Infectious Disease

Question 1

What characteristics (4) of a needle stick injury affect infection risk ?

Answer 1

1. Volume of Blood in Syringe
2. Depth of Injury
3. Size (diameter and length) of Needle
4. Needle User’s viral load

Question 2

HCV-1

EPI BULLETS

Answer 2

• 1 % of all pregnancies worldwide have a HepC+ Mother
• HCV Prevalent countries : Russia, Uzbekystan, Pakistan, Mongolia, Gabon and Egypt
• Vertical transmission rates of HCV are:
  * 5.8 % without t/x and no HIV
  * 10.8 % without t/x and HIV+
• 20 - 30 % of Fetal HCV cases resolve spontaneously by 2-3 Months (~2/6 clear, 3/6 chronic intermittent disease and 1/6 chronic active infection)

11

Question 3

HCV-5

What are Risk Factors for Hepatitis C Virus

Answer 3

Risk Factors for Hepatitis C Virus

• HCV+ Mother
• Born in HCV Prevalent area/country
• IN/IV/Inhaled Drug Use
• Unprotected bloody sexual practices
• Victim of Sexual Assault (no matter what acts were reported)
• Receiving surgical managements in 3rd world
• Exposed to contaminated skin-breaking procedures

HCV countries: Russia, Pakistan, Mongolia, Uzbekystan, Egypt and Gabon.

Question 4

What is the Infection Control Protocol for a febrile thrombocytopenic rash ?

(petechiae, ecchymoses)

Answer 4

Droplet Precautions

Until meningitis is ruled-out or 24 h of anti-biotics

(The big worry here is meningococcemia)

Question 5

What are the 3 most common pathogens for acute osteomyelitis?

Answer 5

​​Acute Osteomyelitis Pathogens

• Staphylococcus aureus
• Kingella kingae*
• Streptococcus pneumoniae
• Streptococcus pyogenes
• Haemophilus influenza B (unvaccinated)
• Salmonella (sickle cell disease)
• Enterobacter spp. (NICU)

*Typically culture negative. Resistant to anti-staph medications (Clindamicin, Vancomycin, Cloxacillin)

Question 6

What are the inclusion criteria for Pavilizumab therapy ?

Answer 6

RSV Prophylaxis Inclusion Criteria

• < 12 months old during the RSV season
• Hemodynamically important Heart Disease (If on meds/O2)
• Chronic Lung Disease needing medications
• Required Oxygen at 36 weeks gestation
• Indigenous or northern rural families < 6 months of age

Consider for < 24 months if severely Immunocomp., T - 21 or CPD

DO NOT GIVE TO ADMITTED CHILDREN / NICU BABIES

Question 7

What are the common pathogens for

Opthalmia neonatorum

Answer 7

Opthalmia Neonatorum Pathogens

• Chlamydia trachomatis (2 - 40 %)
• Staph spp., Strep spp., Haemophilus spp., G -
• Gonorrhoeae (40 - 50 % if exposed during delivery)

Question 8

Regarding Varicella zoster, how should camps restrict admission to protect their population ?

Answer 8

• Staff and Participants should have strict reporting of Varicella zoster vaccine and immunity status
• No admission if positive exposure in the last 21 days
• No admission if suspected or confirmed active disease

Question 9

What volumes of blood are needed for a blood culture in a:

• 1 - 2 kg baby
• 2 - 12 kg baby
• 13 - 40 kg child
• > 40 kg child

Answer 9

Blood Culture Volumes

• 1 - 2 kg = 2 - 4 mL
• 2 - 12 kg = 6 mL
• 13 - 40 kg = 20 mL
• > 40 kg = 40 mL

Question 10

In what contexts is a non-fully retractable foreskin physiologic ?

Answer 10

• Normal Urination stream (reflects fertility)
• No recurrent infections

~50 % of 6 y.o. can completely retract their foreskin & 95 % at 17 y.o.

Question 11

What are 3 risk factors for contracting HPV ?

Answer 11

Risk factors for HPV

• Number of sexual partners
• Risky behaviours (EtOH, Marijuana, Illicit drugs, tobacco)
• Sexual Abuse
• Early age of sexual activity onset
• HIV + or other immune suppresion
• Previous STIs

Question 12

What are Risk Factors for contracting neonatal HSV ?

Answer 12

• Maternal Primary Infection (she has no anti-bodies to transfer)
• Intrapartum Skin Breakdown (foreceps, nuchal monitor…)
• Premature Rupture of Membranes (C/S and vaginal delivery)
• No anticipatory acyclovir in known HSV carrying Moms

Question 13

What is the Infection Control Protocol for enteroviral infections ?

