W4 Flashcards
Intensive vs Moderate vs No Infection control program
Intensive decreases infections
Moderate: NO CHANGE
none: increased infections
Bundles Concept in Infection control
A “bundle” is a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are “bundled” together and, when combined, significantly improve patient care outcomes.
- worked perfectly to reduce Catheter-Related Bloodstream Infection rates
CDAD
C. Difficile
Which infections INCREASED during covid, which DECREASED
INCREASE:
Catheter assoc. bloodstream infections
Ventilator assoc. pneumonia
MRSA bacteremia
- over worked staff, packed hosptials, harder for infection control
DECREASE:
Surgical site infections
C. Difficile diarrhea
- COVID related infection control maybe helped for these ones
Infectious Standard of care for all patients
Assumes “body substances” * from any patient could be infectious
- aims to prevent transmission from patients who are asymptomatic or have undiagnosed infections
Aims to prevent infections associated with invasive procedures
Practices based on nature of interaction with patient
- blood, body fluids, excretions, secretions, exudates
Hand washing vs Alcohol based hand rinses
Now considered method of choice for hand hygiene in health care
Effective, convenient, fast
Increased compliance with hand hygiene
Decreased infections rates
Respiratory Etiquette for Source control
PROMPTLY IDENTIFY patients with febrile respiratory illness
POST SIGNS instructing coughing patients to
- cover nose & mouth when coughing or sneezing
- dispose of tissues promptly
- clean hands after contact with respiratory secretions
- wear surgical mask if possible
SEPARATE coughing patient from others
PROVIDE tissues, masks, waste receptacles, hand hygiene product
When are CONTACT precautions used?
Skin and wound infections
Diarrhea
Colonization with selected multi-drug resistant organisms
Viral respiratory infections (with droplet)
Contact Precautions Include;
SINGLE ROOM or maintain spatial separation between patients
GLOVES to enter the patient’s room
GOWN if clothing or forearms will have direct contact with patient or contaminated items
Hand hygiene with ANTISEPTIC after removing gloves
Dedicated equipment (or DISINFECT before re-use)
DROPLET precautions for which infections?
Viral respiratory infections (with contact)
Meningococcus
Invasive Streptococcus group A infections
Pertussis, mumps, rubella, parvovirus
Droplet Precautions include
Single room or spatial separation of > 1-2 m
Surgical mask if < 1-2 m of patient
For viral respiratory infections, consider eye protection (mask with visor, face shield or goggles) *
Patient to wear surgical mask when out of room
Airborne Precautions
- more difficult to prevent
Single room
Special ventilation and negative pressure (air flows into room, not out)
High efficiency mask (N95)
- for contagious tuberculosis
- for measles, varicella if not immune
N 95 Mask
Originally designed for industry
(asbestos, other irritant particles)
Tight-fitting mask, built-in filter
Requires fit-testing and fit-check
Introduced for care of tuberculosis in 1994
- Recommended for varicella, measles in 1997
- Also used for SARS, Avian influenza,
Ebola
- Recommended if performing specific
procedures on patients with influenza
Antibiotic Resistant Organisms Infection Control
Use antibiotics wisely
Don’t use antibiotics as antipyretics !
Don’t substitute treatment for diagnosis
Prevent transmission of resistant organisms
Take appropriate Isolation Precautions
Physician Health in Infection Control
Have the appropriate immunizations:
- be immune to *hepatitis B, *measles, *mumps, *rubella, *varicella, *pertussis, polio, diphtheria
- get *influenza vaccine yearly
Have a PPD test if indicated
Have fit-test for N95 mask; know how to do a fit-check
Take appropriate precautions if working while ill with a contagious infection!
Students and Blood Borne Viruses
Carriers of BBV
- are not prohibited from patient-care activities solely on the basis of BBV infection
- are prohibited from performing selected high risk procedures which pose a risk to patients unless certain criteria are fulfilled
(low viral load, following advice from expert panel, routine medical follow-up & monitoring of viral load, adherence to specified infection control practices)
TRansmission of SARS, most transmission occured in…
Health Care settings!!
