1
Q
Infectious or non-infectious risks are most common with transfusion?
A
Non-infectious.
2
Q
What are two septs to prevent infections from blood transfusions?
A
- Restrictive policy (only get RBC when you need it)
2. Donor screening, selection, testing, infusion
3
Q
What infections do we test in blood donors?
A
HIV (type 1 and 2) HTLV (type 1 and 2; human T lymphotropic virus) HBV HCV West Nile virus Other: CMV, Chagas Dx Syphilis Bacteria
4
Q
How do we screen and keep blood safe?
A
- Screen donor for infections
- Aseptic collection + infusion
- first 40 mL always not used
- viral inactivation
- leukocyte reduction technique to reduce CMV
- freezing
- transfusion surveillance system to provide data on transfusion related injuries
5
Q
What is the highest incidence of AE across all blood transfusion products?
A
- Severe allergic/anaphylactic reaction
- Acute hemolytic transfusion reaction
- Delayed hemolytic transfusion reaction
- Transfusion associated circulatory overload
- Transfusion-related acute lung injury
6
Q
What is the general estimate of blood donor infections?
A
HIV - 1 in 8 to 12 million (<1 in 10 million)
HCV- 1 in 5 to 7 million (< 1 in 10 million)
HBV- 1 in 1 million (< 1 in 10 million)
7
Q
T or F: west nile virus has been reported in Canada blood products?
A
- False
- non since screening introduced in 2003
8
Q
Examples of agents NOT tested in blood transfusion products?
A
- Parovirus B19
- Malaria
9
Q
What are biologic response modifiers?
A
antibodies to pro-inflammatory cytokines or proteins that target cytokine receptors
Examples: Abatacept, adlimumab/humira, anakinra/kineret, etanercept/enbrel, infliximab/remicade,
10
Q
Why are kids on biologic response modifiers at higher risk of infection?
A
- med inhibits T cell destruction
=permitting reactivation of infection that were previously dormant or new poor response to new pathogen needing cell-mediated immunity - highest risk w/ TB, mycobacteria, fungal, Listeria (intracellular), reactivation (Strongyloides)
11
Q
T or F: kids on biologic response modifiers at increased risk of infections with more common bacterial pathogen?
A
False
- no significant risk of infection of common bacterial pathogen (like S. pneumoniae)
12
Q
What major factor is relates to risk of infection for kinds on biologic response modifiers?
A
Length of treatment
13
Q
How do you prevent infections for kids with biologic response modifiers?
A
- All routine immunization PRE-treatment
- all live virus vaccine min. 4 wk before med (unless contraindicated)
= inactivated vac 2 week before med
= 1 month delay btwn vacc + med if on high dose steroids
= get primary pneumococcal if < 5 y.o.
pneumococcal polysacc given min. 8 wk after last dose if min. 2 y.o.
= annual inactivated flu - All asymptomatic pt evaluated for latent TB prior to starting med
= hx, TST, CXR
* blood-based assay if min. 5 y.o.
+/- 2B. Consider serology for Histoplasma, Toxo, and other intracellular pathogen (Depending on risk of past exposure). Consider serology of Hep B, varicella-zoster, EBV
- decrease exposure to infections
Toxo, listeria= undercooked meats, egg, soft cheese
Toxo= kitty litter, Bartonella= kittens, reptile (Salmonella) - live vaccine contraindicated
- ensure household vacc UTD
= vaccination to prevent exposure to varicella, influenza, and other - Counselling: food safety, dental hygiene, exposure to heavy concentration of garden soil/pet/animal, high risk activity (spelunking), travel to pathogenic fungi or TB
14
Q
What is swimmer’s ear?
A
Acute otitis externa = diffuse inflam of external ear canal
- primarily > 2 y.o.
- associated w/ swimming
15
Q
What are RF for acute otitis externa?
A
- swimming
- trauma
- foreign body in the ear
- use of hearing aid
- certain derm dx
- chronic otorrhea
- wearing tight head scarves
- immunocompromised
16
Q
What are typical acute otitis media bugs?
A
Polymicrobial.
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Rare: gram (-), fungal
17
Q
What is the acute otitis externa clinical ppt?
A
- otalgia (esp pain + TMJ pain when chewing)
- d/c (tender when pinna pulled)
- itching
- hearing loss
- fullness
18
Q
Criteria for AOE Diagnosis:
A
- RAPID onset (within 48h) in past 3 week
- SYMPTOMS of INFLAMMATION (otalgia, itchy, full, +/- hearing loss or jaw pain)
- SIGNS of INFLAMMation (tender triages, pinna, or diffuse ear canal edema, erythema +/- otorrhea)
19
Q
Do you swab suspected AOE?
A
Only if unresponsive to treatment or severe case since often polymicrobial and can reflect normal colonizing bugs.
20
Q
How do you manage AOE?
