Infectious disease ABC Flashcards
low CD4 count- what interventions are needed
prevent PCP (bactrim), toxoplasmosis MAC (mycobacterium avium complex) - Azithromycin
below 50
cryptococcus prevention with fluconazole
delivery/intrapartum with HIV.
viral load <1000
vaginal delivery
aviod AROM, FSE, operative vaginal bleeding
<400 viral load AZT not required but could be given
2 mg /kg bolus than 1mg/kg/hr (2 hours prior to c-section)
baby washed at delivery
scheduled delivery at 38 weeks if CD is needed
hiv diagnosis
hiv ag/ab screen
- negative no HIV
- positive send HIV 1/2 multispot (reactive - has HIV, non-reactive- send HIV-1 RNA qualitative and rtPCR
3rd trimester HIV testing for what population
high rate of HIV in population incarceration sign/symptoms of infection STI in last year new partner more than 1 partner during pregnancy known infected partner personal or partner IV drug use prostitution
labs for new dx of HIV
viral load CD4 antiretroviral drug resistance 6PD and HLA-B5701 toxo igg hep B antigen/antibody Hep A total antibody Hep C antibody PPD
preconception for HIV
contraception VL <1000 Review CART discuss if partner is aware offer partner testing ensure she is vaccinated
HIV management during pregnancy
cd4 every 3 months
viral loads monthly
vaccines to consider: pneumococcal, influenza, Hep A, Hep B
If on protease inhibitor check glucose
If VL >500 in 2nd trimester- check adherance, consider HIV genotyping
In 3rd trimester
RPR, GC/Chlam
viral load at 34-36
Risk factors for HIV transmission to the fetus
no therapy no prenatal care AIDs, Low CD4, High viral load illicit drug use preterm delivery breastfeeding
% of hiv transmission that occurs intrapartum
70-80%
Hep B management in pregnancy
check viral load in 3rd trimester and consider tonofovir (>6-8 log 10 copies/ml)
avoid amnio (greater risk at 7 log 10 copies)
test partner
Hep B vaccine and HIB
Hep B panel
sAg(-) antic (-) anti s(-) suceptible
sAg(-) antic(+) antis (+) immune (natural infection)
sAg (-) antic (-) antis (+) immune (vaccination)
sAG(+) antic (+) Igm antic(+) anit s (-) acute infection
sAg(+) antic (+) antic igM (-) antis (-) chronic infection
sAg (-) anti c (+) antis (-)
- resolved /false positive/chronic/resolving
chronic hep b rates
neonatal
child
adult
neonatal- 90 %
children 10-25%
adults 5-10%
chronic hep B
20% end stage liver disease, cirrhosis, liver cancer
what pregnancy risks are considered with cirrhosis
increase in maternal/ fetal death, gHTN, abruption, PTB, FGR
Chicken pox
- diagnosis
- Risks to pregnancy
- Follow-up
- Treatment
Dx: VZV IgM
Risks: fetal demise, FGR, congenital anomalies (microcephaly, ventriculomegaly, echogenic foci in liver, limb abnormality)
Follow-up: serial growth utlrasound
Treatment: VZIG OR acyclovir/valacyclovir
39 week varicella
5 days-2 weeks after delivery (not enough protective antibodies)
minimize contact with lesions.
VZIG or acyclovir/valacylovir
Is there a recommended time to delay pregnancy after getting a varicella vaccine?
3 months
Treatment regimens for Herpes
Primary - valtex- 1 gm BID x10 days
Recurrent valtrex 1 gm x 5 days
supression- valtrex 500 mg BID
Severe- acyclovir 5-10 mg/kg IV than switch to valacylovir 1 gm BIDx 10 days
Is herpes screening recommended in pregnancy
No
Cesarean delivery for herpes
Recommended for genital lesions, or prodromal symptoms
can offer with outbreak in the 3rd trimester
IgG CMV avidity testing
high- likely 6 months prior
low- likely < 4 months
early antibodies have lower antigen avidity
CMV on ultrasound
cerebral calcifications microcephaly, echogenic bowel, FGR, subependymal cysts (cyst lining the walls of the brain), ventriculomegaly, pericardial effusions hyperechoic kidneys hepatomegaly placentamegaly placental calcifications liver calcifications hydrops
Neonatal CMV
jaundice rash hepatosplenomegly death deafness neurodevelopmental impairment
Congenital Syphilis
can infect at 6 weeks
- ultrasound concerns usually don’t start till 16 weeks
Stages of syphilis
Primary - chancre (screening and confirmatory test may be negative)
2nd - skin rash starts on trunk/palms/soles
early latent within 1 year - asymptomatic but serology + and contangious
late latent- > 1 year (not contagious sexually but can transmit to fetus)
teriary - eye/ear/gumma/CV disease (aortic aneuysm)
Argyll roberton pupil (does not react to light)
neurosyphilis
Congenital syphilis
1 or 2ndary/early latent have highest risks ( 40-50%)
3rd/late latent (<10%)
stillbirth non-immune hydrops placentamegaly hepatomegaly - most asymptomatic at birth
maculopapular rash snuffles mucous patches in mouth hepatosplenomegaly jaundice osteocondritis chorioretinitis iitis
huthcinson teech mulberry molars 8th nerve deafness saddle nose saber shins CNS concerns
syphilis screening
non-specific antibody (RPR)
confirm with treponemal FTA (positive will stay positive)
syphillis treatment
2.4 million units penicillin (1x primary 3x late latent)
Jarisch- Herxheimer- fever, decreased fetal movement, contractions, chills, myalgia, headache, hypotension, - resolves in 24-36 hours
Reexamine at 28 weeks/and delivery
- need a four fold (2 dilutional) decrease in non-treponemal titer by 1 year after treatment
TB
dx
treatment
latent definition and treatment
Evaluation: sputum culture
Treatment: INH, rifampin, pyrazinamide (not in pregnancy) ethambutol
Latent: postitive TB without symptoms, negative CXR - treat with INH
Evaluate for HIV
No breastfeeding until 2 weeks after treatment for active infections
Screening for TB
type
who to screen
Screen with ppd (not with BCG within 10 years)
HIV contact with TB Born in high risk places low income alcoholics IV drug use Jail
Confirmation of + PPD
CXR: adenopathy
multinodular infiltrates
cavitations
loss of upper lobe volume
AM sputum for acid-fast bacilli
Treatment with
PPD+ with symptoms
Treatment for PPD+/ CXR negative
no symptoms
symptoms- 3 am sputums, and eval for extrapulmonary TB
+ treat with INH/Rifampin/Ethambultol for 6 months
- <35 treat with INH/B6 postpartum for 6 months
No symptoms-
converted recently <2 years- INH after 1st trimester- 6 months postpartum + B6
Old conversions- >2 years or 1st PPD - 35 years or younger treat postpartum with INH/B6
** do not treat >35 if low risk due to risk for hepatotoxicity with INH
- 20% of those treated with INH get elevated LFT which resolve
- don’t use streptomycin due to cranial nerve 8 deafness in kiddos
Testing/treatment for fetus if mother has TB
PPD at birth and 3 months
- (if active) INH until mom has tested negative for 3 months
