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FRCPC > Infectious disease > Flashcards

Infectious disease Flashcards

1
Q

Name 4 infectious disease emergencies in the returned traveler

A

Malaria
Typhoid fever
Meningococcemia
Viral hemorrhagic fevers

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2
Q

What investigations do you order in fever in a returned traveler?

A

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

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3
Q

What are the 5 species of malaria affecting humans

A 
P. faciparum
P. vivax
P. ovale
P. malariae
P. knowlesi
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4
Q

What is the incubation period of P.falciprum and P. vivax?

A

P. falciprum-within 2 months

P.vivax-Can be many months

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5
Q

What are the clinical and laboratory criteria for severe malaria in children?

A 
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)

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6
Q

How do you diagnose malaria?

A

3 thick and thin smears

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7
Q

How do you treat malaria?

A

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
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8
Q

How does typhoid typically present?

A

Fever without localizing signs

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9
Q

What is the sensitivity of blood cultures for typhoid?

A

50%

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10
Q

How effective is the typhoid vaccine?

A

50-70% effective

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11
Q

How do you treat typhoid?

A

IV ceftriaxone

Cipro resistance is common

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12
Q

What are some considerations for care of children new to Canada?

A
  • 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
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13
Q

What areas should you focus on physical exam of immigrant child?

A
  • Growth and development
  • Signs of undiagnosed chronic illness
  • Signs of congenital infections
  • Vision and hearing screen
  • Dentition
  • BCGscar
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14
Q

What is a reasonable preliminary infectous disease workup in an immigrant child?

A 
CBCand differential
Liver and renal function tests
Serology for HBV, HCV, HIV, syphilis
TB skin test
Chest x-ray
Stool O&amp;P
Urinalysis
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15
Q

What is the definition of classic FUO?

A
  • 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

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16
Q

What is the differential diagnosis of FUO?

A

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

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17
Q

What is the infectious disease differential for FUO-localized and systemic?

A 
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
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18
Q

What are first step investigations for FUO?

A

CBCwith differential, liver enzymes

ESR/CRP, ANA/RF

Blood cultures

Monospot, EBV, CMVserology

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19
Q

What are some second tier investigations for FUO?

A

Malaria smears

Tuberculin skin test

Echocardiogram

Imaging (radiographs, radionuclide scans, ultrasound, CT etc.)

Bone marrow aspirate

HIV and other serologies

Investigations for rheumatologic, neoplasticdiseases

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20
Q

What causes of FUO can be associated with pica?

A

Toxocariaisis

Toxoplasmosis

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21
Q

What two tests would you do in fever in a returning traveler from Nigeria?

A 
Malaria smears (thick and thin)
Blood culture (S. typhi, N. meningitidis)
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22
Q

Name 4 vaccine preventable illnesses from Africa

A 
Typhoid fever
Meningococcal disease
Hepatitis A and B
Yellow fever
Rabies
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23
Q

What are the two most common differentials for an isolated tender axillary lymph node?

A

Bartonella

Bacterial adenitis

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24
Q

What is parinaud oculoglandular

syndrome?

A
  • Caused by Bartonella

- Submandibular/preauricular lymphadenopathy and ipsilateral unilateral granulomatous conjunctivitis

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25
Q

What is the most common cause of afebrile chronic lymphadenopathy with no TB/CSD risk factors?

A

Atypical mycobacterium

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26
Q

What is the differential for acute bilateral cervical LAD?

A 
Respiratory viruses
Enteroviruses
Adenovirus,
EBV
CMV
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27
Q

What is the differential for acute unilateral cervical LAD?

A

S. aureus

S. pyogenes (80%)

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28
Q

What is the infectious differential for chronic bilateral cervical LAD?

A

HIV
EBV
CMV
Toxoplasmosis

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29
Q

What is the infectious differential for chronic unilateral cervical LAD?

A 
Non-tuberculous mycobacteria
M. tuberculosis
Bartonella henselae
Tularemia,
Plague (Y. pestis)
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30
Q

Name 6 clinical presentations associated with cat scratch disease

A

Lymphadenitis (axillary most common)

Perinaud oculoglandular syndrome

Hepatosplenic bartonellosis (granulomatous disease)

Neuro-retinitis

Encephalopathy

Fever of unknown origin

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31
Q

How do you treat cat scratch disease?

A

Observation is reasonable
Azithromycin for lymphadenitis (to shorten duration of sx)
Doxycycline + rifampin for neuroretinitis/CNS disease

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32
Q

What is a mnemonic to remember TORCH infections?

A 
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
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33
Q

What % of patients with congenital CMV are asymptomatic at birth?

A

2/3 of those with sequelae are asymptomatic at birth

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34
Q

Name 7 clinical features of congenital CMV

A 
IUGR
Hepatosplenomegaly
Thrombocytopenia***
Microcephaly
Periventricular calcifications***
SNHL***
Chorioretinitis
Others:
Strabismus
Optic atrophy
Microphthalmia
Seizures
Hyperbilirubinemia
Elevated ALT
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35
Q

Name 3 long term sequelae of asymptomatic CMV

A

Sensorineural hearing loss (7% to 15%)-can be delayed onset
Mental retardation, learning disabilities (3.5%)
Chorioretinitis (2.5%)

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36
Q

Name 3 indications for treatment in congenital CMV

A
  • CNS involvement
  • SNHL
  • Chorioretinitis
  • Case-by-case for “mildly symptomatic” neonates
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37
Q

How do you treat congenital CMV?

A

Valganciclovir 16 mg/kg/dose bid for 6 months

IV ganciclovir for hospitalized,
severely affected newborns

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38
Q

List 2 toxicities do you need to monitor for when treating CMV

A

Neutropenia
Nephrotoxicity

Close monitoring of CBC (neutrophil count) & creatinine

Consider interruption of therapy if ANC < 0.5

Consider GCSF if neutropenia is persistent

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39
Q

Name 5 features of congenital syphilis

A

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
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40
Q

Name 7 late onset manifestations of congenital syphilis

A 
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

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41
Q

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-

A

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

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42
Q

When do you do a FULL evaluation for congenital syphilis in an infant AND treat (Name 6 indications) ?

A

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

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43
Q

What is a full evaluation for congenital syphilis?

A

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!

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44
Q

In a mother who was treated for syphilis and has no indications for the full work up, what test do you do?

A

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

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45
Q

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?

A

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!

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46
Q

How do you treat congenital syphilis?

A

IV Penicillin G x 10-14 days

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47
Q

What is the classic triad of congenital toxoplasmosis?

A

Hydrocephalus/macrocephaly*
Cerebral calcifications*
Chorioretinitis

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48
Q

What percentage of toxoplasmosis is symptomatic at birth?

A

15% (similar to CMV)

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49
Q

During what trimester(s) is symptomatic congenital toxo acquired?

A

1st and 2nd

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50
Q

During what trimester is asymptomatic congenital toxo acquired?