Baby boy: Presents to your office with three days of fever to 40C, irritability, poor sleep and clawing at his face/pulling his ears
On exam, you note a febrile, crying baby with a bright red and bulging tympanic membrane
- Diagnosis
Acute Otitis Media
What is the most common pathogen identified in acute otitis media
Viral pathogens!
what are common bacterial pathogens for Acute Otitis Media
Common bacterial pathogens include:
*Streptococcus pneumoniae
Haemophilus influenza Moraxella catarrhalis Streptococcus pyogenes
Most complications of AOM (mastoiditis, perforation) happen in the context of a S. pneumoniae infection
Acute otitis media
Risk factors for resistant streptococcus pneumoniae strains:
Daycare
Children <2 years
Recent hospitalization
Recent antibiotic use (within 30 days) Frequent history of AOM
Presentation of Acute Otitis Media
Recent and often abrupt onset of fever and ear pain, often accompanied by congestion
Presence of the following features:
- Evidence of middle ear inflammation (an erythematous TM)
- Evidence of mucopurulent effusion in the middle ear (a TM that bulges)4
TReatment for Acute Otitis Media
Amoxicilin
Advice to parents of kids with ear infection within 24 hours
likely a viral infection - which resolves within 24-48 hours
better to AVOID antibiotics if not needed
with a family you can give them an walk out prescription, if they don’t get better after two days then take meds.
Savannah is a healthy 7 year old girl with no past medical history She presents to care with: • Sudden onset 48h of fever • • • • Extreme throat pain Vomiting x 1, poor appetite Absence of cough or congestion • Tender anterior lymphadenopathy Tonsillar and pharyngeal inflammation with exudate on her tonsils Petechiae on palate No rash On exam, you notice: • • • •
Diagnosis
Pharyngitis
- can be caused by many things: most common pathogen is VIRAL
Pharyngitis
common pathogens:
What is the most common pathogen identified in acute pharyngitis?
Viral pathogens!
If a bacterial cause is identified, it is usually group A beta-hemolytic
streptococcus (GABHS): streptococcus pyogenes
- 5-15% of pharyngitis/tonsillitis in children
- 20-305 of pharyngitis/tonsillitis in adults
The diagnostic challenge is identifying which cases are in fact bacterial and require antibiotic treatment
Pharyngitis
- Important DDX
Viral: Epstein-Barr virus, coxsackie, adenovirus, herpes simplex virus
Peritonsillar or retropharyngeal abscess
Thrush
N. gonorrhoeae (in sexually active patients)
Foreign body
Kawasaki disease
Key Management Principles for Pharyngitis
Don’t treat viral pharyngitis with antibiotics
Analgesia is very much recommended in the first few days (very painful so you wanna relieve symptoms)
Do not initiate treatment in the absence of a positive rapid test or a positive culture of the throat, unless:
- Very severe symptoms
- Clinical signs of Scarlet fever
- Complications (i.e. evidence of tonsillar abscess)
- A history of acute rheumatic fever (complication of strep)
Scarlet fever
Complications of infection by GABHS; “strep throat with a rash”
Scarlatiniform rash is characterized by:
Diffuse erythema that blanches with pressure
Starts usually in groin and armpits; accompanied by circumoral pallor and strawberry tongue
Rash progresses to trunk, then to extremities, then desquamates; palms and soles are often spared
Most MARKED in the inguinal, axillary, antecubital and abdominal areas
- Axillary and antecubital: Linear petechial pattern called PASTIA’S LINES
Scarlet fever
- cause
- Management
Rash usually occurs because of a delayed-type skin reaction to pyogenic exotoxin
Untreated scarlet fever with pharyngitis can predispose to acute rheumatic fever
- Management of scarlet fever is the same as management of pharyngitis/tonsillitis
- Children may return to daycare 24 hours after antibiotics
- No specific monitoring of these patients is needed
Pharyngitis and scarlet fever: treatment
Why treat
Reduces symptoms
Reduces risk of complications as well as person-to-person transmission
Will prevent acute rheumatic fever if treatment is started within 9 days of initial onset of symptoms
so you use treatment to PREVENT complications*
Mono is a high DDX for….