Answer 13

Contact Precautions

Duration of Illness

Question 14

What three clinical aspects dictate evidence based prognosis for acute infectious meningitis in children ?

Answer 14

1. Time to anti-biotic therapy (empirical)
2. Hemodynamic and Neurologic Clinical Presentation
3. Presence of Penicillin Resistant S. pneumoniae

Question 15

What are the CENTOR Criteria for Strep Throat ?

Answer 15

CENTOR Clinican Design Tool
1. Exudative or Swollen Tonsils
2. Anter c-Lymphadenopathy
3. Fever
4. No Cough or URTI s/x

≥3 of these has a 32-56 % probability of an active GAS infection

Question 16

EPI BULLETS

Answer 16

• Soft and Firm toys were cultured 1 week after last clean, growing coliforms on 90 % and 13.6 % of them respectively.
  *

Question 17

What is the Infection Control Protocol for Pertussis?

Answer 17

Droplet Precautions

Until completing 5 days of appropriate anti-microbrial therapy

Question 18

What is the Infection Control Protocol for gastroenteritis?

Answer 18

Contact Precautions

Duration of Illness or until treatable infectious etiology is identified

Question 19

What are the Infection Control Precautions for Tuberculosis?

Answer 19

Airborne Precautions

Until Infectious Disease says they aren’t contagious anymore

Question 20

What is the management of C. difficile disease ?

Answer 20

Clostridium difficile Management

1. Reassess current anti-biotic regimen (80 % cure in mild disease)
2. Metronidazole (PO if tolerated, otherwise IV)
3. Consider PO Vancomycin (combined with IV Metronidazole in sev.)
4. Probiotics to prevent recurrence, not to treat active dis.
5. Tapering Tx with vancomycin as per the following:

• 4 doses (10 mg/kg/dose) per day x 7-14 days
• 2 doses per day x 1 week
• 1 dose per day x 1 week
• 1 dose per 2-3 days x 2 - 8 weeks

Remember that Vancomycin does NOT cross membranes very easily, so IV does not impact infections in the enteral lumen. There are no IV to PO equivalences.

Question 21

HCV-3

List Fetal Risk Factors for Vertical HCV Transmission

Answer 21

Fetal Hepatitis C Virus Vertical Transmission Risk Factors

• Female Sex
• Premature Rupture of Membranes
• Fetal Scalp Monitoring
• Second Born Twin (Twin B or Triplet B/C)

There is NO difference of risk between a C/S or SVD

Question 22

When is conjunctival erythromycin gel indicated for opthalmia neonatorum prophylaxis?

Answer 22

RARELY

The only CPS indication for this is for children exposed to known or strongly suspected Chlamydia at the time of delivery.

Chlamydia presents as congenital pneumonia

Question 23

HCV-4

Describe your Management for Infants born to HCV+ Mothers

Answer 23

Management of Infants born to HCV+ Mothers
(1) Ante/Intra-partum actions
* Avoid trauma (Episiotomy, scalp monitoring, RF for perineal/vaginal tearing)
* f HIV status is unknown or sub-optimal treatment, prepare for HIV+ Management
* Blood born disease prevention protocols for yourself

(2) Immediate and Follow-up
* Bath the baby
* Breastfeeding is OK if Nipples are intact and HIV Negative
* Order infant **HCV serologies at 12 m.o. **
* You can order infant HCV serologies at 2 and 12 m.o. for anxious parents
* If Serologies are +, then order an HCV ag PCR
* If PCR is POSITIVE - the baby is infected and referred to GI and ID

Question 24

What are the Isolation Protocols for SARS/MERS/CoVID19?

Answer 24

Droplet Precautions

Until 10 days after fever resolution

Question 25

What is the **management** of a **baby** born to a Mother with inactive **recurrent HSV**?

Answer 25

_Management of Baby born to Recurrent HSV_ * **Anticipatory acyclovir** for the Mother pre-natally 36 w + * **Swab** nasopharynx *(consider serum)* for HSV 1/2 * **Routine** newborn **care** * **Educate** on signs of encephalitis, respiratory distress and cutaneous/occular lesions. * If HSV + or baby develops symptoms, admit and treat

Question 26

**EPI BULLETS**

Answer 26

* The incidence of **breakthrough** V*aricella zoster* infections is **only 3.1 %** *(infection \>42 days after vaccine)* * **72 %** of these breakthroughs are in **immunocompromised** kids * The **magnitude** of disease is **lessened** by vaccination * There are **2 recorded camp outbreaks** of Varicella; both outbreaks were **secondary to lax screening** protocols for immunity and/or active disease.