A

3rd

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51
Q

What is the prognosis for congenital toxo that is asymptomatic at birth?

A

Untreated majority will go on to develop disease (unlike CMV)

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52
Q

What is the most common manifestation of congenital toxo that is asymptomatic at birth?

A

Chorioretinitis

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53
Q

How do you diagnose congenital toxoplasmosis (name 3 tests)?

A

Serology (IgG, IgM, IgA) in serum of infant
PCR on CSF, blood and/or urine
Placental pathology

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54
Q

What two findings will you see on CSF in congenital toxo?

A

Lymphocytic pleocytosis

Elevated CSF protein (often very high)

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55
Q

How do you treat confirmed congenital toxo?

A

Pyrimethamine + sulfadiazine + leucovorin x12 months

Steroids for eye disease and possibly hydrocephalus

VP shunt for hydrocephalus

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56
Q

What toxicity do you need to monitor for when treating congenital toxo?

A

Neutropenia

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57
Q

What are the clinical features of congenital VZV?

A 
Microcephaly
Cicatricial scars***
Limb hypoplasia***
Microphthalmia
GERD
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58
Q

What are the potential sequelae of VZV infection during pregnancy on infants in

a) first/second trimester
b) third trimester
c) perinatal

A

a) Congenital varicella syndrome
b) Herpes zoster in infancy/childhood
c) disseminated neonatal varicella

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59
Q

How do you manage VZV exposure during pregnancy?

A

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

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60
Q

What is a significant VZV exposure in pregnancy?

A

Household exposure

Face-to-face contact for ≥ 5 minutes

Indoor contact for ≥ 15 minutes

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61
Q

Name 7 clinical features of congenital rubella?

A 
IUGR
Blueberry muffin rash
Hepatosplenomegaly
Cataract***
Bony lucencies***(can be confused with syphilis)
Cardiac anomalies (PDA)***
SNHL

Others:
Hemolytic anemia
Thrombocytopenia

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62
Q

At what point in pregnancy are you most at risk of congenital rubella syndrome?

A

First trimester

After 16 weeks congenital anomalies are uncommon

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63
Q

Name 5 long term features of congenital rubella syndrome

A 
Sensorineural hearing loss
Cataract
Chorioretinitis
Microphthalmia
PDA
Peripheral pulmonary stenosis
Pulmonary valvular stenosis
VSD
Myocarditis
Global developmental delay
Language defects
Behavioral disorders
Seizures
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64
Q

What tests should you do if a pregnant woman is exposed to parvovirus?

A

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)

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65
Q

What are the clinical features of parvovirus infection?

A 
Papular-purpuric glove and sock syndrome
Arthropathy
Transient aplastic crisis
Pure RBC aplasia (HIV, transplant)
HLH
Myocarditis
Encephalitis
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66
Q

Name two risk factors for parvovirus infection?

A

Young school aged children in home

Occupational (teachers of 5-7 year old children, health
care workers)

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67
Q

Name 2 potential sequelae of parvovirus infection during pregnancy?

A

Fetal loss

Non-immune hydrops fetalis

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68
Q

When during pregnancy is the risk of fetal loss highest in parvovirus infection?

A

First trimester

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69
Q

What type of virus is Zika?

A

Flavivirus

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70
Q

How is Zika transmitted

A

Mosquito

Sexual

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71
Q

What are the clinical manifestations of Zika?

A

Asymptomatic infection (75-80%)

Clinical illness typified by fever, maculopapular rash,
conjunctivitis and myalgia

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72
Q

When during pregnancy is the highest risk period for Zika?

A

First & early second trimester

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73
Q

How do you make an antenatal diagnosis of Zika?

A

Fetal US

Amniotic fluid PCR

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74
Q

How do you make a postnatal diagnosis of Zika?

A

Zika IgM, dengue IgG and IgM
If either positive PRNT
CSF Zika IgM

PCR on placenta, umbilical cord tissue, serum, urine and CSF

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75
Q

What are the clinical features of congenital Zika?

A

Severe microcephaly with partially collapsed skull

Thin cerebral cortices

Subcortical calcifications

Macular scarring

Contractures

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76
Q

Which congenital infections are associated with brain calcifications?

A

CMV-periventricular
Toxo-parenchymal
HIV-basal ganglia

Rarer:
HSV-parenchymal
LCMV-parenchymal
Zika-subcortical

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77
Q

Which congenital infections are associated with microcephaly?

A

CMV, HSV, Rubella, TOXO, syphilis, VZV

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78
Q

Which congenital infections are associated with macrocephaly?

A

TOXO, LCMV, syphilis

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79
Q

Which congenital infections are associated with chorioretinitis?

A

CMV, TOXO, syphilis, rubella

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80
Q

Which congenital infections are associated with SNHL?

A

CMV, Rubella, syphilis, TOXO

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81
Q

Which congenital infections are associated with microopthalmia?

A

VZV

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82
Q

Which congenital infections are associated with cataracts?

A

Rubella (syphilis)

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83
Q

Which congenital infections are associated with pseudoparalysis?

A

Syphilis

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84
Q

Which congenital infections are associated with optic atrophy?

A

CMV

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85
Q

Which congenital infections are associated with hydrops?

A

Parvovirus B19, syphilis, CMV, TOXO

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86
Q

Which congenital infections are associated with HSM?

A

CMV, HSV, rubella, syphilis, TOXO

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87
Q

Which congenital infections are associated with hemolytic anemia?

A

Syphilis

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88
Q

Which congenital infections are associated with blueberry muffin rash?

A

Rubella, CMV

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89
Q

Which congenital infections are associated with cytopenias?

A

CMV, TOXO, HSV, syphilis, rubella

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90
Q

Which congenital infections are associated with liver failure?

A

Enteroviruses, TOXO, HSV

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91
Q

What are the typical manifestations of early onset (<7 days) GBS?

A

Pneumonia, septicemia, meningitis

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92
Q

What are the typical manifestations of late onset (>7 days) GBS?

A

Meningitis, osteomyelitis, soft tissue infections, sepsis

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93
Q

What are indications for intrapartum antibiotics?

A

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)
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94
Q

What are the only two antibiotics that are considered adequate IAP?

A

Penicillin

Ampicillin

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95
Q

What antibiotics can be used for IAP in a mom who is penicillin allergic?

A

Mild allergy-cefazolin

Severe allergy-clinda

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96
Q

What are the low risk criteria for febrile infants 29-90 days old?

A

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)

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97
Q

If any of the low risk criteria are NOT met for a febrile infant 29-90 days old, what should you do?

A

FSWU

  • If CSF abnormal: amp+cefotax+vancomycin
  • If CSF normal-amp+cefotax
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98
Q

What are the most common bacterial pathogens for 0-28 d infants with fever without source ?

A

Most common:
GBS, E. coli

Less common
Listeria, S. aureus, GAS, Klebsiella pneumoniae

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99
Q

What are the most common bacterial pathogens for 29-90 d infants with fever without source ?