- what organism is it caused by?
high DDX for strep throat
mono is caused by EBV
Madeleine is a 35 year old previously healthy woman presenting with dysuria, urgency and increased urinary frequency, as well as ‘funky-smelling urine’
She takes no medications
She is sexually active with her monogamous partner of 10 years, and has no history of STI
She denies fever, nausea, vomiting or low back pain
Her last menstrual period was 2 weeks ago, and she has an IUD for contraception
Her physical exam is normal except for mild suprapubic tenderness. She has no costovertebral angle tenderness
Diagnosis?
UTI!
Cystitis vs Pyelonephritis
Cystitis vs Pyelonephritis
Pyelonephritis
Symptoms of cystitis Fever/chills
Nausea and vomiting
CVA tenderness (positive renal punch)
Cystitis
Dysuria
Urinary frequency Burning/pain during urination Hematuria
Suprapubic pain
Cloudy or foul-smelling urine
Absence of temperature/change in vital signs
DDX for UTI
Consider an alternate diagnosis if the following symptoms are present
Women: Vaginal discharge, vulvar itch, symptoms of pregnancy
Men: Pain elicited by prostatic or testicular examination
DDX
Women: Vaginal or pelvic infection, pregnancy, gynecological pathology (PID, ruptured ovarian cyst, ectopic pregnancy)
Men: Prostatitis, epididymo-orchitis
All: STI, urolithiasis, abdominal infection (diverticulitis, appendicitis)
Common Bacteria for UTI
E. coli
Klebsiella Pneumoniae
Staph saprophyticus
Enterococcus
staph aureus is RARE
Urinanalysis
Urinalysis
A simple, low cost, reliable test
The presence of leukocytes, nitrites and new onset of symptoms** has a 90% positive predictive value (PPV)
The absence of leukocytes and nitrites in a newly symptomatic patient has a 90% negative predictive value (NPV)
Urine culture: Helpful to identify bacteria
UTI treatment
DONT MEMORIZE
Simple cystitis:
NITROFURATOIN*** , 100 mg po bid x 7 days
Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg po bid x 3 days (shorthand: Septra DS 1 tab bid x 3 days)
Fosfomycin 3g x1
Failure of first line, Second line:
Fluoroquinolone (i.e. ciprofloxacin XL, 500 mg po bid x 3 days) - don’t wanna waste this, save it for when they come back resistant
Jaxon is a 40 year old male presenting to care with congestion and facial pain
He is a PhD student defending his thesis in 2 days and is worried that he won’t be well enough to do so
His past medical history is significant for tonsillectomy/adenoidectomy as a child He smokes a half pack of cigarettes per day
He had a bad cold one week ago which he expected was going to improve on its own. Instead, his secretions became thicker and dark green, he began to cough more, and he began to experience pain on the right side of his face and his teeth
His exam is notable for purulent secretions observed in the right nasal cavity and draining down the back of his throat. He is tender to palpation of the right maxillary and frontal sinuses.
Clear Diagnosis?
Sinusitis
MOST cases are viral; only a small percentage of cases are complicated by a bacterial infection
Most cases are self-limiting and will resolve in 10-14 days
It is important to be judicious in the prescription and use of antibiotics; even in some cases of acute bacterial rhinosinusitis, antibiotics are not needed
Increased antibiotic resistance is seen due to increased (and sometimes inappropriate) prescription of antibiotics
Pathogens that cause Sinusitis
Pathogens are similar to those in acute otitis media
S. pneumoniae H. influenza M. catarrhalis S. aureus S. pyogene
smoking is a risk too
Acute Rhinosinusitis Diagnosis
Main symptoms: unilateral dental or facial pain
Nasal Obstruction or congestions
Coloured anterior or posterior Rhinorrhea
Other symp to consider:
headache
Hyposmia
Cough
+ symptoms persist for 10-14 days without improvement; or Symptoms worsen 5-7 days after initial infection (biphasic infection)
Antibiotic treatment depends on severity of symptoms and how impactful they are to the patient
ABX for viral infection is NOT going to help, so much education patient that treating with ABX will NOT help with their symptoms
Sinusitis: Conservative management
NSAIDs/acetaminophen
Nasal irrigation (especially important in children who cannot manage their own secretions)
Short term topical decongestant
Consideration of intranasal corticosteroid
Proceed to antibiotics if evidence of moderate-severe infection
For which infectiosn are viruses the most common causative pathogens?
otitis media, pharyngitis, and sinusitis
In otitis Media you must see BOTH x and Y
In otitis media, you must see both inflammation and effusion to diagnose
Use of Centor Score
Use the Centor score to help establish the likelihood of a bacterial pharyngeal infection
What is treatment of scarlet fever similar to?