Question 27

What **infections** are considered in **community** needle stick injuries ?

Answer 27

* **Hep**atitis **B** Virus *(~30 % risk - 2 cases\* described in literature)* * **Hep**atitis **C** Virus *(~3 % risk - 3 cases\* described in literature)* * **HIV** *(~0.3 % risk - no cases\* reported)* * **Tetanus** *(Always assess vaccine status)* * **Secondary bacterial** infection of injury site *(Assure wound is cleaned)* ## Footnote \*Community Cases, not in hospital. Remember that infection risk varies based on needle user's viral load, depth of injury, size of the needle and volume of blood remaining in it.

Question 28

What is the management of suspected **Strep. pharyngitis**

Answer 28

1. Pen G or V or Amox **x 10 days** 2. **Isolate** until **24 h** of abx is completed 3. Cx throat with **follow-up call** ## Footnote *Pen V 300 mg PO BID if < 27 kg, 600 mg PO BID if > 27 kg. Pen G IM can be given once as well. Amoxicillin 50 mg/kg PO BID*

Question 29

Under what **conditions** is **Tuberculosis Contagious**?

Answer 29

Take Precautions for TB when the following apply * Disseminated **Congenital** Infection * **Extensive Lung** Involvement * **Untreated** Cavitary Lung Disease * **Laryngeal** Involvement * Positive **Sputum**

Question 30

**Describe** what taking **Droplet Precautions** entails

Answer 30

_Droplet Precaution_ ## Footnote *Goal is to prevent launched ENT/Respiratory droplets from making contact with your mucus membranes from direct shots (cough, sneeze) or surfaces-hands-face.* * **Gown and Gloves** *(suggested by CPS)* * Procedural **Masks** *(if \< 1 m of contact with patient)* * NO ventillated rooms needed

Question 31

**EPI BULLETS**

Answer 31

* Maternal **Antibodies** are **transferred** to fetus at **32w +** * **75 - 90 %** of HSV+ people are **unaware** * Neonatal Herpes Infections affect 6 / 100,000 births * **Disseminated** Neonatal HSV has **85 % mortality** and *CNS* NHSV has *50 % mortality*

Question 32

What are the Infection Control Protocols for **Diagnosed Rubella** and _Exposure_ to Rubella ?

Answer 32

_Rubella_ **Diagnosed:** **Contact Precautions** for **7 days** after Rash eruption _Contact:_ Contact Precautions for 7 to 21 days post-exposure *(e.g. If exposure on December 1st, isolate from December 8th to 22nd)*

Question 33

What are the Infection Control protocols for **diagnosed measles** *and* someone who made _contact with_ measles ?

Answer 33

_Measles_ ## Footnote **Diagnosed** Measles : **Airborne** for **4 days** after rash onset _Contact_ with Measles : _Airborne_ starting 5 days after exposure to 21 days post-exposure *(e.g. If exposed on April 1st, you are infectious on April 6th until April 27th)*

Question 34

What is the **empirical** management for bacterial meningitis ?

Answer 34

_Management of Bacterial Meningitis_ 1. Lumbar Puncture if not contraindicated 2. **Ampicillin + Gentamicin if \< 1 month old** 3. *Ampicillin + Ceftriaxone if \> 1 month old* 4. Consider Vancomycin if Staph/MDR S. pneumo prevalent 5. When cultures or PCR are positive, focus antibiotics 6. Audiology pre-discharge or within 1 month post-DC * GBS treatment for 14 - 21 days * S. pneumoniae for 10 - 14 days * Haemophilus influenzae for 7 - 10 days * N. meningitidis for 5 - 7 days * E. coli/Enterobacter need repeated CNS, Image if +

Question 35

What are the Isolation Protocols for **Diagnosed Mumps** *and* _Exposure to_ Mumps ?

Answer 35

_Mumps_ ## Footnote **Diagnosed**: **Droplet** Precautions for **9 days** from onset of Sx _Contact_: Droplet starting 10 days from exposure to 26 days post-exposure *(e.g. If exposed on June 1st, isolate from June 11th to 27th)*

Question 36

What are the Infection Control protocols for **suspected Varicella** zoster, and _exposure_ to suspected Varicella?