A

Most common:
GBS, E. coli

Less common:
S pneumoniae, Neisseria meningitidis, Listeria, S. aureus, GAS

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100
Q

What are the most common bacterial pathogens for 3-36m infants with fever without source ?

A

Most common:
S pneumoniae

Less common:
S. aureus, GAS, Neisseria meningitidis

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101
Q

What is empiric antibiotic therapy for rule out sepsis
0-28 days
29-90 days
3-36 months

A

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

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102
Q

What are the three clinical presentations of neonatal HSV?

A

Mucocutaneous (Skin, eye, mouth) (45%)
Enchephalitis (30%)
Disseminated

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103
Q

When does mucocutaneous neonatal HSV usually present?

A

Day 10-12 of life

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104
Q

Does clinically silent CNS infection occur with mucocutaneous HSV?

A

Yes

Dissemination can occur without treatment

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105
Q

When does neonatal HSV encephalitis present?

A

Day 16-19 of life

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106
Q

How does neonatal HSV encephalitis typically present?

A

Fever
↓LOC
Seizures
Skin lesions in 2/3 of cases

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107
Q

When does disseminated neonatal HSV typically present?

A

Day 10-12 of life

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108
Q

What are the clinical features of disseminated neonatal HSV?

A

Sepsis-like presentation
Multi-organ involvement-elevated LFTs (in 100s)
2/3 have concurrent encephalitis

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109
Q

What investigations should you do for suspected neonatal HSV?

A

Culture/PCR of vesicle fluid, nasopharynx, eyes, urine, stool, blood, CSF

Do LP even if clinically well (e.g. isolated mucocutaneousdisease)

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110
Q

How do you treat neonatal HSV and for how long?

A

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

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111
Q

Name 5 factors determining transmission risk in HSV?

A

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%)

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112
Q

What percentage of whomem who deliver an HSV-infected child have no history of genital herpes?

A

60-80%

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113
Q

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

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
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114
Q

What bacteria cause AOM?

A

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%

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115
Q

What antibiotics are first line for AOM?

A

Amoxicillin 75-90 mg/kg/day divided BID

Amoxicillin 45-60 mg/kg/day divided TID

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116
Q

What antibiotics are first line for AOM with mild amoxicillin allergy?

A

Cefprozil30 mg/kg/day divided BID
Cefuroxime30 mg/kg/day divided BID
Ceftriaxone 50 mg/kg IM/IV x 3 doses

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117
Q

What antibiotics are first line for AOM with severe amoxicillin allergy?

A

Azithromycin
Clarithromycin
Clindamycin
Levofloxacin in select circumstances

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118
Q

What antibiotics do you use for treatment failure?

A

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

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119
Q

For how long do you treat AOM?

A

5 days for children ≥2 years

10 days for 6 months-2 years OR perf TM OR recurrent AOM

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120
Q

When can you employ watchful waiting in AOM (children >6 months)?

A

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

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121
Q

What bacteria cause acute pneumonia?

A 
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
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122
Q

What is empiric antibiotic therapy for uncomplicated community acquired pneumonia?

A

Well-amoxicillin/ampicillin
Respiratory failure/shock-ceftriaxone +/- vanco

Rapidly progressive multilobar disease or pneumatoceles-ceftriaxone + vanco (for possible MRSA)

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123
Q

What is the rationale for upgrading from ampicillin to cefriaxone for unwell children with community acquired pneumonia?

A

Ceftriaxone offers better coverage against β-lactamase+ H. influenzae and possibly for S. pneumoniae with high level resistance to penicillin

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124
Q

What bacteria typically causes meningitis?
A. <1 month
B. 1-3 months
C. >3 months

A

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

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125
Q

How do you treat suspected bacterial meningitis?
A. <1 month
B. 1-3 months
C. >3 months

A

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
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126
Q

Should you give dexamethasone for bacterial meningitis, and if so when?

A

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

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127
Q

When do you consider repeat LP at 24-36 hours in bacterial meningitis (name 4 indications)

A

Failure to improve clinically

Immunocompromised host

S. pneumoniae resistant to penicillin/cephalosporins

Meningitis due to gram negative bacilli

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128
Q

What are the most common bacteria causing purpura fulminans?

A

N. meningitidis
S. aureus
S. pneumoniae
GAS

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129
Q

What antibiotics do you use for purpura fulminans?

A

Ceftriaxone + vancomycin

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130
Q

What are the most common bacteria causing toxic shock syndrome?

A

S. pyogenes, S. aureus

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131
Q

How do you treat TSS?

A

Cloxacillin (or cefazolin)+ clinda

If TSS due to group A strep-Penicillin + clindamycin±IVIGfor

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132
Q

What are physical exam findings associated with endocarditis?

A

Osler nodes
Splinter hemorrhage
Janeway lesions

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133
Q

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

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

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134
Q

What are the typical bacteria causing impetigo?

A

S. aureus, Group A streptococcus

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135
Q

What empiric antibiotics do you use for impetigo?

A

PO: Cloxacillin, Cephalexin

topical mupirocin

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136
Q

What are the typical bacteria causing cellulitis?

A

S. aureus, Group A streptococcus

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137
Q

What empiric antibiotics do you use for cellulitis?

A

IV: Cloxacillin, Cefazolin
PO: Cloxacillin, Cephalexin

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138
Q

What are the typical bacteria causing pyomyositis?

A

S. aureus, streptococci

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139
Q

What empiric antibiotics do you use for pyomyositis?

A

IV: Cefazolin, Cloxacillin

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140
Q

What are the typical bacteria causing necrotizing fasciitis?

A

Group A streptococcus, S. aureus

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141
Q

What empiric antibiotics do you use for necrotizing fasciitis?

A

IV: Cloxacillin(or Cefazolin) + clindamycin ±vancomycin

Penicillin +clindamycin if you suspect GAS (e.g. in chicken pox)

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142
Q

What complication of chickenpox would you suspect in a child who develops refusal to weight bear, significant pain, indurated area, bluish hue?

A

Necrotizing fasciitis

Suspect GAS as underlying cause

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143
Q

List 4 management steps in suspected necrotizing fasciitis?

A

CBC & blood culture

Urgent surgical consult

IV antibiotics

IVIG

Imaging should not delay surgical intervention

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144
Q

Name 5 complications of chickenpox

A

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)
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145
Q

What are some complications of enterovirus?

A 
Meningitis
Encephalitis
Acute flaccid paralysis
Myocarditis
Hepatitis
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146
Q

What are some complications of EBV?

A 
Upper airway obstruction (adenopathy)
Splenic rupture
Encephalitis
X-linked lymphoproliferative diseas
ITP
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147
Q

What are some complications of influenza?

A

Otitis media
Secondary bacterial pneumonia
Myositis, Encephalopathy/encephalitis
Reye syndrome

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148
Q

What are some complications of measles?