Scarlet fever is bacterial pharyngitis with an associated rash; the treatment of scarlet fever does not differ from that of regular bacterial pharyngitis
When does Rhinosinusitis stop?
Most cases of rhinosinusitis are self-limiting, even if bacterial
- Encourage use of nasal irrigation
- Use ANTIBIOTIC STEWARDSHIP
Macule
Macule: A flat, distinct, discoloured area of skin. It usually does not include a change of texture or thickness.
Papule
Papule: A solid or cystic raised spot on the skin that is <1cm wide.
Maculopapular
Maculopapular: A combination of both flat and raised lesions on the skin.
Exanthem vs Enanthem
EXanthemA rash or eruption on the skin.
From Greek ‘exanthein’ - “to bloom, break out”
ENanthem: Oral mucosal lesions
When a healthcare provider refers to a maculopapular exanthem, it is typically implied that it’s onset is acute
Many medical conditions present with maculopapular exanthems - their identification is not particularly specific
Ryan is a 3 year old boy in your family medicine practice. He presents for a same-day appointment. He is brought in by his father who became concerned when a rash appeared all over his body last night and today.
No past medical history, no medications, vaccines up to date
Attends daycare
History:
4 days of mild rhinorrhea, low grade fever and fatigue
Yesterday, fever broke, and developed bright red rash on cheeks
Today woke up with rash over trunk and arms
Currently, is feeding well, afebrile, and seems unbothered by rash, occasional scratching
Diagnosis
Erythema Infectiosum: Parvovirus B19
Infectious Exanthems
Generalized cutaneous eruptions associated with a primary systemic infection
Mostly caused by viral agents, but can occasionally be associated with bacterial or parasitic infections
Usually macular, maculopapular, papular or papulovesicular
Erythema infectiosum
Caused by parvovirus B19, a small DNA virus
Occurs commonly in children aged 4-10
- 60% of adults are seropositive to anti-HPVB19 IgG
Incubates for 4-21 days, an average of 14 days
Transmitted via droplet aerosols, vertical placental transmission, percutaneously and/or through blood products
Can be spread 1-5 days before the onset of rash
A healthy immunocompetent individual is NO LONGER contagious following emergence of rash and/or arthralgia associated with infection
Erythema infectiosum
Clinical presentation
Prodrome of low grade fever, malaise, headache and coryza
Rash typically emerges 1-2 days later
- With rash, patients can be quite well overall
- May also have nonspecific viral symptoms associated (fever, cough, coryza, malaise, diarrhea, vomiting)
Children very uncommonly have arthralgia (more common in adults)
Children are often asymptomatic other than the emergence of rash
Two features we MUST know for Erythema Infectiosum
- “Slapped cheeks”:
First to appear
Red on light skin; on dark skin, may be flesh coloured
TEXTURED and elevated, can be palpated
Will disappear 1-2 days following emergence
- Exanthem: Erythematous macules and papules
- Become confliuent, giving a LACY or RETICULATED appearance of the skin
- Reticulation difficult to appreciate in dark skin
- Papules may not be red on dark skin, may appear hyper or hypo pigmented, often elevated and textured
Distributes over face, extensor surfaces of extremities, trunk and neck
again when you can SEE the rash, they are nO LONG contagious
How does Exanthem resolve?