Answer 36

_Varicella zoster_ **Diagnosed: Airborne** plus contact until lesions are dried/**crusted over** Contact: _Airborne_ from _8 to 21 days_ post-exposure *(e.g. if exposed on March 1st, isolate from March 8th - 29th)*

Question 37

What valences of **HPV** are covered with the HPV-4 vaccine ? ## Footnote *(which are the cancerous one, which are genital warts typically)*

Answer 37

_HPV 4 Vaccine Coverage_ * HPV 6 - Warts * HPV 11 - Warts * HPV 16 - Cancer * HPV 18 - Cancer

Question 38

What is the Infection Control Protocol for **Avian** (bird) **Flu**?

Answer 38

**Droplet and Contact Precautions** ## Footnote _14 days_ since onset of illness

Question 39

What is the Infection Control Protocol for **Meningitis**?

Answer 39

**Droplet and Contact Precautions** ## Footnote **Until 48 h** **of** appropriate anti-biotic/viral **therapy** is given

Question 40

What are the **managements for** a **baby** of a Mom with **Primary HSV** Infection in the following contexts 1. Asymptomatic baby born by C/S without ROM 2. Asymptomatic baby born by C/S with ROM 3. Asymptomatic baby born vaginally with ROM 4. Symptomatic baby

Answer 40

_Asymptomatic baby born by C/S without ROM_ * **Swab** baby's **nasopharynx** for HSV 1/2 PCR * **Consider** baby's **serum** HSV 1/2 PCR if available * Routine well newborn care with **education** HSV signs * **If** develops **symptoms** or **HSV +** **_admit_** and treat _Symptomatic or Asympt. born by C/S or vaginally with ROM_ * HSV 1/2 **PCR** of nasopharynx and serum *(if available)* * **Lumbar Puncture** for HSV PCR * **Acyclovir** x 10 days * **Repeat** PCR/LP at **48 h of life** *(initial PCR may be falsely negative)*

Question 41

How should **we prepare** parents of **immunocompromised** children V*aricella zoster* **exposure**?

Answer 41

* **Educate** on infection risk based on exposure * *Children are contagious -48 h from rash eruption* * *Incubation Period is 10 - 21 days* * *Infection can be airborne, droplet and contact born* * When exposed, **parents** are to **contact you** to grade risk * **If** exposure is **High Risk**, consider medication **prophylaxis**

Question 42

What are the Infection Control Protocols for open, oozing or draining **wounds**?

Answer 42

**Contact Precautions** ## Footnote _Until_ wounds are _closed_/stop draining

Question 43

**EPI BULLETS**

Answer 43

* C. *difficile* has a **2-3 day incubation** period * 15 - 63 % of infants, 3 - 33 % \< 2 y.o.'s and 8.3 % of children are colonised with C. *difficile* * There is a **25 % risk of recurrence** in C. difficile colitis. * Absence of C. *difficile* disease in the young is likely secondary to **maternal anti-body** persistence and **immature receptors** for C. *difficile* toxins a/b

Question 44

What are the Infection Control Protocols for **Hepatitis** A, B, C, D and E?

Answer 44

* Hepatitis **A**: **Contact** for **7 days** since onset of symptoms * Hepatitis _B_ : _None_ - caution with surgery/delivery/blood manipulation * Hepatitis _C_ : _None_ - caution with surgery/delivery/blood manipulation * Hepatitis _D_ : _None_ * Hepatitis **E** : **Contact** for **7 days** since onset of symptoms

Question 45

What are the Infection Control Precautions for **Impetigo**?

Answer 45

**Contact Precautions** ## Footnote Until _24 h of_ topical/systemic _therapy_ has been completed

Question 46

EPI BULLETS

Answer 46

* 20-30 % of bacterial pharygitis are S. pyogenes (GAS) * Children 5 and above are asymptomatic carriers 11-15 % of the time * The incidence of ARF in Northern Ontario FN communities is 21.3/100k vs 0.3/100k in the general population. * This increased risk for ARF is likely a mix of M-protein serotypes native to the North, and healthcare access.*

Question 47

What is the **management** of Acute Otitis Media ?

Answer 47

_Acute Otitis Media Management_ 1. **Appraise** for bacterial\* versus viral aetiology 2. If *viral*, *educate* on watchful waiting and return if development/persistence 3. If **bacterial** infection or poor capacity for follow-up/access 1. Assess for **Mastoiditis** 2. **Amoxicillin** as first line *(cefuroxime for allergy)* * Clavulin as next step for refraction * Ceftriaxone (IM/IV) as next step for more refraction 3. **Educate** on return to care *\*Signs of bacterial infection include Middle Ear Effusion WITH bulging, no viral URTI signs, severe persistent otalgia, TM perforation, ill appearance despite analgesia, \> 48 h persistence of symptoms on presentation or return.*

Question 48

What are the Isolation Protocols for **viral** **respiratory** infections ?