A

Otitis media
Secondary bacterial pneumonia
Encephalitis
SSPE

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149
Q

What are some complications of mumps?

A 
Meningitis
Encephalitis
Orchitis/oophoritis
Arthritis
Pancreatitis
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150
Q

What are some complications of parvovirus?

A

Papular-purpuric gloves and socks syndrome
Transient aplastic crisis
Chronic bone marrow failure
Polyarthropathy syndrome

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151
Q

What are three options for obtaining a sterile specimen for diagnosis of UTI?

A

Catheterization
Suprapubic aspiration
Clean catch

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152
Q

What are antibiotic options for empiric treatment of UTI >2 months?

A

Majority can be managed with oral antibiotics

Cephalosporin, amoxicillin-clavulanate, TMPSMX

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153
Q

What are indications for IV antibiotics in UTI?

A

Toxic appearance

<1 month

2-3 months controversial

Unable to retain oral intake (including medications)

Immunocompromisedhost (selectively)

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154
Q

What investigations should be done after first febrile UTI?

A

Renal and bladder ultrasound for children < 2 years of age

VCUG selectively

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155
Q

What are indications for VCUG

A

Ultrasound evidence of hydronephrosis, renal scarring or other findings suggestive of high grade vesicoureteralreflux or obstructive uropathy

2nd febrile UTI

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156
Q

What are indications for prophylactic antibiotics for UTI?

A

Grade 4 or 5 VUR

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157
Q

What antibiotics should you use for prophylaxis for UTI?

A

TMP SMX
Nitrofurantoin

If child has UTI due to organism resistant to these –consider stopping prophylaxis

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158
Q

What are the most common organisms for dog/cat bite?

A

Pasteurellamultocida, Streptococci spp., S. aureus, anaerobes, others

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159
Q

What is the best empiric therapy for dog/cat bites?

A

PO amoxicillin-clavulanate
IV cloxacillin+ penicillin
If not improving, surgical debridement

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160
Q

What are the most common organisms for human bite?

A

Streptococci, S. aureus, anaerobes, nontypable Haemophilus influenzae, Eikenella corrodens

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161
Q

What is the best empiric therapy for human bite?

A

PO amoxicillin-clavulanate

IV cloxacillin+ Penicillin

162
Q

What are the most common organisms for puncture wound of foot WITH sneakers?

A

Pseudomonas

163
Q

What is the best empiric therapy for puncture wound of foot WITH sneakers?

A

Piperacillinor ciprofloxacin ±gentamicin

164
Q

What are the most common organisms for puncture wood of foot WITHOUT sneakers?

A

S. aureus

165
Q

What is the best empiric therapy for puncture wood of foot WITHOUT sneakers?

A

PO cloxacillinor cephalexin

IV cloxacillinor cefazolin

166
Q

Name 5 organisms that can cause severe invasive disease in patients with asplenia

A 
S. pneumo (majority of sepsis)
HIB
Neisseria meningitidis
Capnocytophaga canimorsus (dog saliva)
Salmonella (reptiles, food, water)
Malaria
Babesiosis
167
Q

What are three categories of preventive interventions for children post-splenectomy?

A

Immunizations

Antibiotic prophylaxis

Education around fevers

168
Q

What immunizations do asplenic children need?

A

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

169
Q

What do you use for antibiotic prophylaxis in asplenic patients?

A

Birth –3 months: amoxicillin-clavulanate (higher risk of E Coli)

≥3 months: Penicillin (amoxicillin alternative)

170
Q

When are asplenic patients at highest risk of sepsis?

A
  • Younger children
  • First year after splenectomy
  • Congenital asplenia/functional asplenia>traumatic asplenia
171
Q

What ticks transmit lyme disease (borrelia burgdorferi)?

A

Ixodes scapularis

Ixodes pacificus

172
Q

What are the 3 clinical stages of lyme disease and what are the associated manifestations?

A

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
173
Q

How do you diagnose lyme disease?

A

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

174
Q

When can IgM and IgG be detected in Lyme disease?

A

IgM can be detected within 2 weeks of infection

IgG rise usually 4-6 after infection

175
Q

What are oral and IV treatment options for Lyme disease?

A

Oral:

Doxycycline for children ≥8 years of age
Amoxicillin for children <8 years of age
Cefuroxime

IV:

Ceftriaxone
Penicillin G

176
Q

How do you remove a tick?

A

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

177
Q

What should you do with the tick?

A

Send to PHL for identification

178
Q

Do you use chemoprophylaxis is in children with a tick bite?

A

Yes, if >8 years old

Single dose of doxycycline in high-risk exposure (high endemic region, exudes tick)

179
Q

When is the peak incidence of West Nile Virus?

A

Late summer & fall

180
Q

What are the 3 clinical presentations of WNV?

A

Asymptomatic infection (~80%)

West Nile fever (~ 20%)

West Nile neurologic disease (≤1%)

181
Q

What are the neurologic symptoms associated with WNV?

A

Aseptic meningitis
Encephalitis
Acute flaccid paralysis (poliomyelitis like)

182
Q

What are 5 strategies to avoid WNV?

A

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)

183
Q

What are the different levels of severity in C. difficile?

A

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

184
Q

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

A

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

185
Q

List 4 steps for infection control for C. difficile

A

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

186
Q

Who should be screened for STIs?

A

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

187
Q

What tests should be done for an STI screen?

A

First catch urine NAAT chlamydia and gonorrhea

HIV, HepB, syphilis serology

188
Q

How do you treat uncomplicated gonorrhea in children >9 years?

A

Ceftriaxone 250 mg IM OR Cefixime 800 mg po SD

PLUS

Azithromycin1 g SD

189
Q

How do you treat uncomplicated gonorrhea in children <9 years?

A

Ceftriaxone 50 mg/kg IM OR Cefixime 8mg/kg BID po x2 doses

PLUS

Azithromycin 20 mg/kg SD

190
Q

What are the next steps in management of a child born to a mother with untreated gonorrhea?

A

Well:
Conjunctival cultures
IM Ceftriaxone

Unwell:
Conjunctival, blood and CSF cultures

191
Q

What are the next steps in management of a child born to a mother with untreated chlamydia?

A

Routine culture, treatment not recommended

Observe for conjunctivitis, pneumonia

192
Q

Differential diagnosis for genital lesions

A

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)

193
Q

What is the definition of TB exposure?

A

Asymptomatic, negative TST, normal CXR

194
Q

What is the definition of TB infection?

A

Asymptomatic,normal CXR, but positive TST

195
Q

What is the definition of TB disease?

A

Signs and symptoms or radiographic manifestations are apparent

196
Q

What is the definition of a positive TST?

A

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

197
Q

Name 4 reasons for reactive tuberculin skin test

A

Mycobacterium tuberculosis infection

Non-tuberculous mycobacteria infection

BCG in past

Incorrect technique (measurement)

198
Q

Name 8 reasons for false negative TST

A 
Incorrect technique
Active TB disease
Immunodeficiency states
Corticosteroids
Young age
Malnutrition
Viral infections (measles, varicella, influenza)
Live attenuated vaccines (measles)
199
Q

What are the advantages of Interferon γ release assays in the diagnosis of TB?