Exanthem disappears in 1-5 weeks
Lesions may recur in certain settings: Exposure to direct sunlight Stress Exercise B
Treatment
of Erythema Infectiosum
Supportive; hydration, analgesia
Treatment complex in those who:
- Are immune compromised: Can trigger prolonged chronic anemia
- Have hemolytic anemia: Can trigger APLASTIC CRISIS, where you would see fatigue ++, pallor, worsening anemia
- Are pregnant: Infection could be complicated by fetal hydrops and fetal loss
- Infection of fetal RBC precursor cells can lead to fetal anemia, tissue anoxia, hemolysis and heart failure
VERY DANGEROUS FOR FETUS, see if kids parents is PREGNANT**
Pregnancy considerations
IN Erythema infectiosum
Pregnant patients exposed to or with symptoms of parvovirus B19 should have serologic (IgG, IgM) testing
- Must subject to increase monitoring
- Risk of fetal loss - greater in 1st trimester > 2nd trimester
- Only potentially effective treatment is an intrauterine fetal transfusion to treat severe fetal anemia - difficult to do before 20 weeks
- Does not appear to be long-term consequences to infection in those fetuses who are infected but do not develop hydrops fetalis
35 to 53% of pregnant women have pre-existing IgG to parvovirus B19
No specific prevention available
- Basic hand hygiene and masks
- Consider removing non-immune pregnant women from high-risk environments (schools, daycares) preventatively
FETAL HYDROPS
is a serious fetal condition defined as abnormal accumulation of fluid in two or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema.
Charlie, 9 months
Presents to care for 3 days of high fever
No known past medical history or medications. Only child, does not attend daycare, vaccines up to date.
Other than fever, the patient has no other symptoms (absence of cough, rhinorrhea, GI symptoms). She has less of an appetite but has good urine output.
Your physical exam is normal - no clear cause of fever on exam
You ask the patient to follow up in 48h if still febrile
- 48h later, mom returns because while the fever has stopped, Charlie has now broken into a diffuse rash.
Diagnosis
Roseola
Roseola
A viral infection of childhood caused by human herpesvirus 6 (DNA virus)
Infects 6-24 month olds, typically, but can reactivate at any age
Incubation period of about 10 days
Particularly contagious when child is febrile
Transmitted through direct contact with saliva/infected respiratory secretions
Roseola Clinical presentation
- what do you NEED for diagnosis?
HISTORY IS IMPORTANT you NEED it for diagnosis
Prodrome of sustained high fever (often 39C - 41C)
*Fever will break suddenly on day 4-5. and the rash will apper 24-48h after the end of fever
Baby is quite well despite high fever; no symptoms other than mild irritability, loss of appetite
Roseola is the MOST COMMON CAUSE OF FEBRILE SEIZURESsin the <2 age group
Roseola Diagnosis and Treatment
Clinical diagnosis: timing is key
Labs and further investigations are not indicated
Evolution is generally self-limited; patients usually recover within one week
Treatment is supportive:
Analgesia
Hydration
Treatment of any complications
Roseola
- what is the greatest risk if pt presents with fever?
Seizures
While febrile, Charlie (with roseola) was playing with her cousin who is 15 months. Should her aunt be concerned?
YES. infectious
Lief, age 5
Lief is brought into your office by his mother, pregnant at 14 weeks, for a new rash for 4 days.
He is not known for any significant past medical history, no medications
The patient is unvaccinated, attends daycare with other children who are unvaccinated, and has four older siblings who are also unvaccinated
The patient is well other than the rash
Started on his face (where it is now gone). and progressed down to his chest, arms and legs
Mom is not worried, but would like to know what is going on.