Answer 48

**Droplet Precautions** ## Footnote For the duration of illness, or until a respiratory virus is rule-out

Question 49

What are the Infection Control Protocols for **Scabies**?

Answer 49

**Contact Precautions** ## Footnote Until _first therap_y is applied

Question 50

What are the common **pathogens** for bacterial **meningitis**? For Ages * 0 - 1 month* * 1 month and older*

Answer 50

_0 - 1 month *(consider up to 3 months)*_ * Group B Streptococcus *(Gram +, chained cocci)* * E. coli *(Gram -, coccobacillus)* * Listeria monocytogenes *(Gram +, bacilli, outbreak related)* * Enterobacter/Enterococcus spp. *(NICU and surgical babies)* * S. pneumonia *(rare)* _1 month and older_ * S. pneumoniae *(Gram +, chained cocci)* * Neisseria Meningiditis *(Gram -, diplococci)* * Listeria monocytogenes *(Gram +, bacili, outbreak related)* * E. coli *(Gram -, coccobacillus, associated with UTI sources)* * Group B Streptococcus *(rare)*

Question 51

**EPI BULLETS**

Answer 51

* **95 %** community **immunity** is required for **Herd** Immunity

Question 52

What is the Pediatrician's **preventive** role in needle stick injuries ?

Answer 52

_Needle Stick Injury Prevention_ * Educate schools/cities on **environmental cleaning**/safety * **Vaccinate** children against Hepatitis B Virus appropriately * **Teach** children **how to repond** to finding needles/drug parafenalia in their enviroment *(call adult, parents etc.)*

Question 53

**Describe** what **Contact Precautions** entails

Answer 53

_Contact Precautions_ ## Footnote *Goal is to prevent infectious particles on the patient from making contact with your mucus membranes, skin or clothes.* * **Gown** and **Glove** * **Wipe down** environment after child plays in it * Ask to stay **in room** or keep to themselves in waiting room * NO masks needed

Question 54

Describe C. *difficile* **prevention** in Hospital (and clinic) ? *(Housekeeping, Nursing and Physician responsibilites)*

Answer 54

_Physicians and Nurses_ * **Contact isolation** at baseline, with *droplet/contact* when manipulating the *anus* * Recognize and report the clinical **symptoms** of C. *difficile* colitis * Foul smelling watery diarrhea * Blood in stool * Abdominal pain * Recognize and report the **risk factors** for C. *difficile* colitis _Housekeeping_ * **Bleach clean _twice_** rooms of patients with C. diff; *this can take several hours and is important when doing bed management on weekends/evening/nights* ***_Alcohol cleaning products do NOT kill C. diff endospores_***

Question 55

What are the **common** **pathogens** that cause **AOM**?

Answer 55

_​Acute Otitis Media Pathogens_ * S. pneumoniae *(most virulent)* * H. Influenza * Moraxella catarrhalis * S. pyogenes aka GAS *(rare)*

Question 56

**EPI BULLETS**

Answer 56

* **Lifetime** HPV incidence is **70 %** * HPV Vaccines are **~ 100 % effect if given early**, and 70-90 % effective at keeping current infections in check *(no symptoms)* * Studies show getting the HPV Vaccine is **_NOT_** associated with * **Risky Sex** * **More Sex** had * **Earlier sex**ual promuscuity * **Increased STI** incidence * Major **side effects** seen with other vaccines *(Autoimmunity)*

Question 57

What is the Infection Control Protocol (PPE) for **anti-biotic** **resistant** organisms ? ## Footnote *(i.e. VRE, MRSA, CRO, Pseudomonas)*

Answer 57

**Contact Precautions** ## Footnote _Indefinitely_ until they have been ruled-out or treated

Question 58

What is the relationship between **illness severity, contagiousness** and **viral load** for V*aricella zoster* (chicken pox) ?