A

-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

200
Q

What clinical situation are interferon gamma tests most useful?

A

Diagnosis of LTBI in BCG recipients

201
Q

What are the disadvantages of Interferon γ release assays in the diagnosis of TB?

A
  • 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)
202
Q

What are risk factors for development of TB disease?

A

Infants and post-pubertal adolescents

Recently infected (past 2 years)

Immunodeficiency states (PID, HIV, malignancy, organ transplant, immunosuppressive meds, malnutrition)

203
Q

How do you diagnose pulmonary TB?

A

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

204
Q

What are three different ways pulmonary TB can appear on chest imaging?

A

Hilar adenopathy
Ghon complex
Miliary TB

205
Q

How do you treat LTBI?

A

INH x 9 months

206
Q

How do you treat active TB?

A

INH, RIF, PYR, ETH (4 drugs) x 2 months

INH + RIF to complete course

207
Q

What supplement should you give for all children with TB disease?

A

Vitamin D

208
Q

What are the side effects of INH?

A 
Hepatotoxicity
Peripheral neuropathy (interferes withpyridoximemetabolism)
209
Q

What are the side effects of rifampin?

A 
Hepatotoxicity
Hypersensitivity reactions
Memory impairment
Drug interaction
Body fluids turn orange
210
Q

What are the side effects of pyrazinamide?

A

Hepatotoxicity

Increased uric acid levels

211
Q

What are the side effects of ethambutol?

A

Optic neuropathy (decreased acuity, decreased visual fields, color blindness)

212
Q

What are the infectious risks associated with blood transfusions?

A

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

213
Q

What is the leading cause of HIV infection in women?

A

Heterosexual transmission

214
Q

In a mother with HIV, what two things do we test for in the infant and when?

A

PCR(birth, 1, 2 months)

Serology (18 months)

215
Q

What is the likelihood of vaginal transmission if mom on ART and received IV zidovudine during labour?

A

<2%

25% if no interventions

216
Q

Name 5 medical interventions to prevent vertical HIV transmission

A

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

217
Q

What are the initial management steps in an HIV-exposed infant after birth?

A

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!

218
Q

When should you give cotrimoxazole prophylaxis in an HIV exposed infant?

A

Mom has suboptimal virologic control

219
Q

How can you finalize HIV negative status in exposed infant?

A

Exclusion of HIV requires 2 separate negative PCR tests taken at 1 month of age or later

220
Q

How can you finalize diagnosis of HIV infection in exposed infant?

A

HIV infection confirmed by positive PCRx2 prior to 18 months or reactive serology after 18 months

221
Q

What are the two most common laboratory abnormalities with AZT?

A

Macrocytic anemia

Elevated lactate

222
Q

Name 8 AIDS-defining conditions in chidlren

A

PJP pneumonia

Lymphoid interstitial pneumonitis

Recurrent bacterial infections

HIV wasting syndrome

HIV encephalopathy

Candida esophagitis

CMV disease

Mycobacterium avium intracellulare infection

223
Q

Name 11 clinical manifestations of HIV infection in children

A

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)
224
Q

Well controlled children with HIV are almost immunologically normal. Name two ways they are not.

A

Increased risk of pneumococcal disease

Vaccine responses not as good as healthy children

225
Q

What immunizations should be given to children with HIV?

A

All routine childhood vaccines
Annual influenza vaccine
Polysaccharide pneumococcal vaccine (after Prevnar)
Meningococcal vaccine (Menactra)

226
Q

What vaccines are contraindicated in HIV?

A

MMR if severe immune compromise

VZV vaccine if CD4percentage < 25%

BCG & oral polio vaccine contraindicated in developed countries

227
Q

What is the risk of transmission with needle stick injury for the following viruses if positive source?
Hep B
Hep C
HIV

A

HepB 2-40%
HepC 3-10%
HIV 0.2-0.5%

228
Q

What factors affect HIV transmission following needlestick injury?

A 
Community prevalence
Needle size
Hollow bore
Visible blood
Depth of penetration
Elapsed time
HIV infected source:
Disease stage
Viral load
CD4count
Antiretroviral therapy
229
Q

What tests do you do for needlestick injury and how often?

A

HBsAg, HBsAb, HBcAb
HIV serology
HCV serology

0, 6 weeks, 3 months, 6 months

230
Q

What is the schedule for HepB vaccination in needlestick injury?

A

0, 1, 6 months

231
Q

What do you do if a patient is fully vaccinated for HepB and get a needlestick injury?

A

1) HBsAb & HBsAg (STAT)
2) If HBsAb (+) or HBsAg (+)-no treatment, refer to GI if Ag +
3) If HBsAb (−) & HBsAg (−)-HBIg and vaccine

232
Q

What do you do if a patient is not fully vaccinated for HepB and gets a needlestick injury?

A

1) HBsAb & HBsAg (STAT)
Administer HBIG & first dose
of vaccine
2) D/C vaccine if HBsAg+ or HBsAb+

233
Q

List 5 management priorities in daycare bite wounds

A

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

234
Q

What to do when unknown HepB status child bites another unknown HepB status child AND there is break in skin?

A

Vaccinate both

No testing

235
Q

What to do when HBV carrier child bites a non-immune child AND there is break in skin?

A

For bitten child:
HBIg
HB vaccine
Follow up testing (HepB serology at 6 months)

236
Q

What to do when a non-immune child bites HBV carrier AND there is break in skin?

A

For biting child:
HBIg
HB vaccine
Follow up testing (HepB serology at 6 months)

237
Q

What to do when unknown HepB status child bites non-immune child AND there is break in skin?

A

For bitten child:

HB vaccine

238
Q

What to do when non-immune child bites child with unknown HepB status AND there is break in skin?

A

For biting child:

HB vaccine

239
Q

What is a general contraindication to any vaccine?

A

Prior history of anaphylaxis to vaccine or vaccine component (egg allergy is ok-can be observed in office after vaccine administration)

240
Q

What is a contraindication to live vaccines?

A

Severe immune deficiency

241
Q

What are contraindications to influenza vaccine?

A

-History of Guilain Barre within 6 weeks of influenza vaccine in past

242
Q

What are contraindications to live attenuated influenza vaccine?

A

Immune compromising conditions

Severe asthma (oral steroid; high dose inhaled steroids; active wheezing; medically attended wheezing in preceding 7 days)

Chronic ASA therapy

Pregnancy

243
Q

What vaccines are contraindicated in patients with active TB?

A

MMR

VZV

244
Q

What are contraindications for rotavirus vaccine?

A

Hypersensitivity

History of intussusception

Immunocompromisedinfants (especially SCID)

> = 8 months of age

245
Q

What is the period of infectiousness of meningococcal meningitis?