Diagnosis
Rubella
Rubella
“German measles”
Caused by the rubella RNA virus
Used to affect many children <15 years prior to immunization
- Now, in highly vaccinated populations, will see in unvaccinated infants and teenagers
Incubation period of 14-21 days
Contagious from 7 days before the rash appears, until the disappearance of the rash (which can take 1-3 weeks)
- A baby with congenital rubella can be contagious for several months
Transmission is airborne and transplacental
Rubella Clinical Presentation
Absent or low-grade fever in a child otherwise in GOOD GENERAL CONDITION
Most primary infections are SUBCLINICAL
Can note some posterior cervical and/or suboccipital lymphadenopathy
Teens and adults can have distal arthralgia
May also experience this post-vaccination, especially in adult women
MILD MACULOPAPULAR RASH
Rubella
Clincal Diagnosis
Clinical diagnosis
Can perform serologic testing to detect rubella igM, IgG
Can also detect viral DNA by RT-PCR from a nasopharyngeal or throat swab, or urine sample
Unlikely diagnosis in vaccinated individuals, though immunity can wane with age
Differential diagnosis to consider:
- Enteroviral infection
- Adenoviral infection
- Other non-specific viral illness with similar exanthematous presentation
FEVER is rare*
Rubella Treatment
Supportive
Complications to a healthy patient are very rare, but can include:
- Encephalitis
- Hemolytic anemia
- Pericarditis
Rubella Pregnancy Considerations
There is a risk of teratogenic** embryo-fetopathy in non-immune pregnant patients
The risk is present throughout pregnancy, but greatest in the first trimester of pregnancy
Complications include intrauterine fetal death, miscarriage, or CONGENITAL RUBELLA SYNDROME
- Diverse clinical manifestations including cataracts, hearing loss, retinopathy, congenital heart defects, intellectual delay, hypotonia, microcephaly, ASD, hepatitis, jaundice, bone disease, anemia, thrombocytopenia, pneumonia, endocrinopathy…
- Half of infants who acquire rubella in the first trimester show clinical signs of damage from the virus
Pregnant patients should have serologic status evaluated post-exposure and may be considered for immune globulin therapy (variable effectiveness)
Lief is brought into your office by his mother, pregnant at 14 weeks, for fever and a new rash for 4 days.
He is not known for any significant past medical history, no medications
The patient is unvaccinated, attends daycare with other children who are unvaccinated, and has four older siblings who are also unvaccinated
The rash started a few days after the onset of fever and upper respiratory tract symptoms
Started on his face (where it is now gone). and progressed down to his chest, arms and legs
Mom is not worried, but would like to know what is going on.
What is the diagnosis?
MEASLES
MEASLES
A highly contagious and vaccine-preventable viral illness characterized by fever, cough, coryza, conjunctivitis, malaise and rash
Infamous for its transmissibility: the attack rate in a susceptible individual exposed to measles is 90%
Transmitted via person-to-person contact as well as airborne spread
- Infectious droplets can remain airborne for up to two hours, rendering this virus able to be transmitted even in the ABSCENCE of the infectious individual
HISOTRY IS KEY FOR DIAGNOSIS
Measles
Clinical syndromes associated with Measles
Classic measles infection in the immunocompetent host
Atypical measles infection in a partially or incompletely immunized host
Complications of measles (up to 30% of infected individuals!)
- Secondary infection (AOM, diarrhea, laryngo-tracheo-bronchitis)
- Pneumonia
- Encephalitis
Clinical presentation
Fever and malaise
“3 Cs”: Cough, coryza and conjunctivitis
Koplik spots: 1-3mm white/gray/blueish elevations on an erythematous background, usually on the buccal mucosa
Exanthem: An erythematous, blanching, maculopapular rash
Koplik spots are found in…
Measles
Can you get rash from measles vaccine?
YES. Caused by the VACCINE MMR
Because measles is attentuated live vaccine
Measles Treatment
Supportive
Antipyretics, hydration
Treatment of bacterial superinfection
Measles Pregnancy Considerations
Measles in pregnancy is not associated with increased risk of birth defects
Trans-placental infection can increase the risk of miscarriage or stillbirth
Sasha presents to care for 48h of a low grade fever, rhinorrhea, and a rash
She is previously healthy and has no past medical history
She is fully vaccinated
Attends daycare
The rash is “a little bit everywhere” as per her father; more confluent on her hands, feet and near her genitalia. Her father is certain that she has chicken pox, although Sasha is not scratching her lesions.