Answer 58

Viral load α Symptom Severity Viral load α Contagiousness Therefore **Symptom Severity α Contagiousness** * Given these correlations, you'll note a change in recommendations to reflect the patient's overall condition rather than rash-specific criteria for exposure restrictions.* * I.e. Kids well enough to attend school, have low viremia, therefore less contagious.*

Question 59

What are the CPS' **recommendations** for your practice's _adminstrative_ and _office policies_ for **infection control**? ## Footnote *(4 administration, 5 Office)*

Answer 59

_Administrative Policies_ * **Educate** personnel on hygiene/cleaning standards * **Connect** with Public Health for easy disease reporting * **Re-assess** hygiene protocols every **2 years** * Have **PPE a**vailable _Office Design_ * Patient booking & Waiting Rooms layout to **min. crowding** * **Segregate Infectious** and **Immunodeficient** patients * **No** **soft** toys, No **carpet** - routine cleaning! * Ventillation provides a minimum of **6 Air Exchanges/hour** * **Fasciliate** and Promote **Hand Hygiene**

Question 60

# HCV-2 List **Maternal** Risk Factors for **Vertical HCV Transmission**

Answer 60

``` ```Maternal Hepatitis C Virus Vertical Transmission Risk Factors * Elevated **Maternal** HCV antigen **titres** * Maternal **IV Drug Use** * **Steatosis**/Cirrhosis of Liver * Concomitant **HIV or HBV** Infection7 *HCV+ is NOT a contraindication to breastfeed, however CPS suggests cautioning if nipples are dramatically broken down*

Question 61

Describe management for an **infant** born to a mother with **active risky HSV** lesions ## Footnote *(Risky HSV lesions can be systemic disease, genital lesions or accidental contact with low risk lesions)*

Answer 61

**_Management for Newborn with Maternal Active HSV_** *Vaginal Delivery, C/S with ROM or Maternal Systemic Disease* 1. **Plan disposition** with Parents and **Consult I**nfectious **D**isease 2. Swab **nasopharynx** and eyes for HSV 3. **Lumbar puncture** for Culture, Cells, Protein/Glucose and HSV PCR 4. Acyclovir x 10 days (IV) 5. **Repeat LP** and PCR at **48 h** of life *Remember that **acyclovir is a Q8 h medication**, so it may be beneficial for the family to be admitted for the 48 h pending consultation no matter what. Some centers have outpatient IV medication services, but this dosing schedule sucks for everyone - yet it could coincide with bilirubin checks so try to accomodate.*

Question 62

What is the Infection Control Protocol for **Strep. Throat**?

Answer 62

**Droplet Precautions** ## Footnote Until _24 h of_ appropriate Antibiotic _Therapy_ is completed

Question 63

What are **risk factors** for **C***lostridium **diff**icile* disease ?

Answer 63

_Risk Factors for C*lostridium difficile* disease_ * **Chemotherapy** * **Multi**-drug **antibiotic** regimens * **Immunosuppresion** *(HIV, Congenital, Infectious, Hormonal)* * GI **manipulation** *(feeding tubes, surgery, scopes)* ​**P**roton **P**ump **I**nhibitors are **_NOT_** risk factors for C. *diff*

Question 64

List **3 Complications** of untreated **GAS** Pharyngitis | GAS = S*trept. pyogenes*

Answer 64

*Complications of GAS Pharyngitis* * Peritonsillar Abscess *(Older)* * Retropharyngeal Abscess *(Young)* * Sepsis * **A**cute **R**heumatic **F**ever * Post-Streptococcus Glomerulonephritis (**PSGN**) * **PANDAS** ## Footnote PSGN and PANDAS are not shown to decrease in incidence with anti-biotic treatment, whereas the others are.

Question 65

**EPI BULLETS**

Answer 65

* **75 % of children** have an ear infection **by** **1 year old** * **22 % of URTIs** have acute otitis media *(typically viral)* * 1 - 3 % of **ALL infants** are **admitted** because of **RSV** * A season of Pavilizumab costs 5600 $/patient * The development of Pavilizumab has decreased * Ex-Prem admissions by about 8- % * Chronic Lung Disease babies by 40 % * Congenital Heart Diseasers by 45 %

Question 66

**EPI BULLETS**

Answer 66

* S. pneumonia meningitis **dropped 87 % since vaccine** intro * 96.1 % of S. pneumoniae are penicillin susceptible, 98.5 % are ceftriaxone susceptible * There is development of **Penicillin / Ciprofloxacin res**istant **N**eiserria **meningitidis** to be concerned for * **B-lactamase** heavy **H. influenza** prevalence is increasing * **Northern** populations are at risk for **Non-B H. influenza meningitis**

Question 67