A

7 days prior to symptom onset until 24 hours after start of effective therapy

246
Q

Do you give chemoprophylaxis for meningococcal meningitis to contacts that are immunized?

A

YES

247
Q

During what time period of contact with an index case would you consider chemoprophylaxis for meningococcal meningitis?

A

Up to 10 days after last contact with index case

248
Q

What are indications for chemoprophyalxis AND vaccination in close contacts for meningococcal meningitis?

A

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

249
Q

Name 3 options for chemoprophylaxis for meningococcal meningitis

A

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)

250
Q

What are the three types of meningococcal vaccines and what do they protect against?

A

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

251
Q

What are the indications for MenC vaccine?

A

Administer at 12 months of age to healthy children

Close contacts of known group C disease

252
Q

What are the indications for quadrivalent meningoccal vaccine?

A

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

253
Q

Who is at increased risk of invasive meningococcal disease?

A

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

254
Q

What are the indications for multicomponent meningococcal B vaccine (4CMenB)?

A

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

255
Q

What are the indications for HPV vaccine?

A

All girls and boys 9-26 years of age and older regardless of sexual activity

256
Q

What is Gardasil?

A

Recombinant vaccine for the prevention of cervical cancer and condylomata

257
Q

Which HPV serotypes does Gardasil protect against?

A

Covers HPV types 6, 11, 16, 18

258
Q

What does HPV 6, 11 cause?

A

90% of anogenital warts

Recurrent respiratory papillomatosis

259
Q

What does HPV 16, 18 cause?

A

70% of squamous cell and adenocarcinomas
86% of adenocarcinomas of the cervix

Cancers of penis, anus, vulva and vagina

260
Q

What is the dosing regimen for Gardasil?

A

3 dose schedule-0, 2, 6 months

261
Q

Who can get 2 dose schedule (0, 6 months) for Gardasil?

A

Otherwise healthy children 9-14 years of age

262
Q

What pathogen accounts for most admissions for gastroenteritis and most gastroenteritis <2 years of age?

A

Rotavirus

263
Q

How effective is the rotavirus vaccine?

A

Decreases incidence of gastroenteritis by 70-80%

Decreases severity by 85-95% (reduces admissions)

264
Q

When should rotavirus vaccine be given?

A

Between 6-14 weeks of life

SHOULD NOT be given >8 months of age

265
Q

Who should get the flu vaccine?

A

All children >6 months of age

266
Q

In what groups of children in influenza vaccine particularly recommended?

A

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

267
Q

What form of the inactivated influenza vaccine is recommended for children?

A

Quadrivalent

268
Q

What is the dose of inactivated influenza vaccine?

A

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

269
Q

In what age group is live attenated influenza vaccine authorized?

A

> =2 years of age

270
Q

How many after receiving antivirals can you get the live flu vaccine?

A

48 hours

271
Q

If you get an antiviral within 2 weeks of getting the live flu vaccine, when should you give a second dose of vaccine?

A

48 hours after stopping antiviral

272
Q

Who should get antibiotics for pertussis and what is the purpose?

A

Treatment of child indicated to reduce spread; wont impact duration of cough

Household contacts should also get antibiotics

273
Q

What are 4 nationwide strategies to reduce pertussis?

A

Universal vaccination of children

Universal vaccination of teenagers and adults

Invest in more immunogenic vaccines

Post-exposure immunization

Education of public

274
Q

How long after IVIg do you need to wait before giving MMR or varicella vaccines?

A

Recommended interval depends on IVIG dose

300-400 mg/kg=8 months

1 g/kg=10 months

2 grams/kg=11 months***

275
Q

Which vaccines have reduced efficacy after IVIg?

A

MMR and varicella

Not other live vaccines or inactivated vaccines

276
Q

What are the indications for Hepatitis A prophylaxis with JUST vaccine?

A

All individuals within 2 weeks of exposure in those ≥6 months of age

277
Q

What are the indications for Hep A prophylaxis with JUST immunoglobulin?

A

Infants <6 months

Vaccine contraindications

278
Q

What are the indications for HepA prophylaxis with BOTH vaccine and Ig?

A

Immunocompromised

279
Q

What should you do for a newborn born to mom with unknown HepB status?

A
  • Send maternal HBsAgSTAT
  • If result available within 12 hours of birth can await result, if (+) give HBV vaccine and HBIG, if (-) no intervention
280
Q

If mom HepBsAg positive, what time frame do you have to give HepB vaccine and Ig?

A

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

281
Q

What is the HepB vaccine schedule for exposed newborns?

A

0, 1, 6 months

282
Q

When should infant HepB serologies be done after administering the full vaccine series?

A

4 weeks after
Usually at 9-12 months of age
If HBsAg-, HBsAb -, reimmunize

283
Q

Who should get the 4 dose schedule of HepB vaccine (0, 1, 2, 6 months)

A

Infants <2.0 Kg at birth

284
Q

What does the following HepB serology mean: HBeAg−, HBcAg−, HBsAg−
HBeAb−, HBcAb−, HBsAb+

A

Immunized, uninfected

285
Q

What does the following HepB serology mean: HBeAg+, HBcAg+, HBsAg+
HBeAb−, HBcAb+, HBsAb−, IgMHBcAb+

A

Acute infection

286
Q

What does the following HepB serology mean: HBeAg−, HBsAg+

HBeAb+, HBcAb+, HBsAb−

A

Healthy carrier

287
Q

What does the following HepB serology mean: HBeAg+, HBsAg+

HBeAb−, HBcAb+, HBsAb−

A

Chronic infection

288
Q

What does the following HepB serology mean: HBeAg−, HBcAg−, HBsAg−
HBeAb+/−, HBcAb+, HBsAb+

A

Past infection

289
Q

What is the risk of transmission of maternal HCV ?

A

5%

290
Q

What factors increase the risk of maternal HCV transmission?

A

HIV co-infection, higher HCV viral load, elevated ALT, cirrhosis

291
Q

Is elective C/S recommended for mothers with HCV?

A

No

292
Q

What and when do you test an infant exposed to HCV?

A

HCV serology at 12 to 18 months

PCR can be done between 3-6 months of age, but not essential (to relieve anxiety)

293
Q

Name 5 indications for VZIg (within 10 days of exposure)?

A

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

294
Q

What things would you do on an infant born to mom with varicella prior to delivery?

A
  • 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
295
Q

What three infection control precautions should you take in mom with varicella?

A

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)

296
Q

What are 5 things you would do to manage a dog bite?

A

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

297
Q

What are the indications for rabies prophylaxis (RIG and vaccine)?

A

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

298
Q

What are the management steps in a possible rabies exposure?

A

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)
299
Q

How should rabies immunoglobulin be given?

A

Infiltrated into wound, remainder should be given IM

300
Q

How many doses of rabies vaccine are given?

A

Usually 4 or 5 doses

301
Q

What is the recommended post-exposure prophylaxis for Hib type B?