Diagnosis
Hand, foot and mouth disease
Hand, foot and mouth disease
One of the most recognizable viral exanthems of childhood
A benign clinical syndrome, characterized by:
Fever
A macular, maculopapular, or vesicular rash of the hands and feet
A painful papulo-vesiculo-ulcerative oral enanthem (herpangina)
Caused by multiple (at least 15) enterovirus subtypes, the majority of which are Coxsackie A
Transmitted via oral ingestion of secretions shed from the gastrointestinal tract of infected individuals (fecal-oral transmission); also through respiratory secretions of infected individuals as well as vesicular fluid
Clinical features of HFMD
they can return to day care WHEN
Mouth, throat pain and/or refusal to eat
Fever
not ITCHY*
they can return to day care WHEN :
HFMD enanthem
Most commonly on the tongue and buccal mucosa
Occasionally on uvula, lips and tonsils
Progress from erythematous macules to vesicles to ulcers, once the vesicles rupture
1-5 mm
HFMD Exanthem
Exanthem:
Macular, maculopapular and/or vesicular
Usually non-pruritic and non-painful
Typically involves: Hands (dorsum, interdigital, palms) Feet (dorsum of toes, lateral border of feet, soles and heels) Buttocks Legs (upper thighs) Arms
Complications of HFMD
Rare - in primary care, the following are worth mentioning:
- Decreased PO intake
In severe cases, may necessitate intravenous rehydration
Onychomadesis: Separation of the nail plate from the nail matrix due to a sudden and temporary cessation of nail growth
3-8 weeks after HFMD infection
Treatment of HFMD
Supportive
Analgesia, hydration
Do not recommend any oral and/or topical therapies including lidocaine
Sasha presents to care for 48h of a low grade fever, rhinorrhea, and a rash
He is previously healthy and has no past medical history
He was born in Russia and moved to Canada at the age of 2.5. His vaccine history is unclear. His records are unavailable to you at this time.
Attends daycare
The rash is “a little bit everywhere” as per his father; more confluent on his hands, feet and near his genitalia. His father is certain that he has chicken pox. Sasha is scratching his lesions so much that at the time of presentation, his skin is raw and bleeding.
DIAGNOSIS?
Varicella, chicken pox
Varicella
Varicella zoster virus is a highly contagious herpesvirus infection transmitted via aerosolized droplets from nasopharyngeal secretions of infected individuals and/or through direct contact with vesicular fluid from skin lesions
Can also transmit transplacentally
Can cause primary infection or endogenous reactivation of latent VZV in the form of shingles
Varicella Clinical FEatures
Primary VZV infection in a healthy child:
Usually within 2 weeks of exposure
Benign illness
Prodrome of fever, malaise, pharyngitis, loss of appetite
Followed by classic rash
ITCHY
The varicella rash appears in succession over several days
–>A typical varicella patient has lesions of VARYING AGES on different parts of the body
Lesions begin as macules, which progress to papule, then to characteristic vesicles
Vesicles can then become pustular, and finally crust over
Crust falls off and can leave a temporary patch of hypopigmntation on the skin
New vesicles generally stop forming after 4 days; will crust over after 6 days
Varicella Treatment
Supportive
Analgesia, hydration
- Not aspirin - increases risk of Reye syndrome
Antihistamine for pruritis
A word on ANTIVIRAL THERAPY:
- May modestly reduce duration and severity of symptoms
- NOT recommended for immunized, immunocompetent children <12 years of age
Can be considered in children who are at risk of developing varicella complications:
- Infants
- Unvaccinated adolescents
- Children with chronic cutaneous or pulmonary disorders
Varicella Pregnancy Considerations
If a non-immune mother acquires varicella infection during her pregnancy (weeks 8-20), the baby is at risk of congenital varicella syndrome
Maternal varicella infection during infancy is also associated with infantile zoster
Congenital varicella syndrome:
- Has a wide array of clinical features including cutaneous scarring in a dermatomal pattern, neurological abnormalities, ocular abnormalities, limb abnormalities, GI abnormalities and low birth weight
Maternal infection is managed with oral antivirals
Post-exposure prophylaxis with varicella zoster immune globulin (VZIG) in non-immune pregnant women with exposure risk
What helped contain SARS so well
Global Health Response
Rapid Identification of the Responsible Agent and means of spread
Containment
Animal Reservoir culled
LUCK!!
