplik spots
What are the Jones criteria for acute rheumatic fever?
Need 2 major or 1 major+2 minor WITH evidence of GAS infection:
Major:
●Carditis and valvulitis (eg, pancarditis) that is clinical or subclinical – 50 to 70 percent
●Arthritis (usually migratory polyarthritis predominantly involving the large joints) – 35 to 66 percent
●Central nervous system involvement (eg, Sydenham chorea) – 10 to 30 percent
●Subcutaneous nodules – 0 to 10 percent
●Erythema marginatum – <6 percent
Minor:
●Arthralgia
●Fever
●Elevated acute phase reactants (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP])
●Prolonged PR interval on electrocardiogram
What is the common bacteria causing osteomyelitis?
S. aureus (in all age groups)
What % of patients with osteomyelitis have positive blood cultures?
50%
In what part of the bone does osteomyelitis typically begin?
Before growth plate closure-METAPHYSIS
After growth plate closure-DIAPHYSIS
Empiric treatment of osteomyelitis in the following age groups:
i) Neonates
ii) Infant
iii) Child
i) Neonates: cloxacillin and gentamicin/cefotaxime
ii) Infant: cefotaxime and cloxacillin
iii) Child: Cefazolin
How long do you typically treat acute osteomyelitis?
4-6 weeks
How do you treat chronic osteomyelitis?
Surgical debridgement
Antibiotics several months or longer
When do you see changes on XR in osteomyelitis?
After 7-14 days-lytic bone changes
What is the most common site of osteomyelitis?
Femur
How many hours after starting antibiotics should you see clinical improvement with a bacterial pneumonia?
48 hours
If no improvement, consider CXR to r/o complications AND consider alternative diagnoses (viral, aspiration, PID, congenital pulmonary anomaly, TB)
What are the 3 most common bacteria causing complicated pneumonia
- S pneumo
- S aureus
- S pyogenes
What antibiotics should be used for complicated pneumonia and for how long (CPS)?
Ceftriaxone +/- clindamycin (for anaerobic + community acquired MRSA) OR vancomycin (for confirmed or severe suspected MRSA)
3-4 weeks duration; can switch to oral clavulin when drainage complete and off O2
What procedural intervention should be used for complicated pneumonia (CPS)?
Three options with equivalent outcomes:
- VATS
- Early thoracotomy
- Small-bore percutaneous chest tube placement with instillation of fibrinolytics (tPA x 3 days)
When should CXRs be repeated in complicated pneumonia (CPS)?
2-3 months
How long are patients with Hep A contagious?
2 weeks before to 7 days after onset of jaundice
List 3 complications of HepB infection
Acute liver failure
Chronic liver disease
Glomerulonephritis
Hepatocellular carcinoma
List 3 risk factors for otitis externa
Swimming Trauma Foreign body Hearing aid Skin conditions Chronic otorrhea Wearing tight head scarves Immunocompromised
Diagnostic criteria for otitis externa
- Rapid onset (within 48h) in the past three weeks
- Symptoms of ear canal inflammation → otalgia, itching, fullness +/- hearing loss, jaw pain
- Signs of ear canal inflammation (i.e. tender pinna/tragus) OR diffuse ear canal edema/erythema +/- otorrhea, regional lymphadenitis, TM erythema, or cellulitis of pinna/skin
What are the two most common bacteria causing otitis externa?
Pseudomonas aeruginosa + Staph aureus
Treatment of otitis externa
- First Line (mild-to-moderate): topical antibiotic +/- topical steroid for 7-10 days
- First Line (severe): systemic antibiotics covering staph and pseudomonas
List 3 reasons why you might not have response to treatment for otitis externa
If no clinical response in 24-48 hours, consider
- Obstruction
- Foreign body
- Non-adherence
- Antimicrobial resistance
- Viral/fungal infection
What is required for the diagnosis of AOM? (CPS)
Acute onset of symptoms such as otalgia
AND
Signs of a middle ear effusion associated + inflammation of the middle ear (ie, a TM that is bulging and, usually, very erythematous or hemorrhagic, and yellow or cloudy in colour) OR ruptured TM
Treatment of oral thrush
Nystatin suspension 200 000 U PO QID x 2 weeks
Treatment of tinea pedis that involves toe nail
Oral antifungal (e.g. terbinafine)
Treatment of cradle cap
Treat with mild soap; if severe can use shampoos with selenium sulfide or azole
What is the only oral antifungal not metabolized through cytochrome P450?
Terbinafine
What is the best strategy to prevent influenza in infants <6 months of age?
Influenza vaccine for pregnant women
What are the 8 components of Canada’s vaccine system?
- Evidence-based pre-license review and approval process
- Regulations for manufacturers:
- Evidence-based vaccine use recommendations
- Immunization competencies training for health care providers
- Pharmacovigilance for adverse events following Immunization (AEFIs)
- AEFI causality assessment
- Safety and efficacy signal detection
- Canadian Immunization Research Network special immunization clinics (SICs)
How long should athlete with EBV be excluded from sports and what are the requirements for resuming activity?
Minimum 3 weeks
Resume activity if:
- Resolution of symptoms
- Normalization of labs
- Resolution of splenomegaly (CONFIRM WITH ULTRASOUND)
Hoow does posterior element overuse syndrome or “hyperlordotic back pain” present?
Similar to spondylosis Extension related back pain Lumbar spine/paraspinal muscle tenderness BUT Investigations NEGATIVE
Treatment of hyperlordotic back pain?
Ice and NSAIDS
Physiotherapy
+/- Bracing until pain resolves
How does vertebral body apophyseal avulsion fracture present?
Acute-onset flexion-related lumbar pain, similar to disc herniation, although with no associated neurological symptoms
Physical exam:
Spinal flexion and extension limitation
Paraspinal muscle spasm
Diagnostic tests for apophyseal avulsion fracture
Lateral lumbar spine x-rays
CT
Treatment of apophyseal avulsion fracture
Rest (3-6 months for symptoms to resolve), heat and NSAIDs
Urgent neurosx if spinal cord compression symptoms
Management of ankle sprain
PRICE (protection, rest, ice, compression, elevation)
- Functional bracing (rigid lateral stirrups–>lace up brace x 3-6 months)
- NSAIDs
- Physiotherapy
- Stepwise RTP usually within 1-6 weeks