A

Rifampin x 4 days

302
Q

What is the recommended post-exposure prophylaxis for N. meningitidis?

A

Rifampin x 2 days

303
Q

What is the definition of invasive GAS and what is the recommended chemoprophylaxis for close contacts of invasive GAS?

A

Invasive GAS=
Strep TSS
Soft tissue necrosis (NF, myositis, gangrene)
Meningitis

Cephalexin x 10 days

304
Q

What is the recommended post-exposure prophylaxis for B. pertussis?

A

Azithromycin x 5 days

Erythromycin x 14 days

305
Q

What is the recommended post-exposure prophylaxis for measles?

A

IG within 6 days of exposure

MMR within 72 hours

306
Q

What is the recommended post-exposure prophylaxis for rubella?

A

Generally none

IG may be considered in pregnancy if termination not an option

MMR within 72 hours

307
Q

What are the indications for palivizumab?

A

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

308
Q

Name 4 infectious contraindications to breastfeeding

A

HIV
HTLV-1/2
Active HSV lesions on breast (until crusted)
Active TB (until after 2 weeks of treatment in mom)
Untreated brucellosis

309
Q

By what rate does palivizumab decrease admissions related to RSV?

A

50%

310
Q

What part of RSV is palivizumab directed against?

A

Humanized murine monoclonal immunoglobulin G-1 directed against an epitope on the F glycoprotein of RSV

311
Q

Should palivizumab be continued after natural RSV infection has occurred?

A

NO-Continuation of monthly palivizumab is not recommended for children hospitalized with breakthrough RSV infection

312
Q

Which intervention will result in the best form of infection control for RSV?

A

Isolate everyone with respiratory symptoms

313
Q

What do you if you have diarrhea on your hands?

A

Wash with regular soap and water

314
Q

What infections require airborne precautions?

A

Varicella
Measles
TB
Smallpox

315
Q

What infections require droplet/contact?

A 
RSV
Influenza
Rhinovirus
Coronavirus
Parainfluenza
316
Q

What infections require droplet precautions?

A

S. pneumoniae
N. meningitiditis
S. pyogenes
Pertussis

317
Q

What infection require contact precautions?

A

Diarrhea
ARO
VRE
MRSA

318
Q

When can children with impetigo return to daycare?

A

24 hours after treatment initiated

319
Q

When can children with strep pharyngitis return to daycare?

A

24 hours after treatment initiated

320
Q

When can children with pertussis return to daycare?

A

5 full days after treatment initiated

321
Q

When can children with E. Coli 0157:H7 return to daycare?

A

Resolution of diarrhea & stool culture negative x2

322
Q

When can children with shigella return to daycare?

A

Resolution of diarrhea ≥24 hrs ±neg stool cultures

323
Q

When can children with non-typhi salmonella return to daycare?

A

Until resolution of diarrhea

324
Q

When can children with C. difficile return to daycare?

A

Until resolution of diarrhea

325
Q

When can children with typhoid fever return to daycare?

A

Resolution of symptoms & negative stool cultures x3

326
Q

When can children with HepA return to daycare?

A

Until 1 week after onset of illness or jaundice

327
Q

When can children with chickenpox return to daycare?

A

Whenever

328
Q

When can children with mumps return to daycare?

A

Until 5 days after parotid gland swelling

329
Q

When can children with measles return to daycare?

A

Until 4 days after onset of rash

330
Q

When can children with scabies return to daycare?

A

Until after treatment given

331
Q

Do children with lice and varicella need to be exlcuded from daycare?

A

NO

332
Q

Name 4 methods to practice antimicrobial stewardship

A

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

333
Q

What are causes of facial nerve palsy in children?

A 
Idiopathic (incl. HSV)
Otitis media
Lyme disease
VZV (Ramsay Hunt syndrome)
Cholesteatoma
Facial nerve schwannoma
Vestiular schwannoma
Meningioma
334
Q

How do you treat bell’s palsy (excluding Ramsay Hunt syndrome)?

A

Corticosteroids

335
Q

What are the typical clinical features of Ramsay Hunt syndrome?

A

Reactivation herpes zoster in geniculate ganglion
Facial nerve LMN palsy
Ear pain
Vesicles on ipsilateral face, ear, ear canal
Deafness
Vertigo

336
Q

How do you treat Ramsay Hunt syndrome?

A

Antiviral and steroids

337
Q

Name 4 high risk groups for severe influenza infection

A

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

338
Q

What are indications for oseltamivir?

A
  • Moderate/severe, progressive influenza
  • Patients 1-4 years with mild influenza within 48 hours
  • Patients >1 year with mild influenza and risk factors
339
Q

When do you give zanamavir in the treatment of influenza?

A

Moderate/severe influenza with no response to oseltamivir or previous oseltamivir prophylaxis

340
Q

What EBV serology results would you get in acute EBV infection

A 
Monospot +
VCA IgM +
EA IgG +
VCA IgG +
EBNA IgG -
341
Q

What EBV serology results would you get in past EBV infection?

A 
Monospot -
VCA IgM -
EA IgG -
VCA IgG +
EBNA IgG +
342
Q

What is the interaction between clarithromycin and cyclosporine?

A

Clarithromycin reduces cytochrome P4503A activity leading to reduced
cyclosporin clearance

343
Q

What 2 infections can mimic terminal ileitis (especially think about in children with exposure to farm animals)?

A

Yersinia enterocolitica

TB

344
Q

What antibiotic do you use to treat sinusitis?

A

Amoxicillin

345
Q

What are effective regimens for treating lice?

A

Permethrin1% (Nix) (>2 months)
Pyrethrin (R+C shampoo) (>2 months)
50% isoprophyl myrisate (ResultzR) (>4 years)

346
Q

Why do we not use lindane to treat lice?

A

Lindanehas slow killing time, more resistance

and more toxicity

347
Q

What antibiotics do you empirically use for pulmonary exacerbation in cystic fibrosis?

A

Ceftazidime and tobramycin

348
Q

What interventions should you immediately do for suspected HSV keratitis?

A

Swab for HSV PCR
IV acyclovir
Optho consult

349
Q

What are cardiac indications for endocarditis prophylaxis?

A

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

350
Q

What are procedure indications for endocarditis prophylaxis?

A

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

351
Q

What conditions can be associated with erythema nodosum?

A 
Group A streptococcus
M. pneumoniae
M. tuberculosis
B. henselae
Yersinia
Sarcoidosis
Bechet’s disease
Malignancy
IBD
352
Q

What children are at high risk of invasive streptococcal disease?

A 
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
353
Q

What empiric antibiotics do you use for orbital cellulitis?

A

IV cloxacillin+ ceftriaxone±metronidazoleor clindamycin

354
Q

What organisms is most responsible for bacterial tracheitis?

A

S. aureus, mixed organisms

355
Q

What organisms are most responsible for epiglottitis?

A

Hib

S. aureus

356
Q

What is the differential for recurrent fevers?