What are the **prophylactic** medications for **HIV** from a needle stick injury or blood exposure ? ## Footnote *(For young and older children)*

Answer 67

_Young Children (\< 12 y.o. and \< 35 kg)_ * Zidovudine * Lamivudine * Lopanivir or Ritonavir _Older Children (\> 12 y.o. and/or \> 35 kg)_ * Emtricitabine * Tenofovir * Raltegravir or Dolutegravir *Any child currently on medications needs to be consulted with Pharmacy prior to prescription for cross-reactivity. Infectious disease should be contacted prior to presciption of renal/liver/GI absorption disease is present.*

Question 68

**EPI BULLETS**

Answer 68

* 0.8 - **1.6 %** of **non-circs.** will develop **balanitis** * Phimosis occurs in 4 % of non-circs., and **80 %** **respond** to medical **therapy**. * Evidence supports that circumcisions do: * Decrease STI rates * Decrease Cervical CA, Squamous Cell CA * Decrease UTI *(by 90 %)*

Question 69

Describe your **approach** to a child with **acute osteomyelitis** ## Footnote *(Labs, Imaging, Medications, Follow-up)*

Answer 69

_Acute Osteomyelitis_ 1. Consider **differential** *(Cancers, autoimmunity, trauma)* 2. CBC + diff., **CRP**, Electrolytes\* and Blood Cultures 3. **Plain films** can be used to **assess** for **Cancer** 4. **Ultrasound** to facilitate **drainage** of joint/collection 5. **_MRI with Gadolinium_** or Nuclear Scan 6. **Consult Ortho**pedic Surgery for possible drainage 7. Cefazolin/Cephalexin - *total of 4 weeks* 8. Add Vancomycin if S. aureus is a concern 9. Change to PO Antibiotics and discharge when: * Blood **Cultures Negative** * **Tolerating PO** Meds and no absorption issues *(GI comorb.)* * **CRP** is decreasing * Minimal to no symptoms with **ambulation**

Question 70

What **systematic** approaches best **optimize vaccination** rates ?

Answer 70

* **Centralised** Vaccine **Database** * **Automated notification** of vaccine needs for parents * **Optimize Access** to Vaccine Clinics * Vaccine **School Programs** to facilitate access * Vaccination requirements for **School Admission** ​*Canimmunize is a free app. that prompts parents to seek out vaccinations for their children based on the current schedules in place for their province.*

Question 71

What is the **acute** management of a needle stick injury ?

Answer 71

_Acute Needle Stick Injury Management_ 1. **Wash** the **wound** with water and soap *(do not squeeze blood out)* 2. **Assess** patient's HBV and Tetanus **vaccination status** 3. **Assess risk\*** of bloodborne infection 4. **Baseline** HBsAg, HBsAb, HCV Ag, HIV Ag **levels** 5. If considering anti-retroviral prophylaxis measure labs\*\* 6. If **no HBV immunity** suspected, **give HBIG\*** and **Vaccine** now, second at 4 weeks and 3rd at 6 months follow-up 7. If **no Tetanus imm**unity suspected, give **vaccine** 8. Start Anti-retroviral\* if indicated with 3 day, 3 weeks\*\*, 3 months\*\* and 6 months\*\* follow-up *\*High risk is known blood injection, deep penetration of injury, known seropositive user's needle or endemic area.\*\*Measure HIV ag/ab, HCV ag/ab, HBV ag and response to vaccine. If still on anti-retroviral therapy then LFTs, Renal Profile, CBC with diff. and lytes should be followed.*

Question 72

**Describe** what **Airborne Precautions** entails

Answer 72

_Airborne Precautions_ ## Footnote *Goal is to prevent aerosolized particles from being inhaled and/or making contact with your mucus membranes. Droplets are aerosolized with intubation/CPAP/BiPAP/HFNC\** * **Gown** and **Glove** *(droplets and particles will stick to your clothes)* * **N95 Masks** *(must be fitted otherwise you are exempt from work)* * **Negative** Pressure **Rooms** *\*Theoretically, not proven/institutionalised*

Question 73

COVID BULLETS

Answer 73

* **Vertical** transmission **risk** of COVID19 is **0.01 %**. Risk factors are Maternal viral load/disease severity and immunodedeciency. * Breastfeeding transmission of COVID19 is not a thing. * Isolated Maternal COVID19 is **NOT** an indication for NICU to be present at the birth. * **Do not restrict delayed cord clamping** because of maternal COVID19 * **N95 with all aerosol generating manipulations** of suspected COVID19 in the NICU... which means everything except isolated line placement

Question 74

COVID BULLETS

Answer 74