Aggressive and lethal and transmitted mostly while symptomatic
MERS key facts
Middle Eastern resp syndrome
human to camel infection high
The virus does NOT seem to pass easily from person to person unless there is close contact, such as occurs when providing unprotected care to a patient
Pandemics of Influenza
undergo a lot of genetic shifts (big changes) which lead to NEW pandemics because population does not have appropriate immunity
Suppurative Complications of “strep throat”
Suppurative complications: Para-pharyngeal abscess otitis mastoiditis Bacterial sinusitis Invasive infection (necrotizing fasciitis “flesh eating disease”, toxic shock syndrome)
What are the two types of complications for strep throat
Suppurative (pus forming)
and Non suppurative
Non suppurative Complications of Strep Throat
Non-suppurative: Rheumatic fever (RF) and glomerulonephritis (kidney)
Now rare in North America (more prevalent in low-income settings)
Mechanisms of disease not well understood; some strains of GAS are “rheumatogenic” (ie. more likely to cause RF than others)
RF likely result of immune system turning on self because of “mimicry” (Ag-Ab response) – occurs 3-4 weeks after untreated Strep infection
Affects: heart (carditis), joints (arthritis), skin (rash and nodules), nervous system (uncontrolled movements: chorea)*
Epidemiology by age for Causes of Pneumonia
- Infants
- Young Adults
- Older Adults
Infants and young children
Gr B strep
RSV, parainfluenza, influenza
S. pneumonia and H. influenza type B (now less frequent since vaccines)
Young adults
Mycoplasma, chlamydophyla (“atypicals”)
Influenza
Older adults
S. pneumo, H. influenza, S. aureus, gram negatives
TB
Epidemiology by risk factors for Pnemonia
ETOH: S. pneumonia, H. influenza, Klebsiella, anaerobes, TB
Aspiration: mixed flora with anaerobes; staphylococcus and G(-) in hospitalized
***COPD: H. influenza, S. pneumonia, Moraxella, Legionella
*****Hospitalization: G(-) pathogens [normally gram + on us]
****Post-influenza: Staphylococcus, S. pneumonia, H. influenza
Sickle cell: S. pneumonia
Immunocompromised (HIV, chemotherapy, transplant,..): bacterial, fungal, mycobacterial (TB)
Key lesson in the treatment of URTI and LRTI
URTI more common, less severe: mostly caused by VIRUSES so DON’T treat with ABX
LRTI less common but more severe, larger role of BACTERIA so know how to treat empirically
Not all viruses are “benign” and not all bacteria are “dangerous” – it’s an interplay between the status of the host (the patient) and the pathogen
Common infections in Indigenous people
Respiratory Syncytial Virus (kids) Tuberculosis Acute Otitis Media (kids) Impetigo (honey crust, MRSA) Influenza COVID19
OTHERS:
PNEUMOCCOCUS
STIs
hep C
AOM prevention in Indigenous
Avoid daycare
Avoid baby bottle/pacifier
No smoking/second hand smoke exposure
Encourage breastfeeding
What are some RARE conditions that are actually seen more commonly in Indigenous populations
Acute Rhematic Fever
Botulism!
HIV
Toxoplasmosa Gondii (cats)
Botulism
- organism
- mode of transmission
- presentation
Clostridium botulinum - toxin Mainly foodborne Incidence Canada 0.03 per 100,000 Incidence Nunavik 50.5 per 100,000 Mainly due to poorly stored marine mammal meat
rare but COMMON in indigenous
Presentation
Usually presents with neurologic symptoms (cranial nerve palsies)
Treatment iv botulinum antitoxin
Supportive care
No role for antimicrobial therapy – does not affect the toxin
Acute Rhematoid Fever in Indigenous
GAS infection (children and teens) - must emphasize need to complete treatment (10 fulls days of penicilin!)
rare but COMMON in indigenous because of untreated GAS
Which is rare but usually seen in indigenous seen with cats?
Toxoplasmosa gondii
– indigenous usually don’t have cats, possible its coming from the water:
Several factors implicated including consumption of contaminated water, uncooked seal meat, caribou etc
Indigenous: This bacterial infection is related to a bacteria that used to be a major cause of meningitis and epiglottitis among Indigenous children?
Haemophilus Influenza type A**