A 
Recurrent viral infections
True infections with immune deficiency
Chronic non-infectious (e..g autoimmune)
Cyclic neutropenia
Periodic fever syndromes
357
Q

Should you do a full septic work up, HSV OCR lesion scraping, and start IV acyclovir for mucocutaneous HSV?

A

YES

358
Q

Until what age could a baby develop neonatal HSV?

A

6 weeks

359
Q

When should you do surface swabs in mom with active HSV lesions at delivery?

A

24 hours

Mouth, conjunctiva, nasopharynx, anus

360
Q

How do you treat children <2 years of age who are exposed to pulmonary TB and have negative TST/CXR?

A

INH x 3 months, recheck TST, if negative can stop INH

If >2 years, can observe (age 2-5 is controversial)

361
Q

What vaccines should you give a previously unimmunized child >7 years?

A

TdAP IPV
MMR

NO Hib over 7 years

362
Q

Name 4 conditions that HPV vaccine prevents

A

Genital warts
Cervical cancer
Anorectal cancer
Penile cancer

363
Q

What is most likely serology pattern in fully immunized 9 month old infant born to mom with HepBsAg positive?

A

HepBcAb+, HepBsAb+ (cAb from mom)

364
Q

Spot diagnosis: http://accessmedicine.mhmedical.com/data/books/1843/cmdt17_ch35_f008.png

A

Cutaneous larva migrans

365
Q

Spot diagnosis: https://www.atsu.edu/faculty/chamberlain/images/koplik_spots2.jpg

A

Koplik spots

366
Q

What are the Jones criteria for acute rheumatic fever?

A

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

367
Q

What is the common bacteria causing osteomyelitis?

A

S. aureus (in all age groups)

368
Q

What % of patients with osteomyelitis have positive blood cultures?

A

50%

369
Q

In what part of the bone does osteomyelitis typically begin?

A

Before growth plate closure-METAPHYSIS

After growth plate closure-DIAPHYSIS

370
Q

Empiric treatment of osteomyelitis in the following age groups:

i) Neonates
ii) Infant
iii) Child

A

i) Neonates: cloxacillin and gentamicin/cefotaxime
ii) Infant: cefotaxime and cloxacillin
iii) Child: Cefazolin

371
Q

How long do you typically treat acute osteomyelitis?

A

4-6 weeks

372
Q

How do you treat chronic osteomyelitis?

A

Surgical debridgement

Antibiotics several months or longer

373
Q

When do you see changes on XR in osteomyelitis?

A

After 7-14 days-lytic bone changes

374
Q

What is the most common site of osteomyelitis?

A

Femur

375
Q

How many hours after starting antibiotics should you see clinical improvement with a bacterial pneumonia?

A

48 hours

If no improvement, consider CXR to r/o complications AND consider alternative diagnoses (viral, aspiration, PID, congenital pulmonary anomaly, TB)

376
Q

What are the 3 most common bacteria causing complicated pneumonia

A
  1. S pneumo
  2. S aureus
  3. S pyogenes
377
Q

What antibiotics should be used for complicated pneumonia and for how long (CPS)?

A 
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

378
Q

What procedural intervention should be used for complicated pneumonia (CPS)?

A

Three options with equivalent outcomes:

  1. VATS
  2. Early thoracotomy
  3. Small-bore percutaneous chest tube placement with instillation of fibrinolytics (tPA x 3 days)
379
Q

When should CXRs be repeated in complicated pneumonia (CPS)?

A

2-3 months

380
Q

How long are patients with Hep A contagious?

A

2 weeks before to 7 days after onset of jaundice

381
Q

List 3 complications of HepB infection

A

Acute liver failure
Chronic liver disease
Glomerulonephritis
Hepatocellular carcinoma

382
Q

List 3 risk factors for otitis externa

A 
Swimming
Trauma
Foreign body
Hearing aid
Skin conditions
Chronic otorrhea
Wearing tight head scarves
Immunocompromised
383
Q

Diagnostic criteria for otitis externa

A
  1. Rapid onset (within 48h) in the past three weeks
  2. Symptoms of ear canal inflammation → otalgia, itching, fullness +/- hearing loss, jaw pain
  3. 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
384
Q

What are the two most common bacteria causing otitis externa?

A

Pseudomonas aeruginosa + Staph aureus

385
Q

Treatment of otitis externa

A
  • First Line (mild-to-moderate): topical antibiotic +/- topical steroid for 7-10 days
  • First Line (severe): systemic antibiotics covering staph and pseudomonas
386
Q

List 3 reasons why you might not have response to treatment for otitis externa

A

If no clinical response in 24-48 hours, consider

  • Obstruction
  • Foreign body
  • Non-adherence
  • Antimicrobial resistance
  • Viral/fungal infection
387
Q

What is required for the diagnosis of AOM? (CPS)

A

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

388
Q

Treatment of oral thrush

A

Nystatin suspension 200 000 U PO QID x 2 weeks

389
Q

Treatment of tinea pedis that involves toe nail

A

Oral antifungal (e.g. terbinafine)

390
Q

Treatment of cradle cap

A

Treat with mild soap; if severe can use shampoos with selenium sulfide or azole

391
Q

What is the only oral antifungal not metabolized through cytochrome P450?

A

Terbinafine

392
Q

What is the best strategy to prevent influenza in infants <6 months of age?

A

Influenza vaccine for pregnant women

393
Q

What are the 8 components of Canada’s vaccine system?

A
  1. Evidence-based pre-license review and approval process
  2. Regulations for manufacturers:
  3. Evidence-based vaccine use recommendations
  4. Immunization competencies training for health care providers
  5. Pharmacovigilance for adverse events following Immunization (AEFIs)
  6. AEFI causality assessment
  7. Safety and efficacy signal detection
  8. Canadian Immunization Research Network special immunization clinics (SICs)
394
Q

How long should athlete with EBV be excluded from sports and what are the requirements for resuming activity?

A

Minimum 3 weeks

Resume activity if:

  1. Resolution of symptoms
  2. Normalization of labs
  3. Resolution of splenomegaly (CONFIRM WITH ULTRASOUND)
395
Q

Hoow does posterior element overuse syndrome or “hyperlordotic back pain” present?

A 
Similar to spondylosis
Extension related back pain
Lumbar spine/paraspinal muscle tenderness
BUT 
Investigations NEGATIVE
396
Q

Treatment of hyperlordotic back pain?

A

Ice and NSAIDS

Physiotherapy

+/- Bracing until pain resolves

397
Q

How does vertebral body apophyseal avulsion fracture present?

A

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

398
Q

Diagnostic tests for apophyseal avulsion fracture

A

Lateral lumbar spine x-rays

CT

399
Q

Treatment of apophyseal avulsion fracture

A

Rest (3-6 months for symptoms to resolve), heat and NSAIDs

Urgent neurosx if spinal cord compression symptoms

400
Q

Management of ankle sprain

A

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

FRCPC (27 decks)

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