* The Moderna and Pfizer vaccines are **COVID-19 XBB.1.5 mRNA Vaccines** * There is ***no difference between Moderna and Pfizer*** preference now, since myocarditis rates are now shown to be rare and equivocal between the two. * Children 5 y.o. and above should receive XBB.1.5 *[Dosing frequency in footnote]* * COVID-19 **vaccination is safe** during *pregnancy* and *breastfeeding* * COVID-19 vaccines **can** be given WITH other vaccines ## Footnote https://cps.ca/en/documents/position/covid-19-vaccine-for-children-and-adolescents

Question 75

When can patients with a history of Multisystem Inflammatory Syndrome associated with COVID-19 (**MIS-C**), receive a COVID-19 vaccination ?

Answer 75

You must wait a for **complete recovery from** *OR* **90 days since diagnosis** of the MIS-C. *This does NOT apply to myocarditis. At this time, a history of COVID-19 associated myocarditis means no vaccine until more data is available.* ## Footnote https://cps.ca/en/documents/position/covid-19-vaccine-for-children-and-adolescents

Question 75

What are **patient risk factors** for COVID-19, **meritting vaccination** before 5 years of age ?

Answer 75

* **Children below the age of 5 y.o. can receive the COVID-19 vaccine.** * The vaccine is **strongly recommended for** those who: - >1 **comorbidities**, neurologic d/o, chronic lung disease - **T**risomy **21** *(independant of specific associated diseases)* - **Immunocompromise** *(in any form)* - Social risk factors for COVID-19 exposure * Vaccines are** still offered** to those with a **Hx of confirmed COVID-19** infection. * First dose of XBB.1.5 should be at minimum** 6 months** from the last COVID-19 vaccine OR infection.* [See footnote for schedule]* ## Footnote https://cps.ca/en/documents/position/covid-19-vaccine-for-children-and-adolescents

Question 76

**Who** should receive an influenza vaccine ?

Answer 76

**Everyone.**

Question 77

**When** should a Mother be checked for **Syphillis** serologies ?

Answer 77

Syphillis Screening in Pregnancy * Performed during **first pre-natal visit** * Repeated at **28 - 32 weeks** * At delivery *(if there is an outbreak in the area)* * If clinically suspicious *(e.g. symptoms of syphillis, another STI)* *Treponemal specific tests have great sens/spec., but once positive will be positive for life and cannot assess reponse to therapy. Non-specific VDRL (for CSF) and RPR (for blood) should be repeated in 4-6 weeks if negative, as their response may be delayed. **Direct PCR swabbing** of Amniotic fluid, ulcers and umbilical cord is available. * ## Footnote https://cps.ca/en/documents/position/congenital-syphilis

Question 78

How does one appraise a **Mother's chart**, when looking for Congenital **Syphillis** Risk ?

Answer 78

**Adequate treatment of Confirmed Maternal Syphillis** * Treated with Penicillin G * Treatment was > 4 weeks before delivery * Appropriate treatment for infection stage * > 4x decline in VDRL or RPR If any of the above are false - the baby is at high risk **Red Flags to consider treatment** * Maternal reinfection risk (e.g. multiple unprotected partners, partner was not treated) * Fetal US suggests congenital syphillis * Neonate's labs or Mother's lesions are suggestive of syphillis ## Footnote https://cps.ca/en/documents/position/congenital-syphilis

Question 79

What are common findings in an **infant** with **Congenital Syphillis** ?

Answer 79

**Common Findings in Congenital Syphillis** * Failure to Thrive * Maculopapular desquamating rash * Hepatosplenomegaly * Periostitis *I've attached the full list of clinical findings, but they're super non-specific* ## Footnote https://cps.ca/en/documents/position/congenital-syphilis

Question 80

What is the management of an infant born to a **Mother** with **positive syphillis serologies** ?

Answer 80

See attached flowchart from the CPS This flowchart is applicable for : 1. **Confirmed** positive maternal syphillis serologies 2. Mother's status is **unknown** ## Footnote https://cps.ca/en/documents/position/congenital-syphilis

Question 81

What **investigations** are required for *suspected* Congenital Syphillis in an infant ?

Answer 81

Congenital Syphillis Work-up * **CBC** w/ differential * AST, ALT, BiliT, Albumin, ALP, GGT * **CSF** for cell count/diff., glucose, protein and VDRL * **Long-bone radiographs** with prompt for suspected syphilis * Solid organ **abdominal ultrasound** * Cranial ultrasound or **MRI** Refer to specialists with a prompt to assess of syphillis * Infectious disease *(facilitates the investigations with the lab)* * Opthalmology * Placental pathology * Audiology *Repeats and follow-up based on the attached flow-chart*