A
- Mild-mod: topical Abx +/- topical steroids x 7-10d
- More severe= systemic Abx (cover Staph. Aureus + Pseudomonas)
- Pain control (systemic tylenol, NSAID)
21
Q
Can gentamicin or neomycin be used if tubes or perforated TM?
A
No.
-these are ototoxic = harm if tubes or perforated TM
22
Q
T or F: Topical steroid can be used as mono therapy in AOE?
A
No. False.
- for mild-mod dx = topical abx +/- topical steroid
i. e. Ciprodex= ciprofloxacin-dexamethasone
23
Q
List a differential for AOE that fails treatment.
A
- non-adherence to treatment
- antibiotic resistance
- ear obstruction
- foreign body
- altered dx (dermatitis w/ contact w/ nickel, viral or fungal infection)
24
Q
What are RF for malignant otitis externa?
A
- Immunodeficiency
2. Insulin-dependent DM
25
What is malignant externa?
Invasive infection of cartilage + bone of canal and external ear
CC: facial nerve palsy + pain
Imaging: CT or MRI may be needed
Tx: systemic Abx
26
T or F: Zika virus is usually symptomatic.
False
| - usually asymptomatic
27
T or F: Zika virus is transmitted via blood products AND sexual transmission.
True
| - typically via bite of specific mosquitoes not seen in CAN
28
What are the most common symptoms of Zika virus?
- asymptomatic usually
- common: maculopapular rash (pruritic, proximal to limbs), low grade fever, arthralgia
- rarely: myelitis, encephalitis, hearing loss
- recovery within 2 wk
29
Describe features of Congenital Zika Virus.
- usually T1 (can be T2 or T3 too)
- IUGR
- severe microcephaly
- cerebral atrophy
- rarely= cataracts, retinal issue, hearing loss
30
T or F: perinatal transmission usually bad.
False
| - usually benign
31
What are features that can distinguish Congenital Zika Virus from other TORCH?
- severe microcephaly + partially collapsed skull
- thin cerebral cortices w/ subcortical Ca2+
- macular scarring + focal pigmentary retinal mottling
- congenital contractures
- ++ hypertonia and EPIS
32
How is Zika Virus diagnosed?
Serology or PCR
- IgM or IgG (*note must confirm via Zika virus antibodies as IgG + IgM can cross react w/ other viruses)
- RNA PCR
33
Which moms + kids do you test for Zika Virus?
- if infant born to mother w/ potential exposure = request ZIKV on mother. If in last 4 week send for urine and blood PCR
- if (+) = test baby
- no testing on kids (symptomatic or asymptomatic) UNLESS need hospitalization
34
Zika serology + blood and urine PCR in mother and child IF:
unexplained microcephaly, intracranial Ca2+, ventriculomegaly or major structural CNS abN
AND maternal hx of travel to ZIKV-endemic nation during pregnancy or sexual contact during preg w/ male who travelled to ZIKV endemic nation in preceding 6 mon.
** if results are inconclusive send placenta for pathology and ZIKV PCR
35
What imaging do you do for kids w/ suspected congenital zika virus?
- non-urgent U/S and MRI
36
Is there a preventive medication for Zika virus?
No.
- use personal protective measure (i.e. bed net, clothing, repellent)
- if can become pregnant avoid travel to affected areas
37
List ways to make vaccination as pain-free as possible.
- Prep: information, tools, discuss pain strategies w/ parents
- use topical anesthetics
- BF or sucrose best for infants
- use distraction
- rub skin near IM site (if 4 yr min. +)
- deep breathing (min. 3 yr +)
always hold upright; no supine
- give most painful vac last
- rapid IM injection; no aspiration
- parents stay calm (picked up by child)
38
Which location do you give vaccines?
Butter thigh if < 12 months
| Upper Arm if > 12 months
39
What is the name of Canada's national surveillance network for AE involving vaccines?
IMPACT
= Canada's Immunization Monitoring Program ACTive
- designated RN monitor; cases of AE seen in hospital reported -> forward to local public health
- monitor vaccine safety
40
T or F: routine prenatal HIV testing only recommended for high risk testing.
False
- routine prenatal testing for ALL women
- if increased hisk (IVDU, commercial sex worker, f unprotected intercourse w/ multiple partners) test in T3 and delivery
41
T or F: it's okay to d/c a BB home if HIV test pending
False
| - CPS: no infant should be d/c home w/out HIV status of mother known
42
When should women with HIV get a pre-labour elective C/S?
- no ART
| - inadequate suppression (viral load > 1000 copies/mL)
43
Do you need to consult peds HIV expert newborn with HIV (+) mother?
Yes - peds HIV expert for all newborns HIV (+) mother
44
What antiretroviral prophylaxis should infants of HIV infected mothers get?
Basically min: Zidovudine x 6 weeks
- if no ART or viral load min. 1000 copies/mL + = combination antiretroviral therapy (or zidovudine + nevirapine)
- give preferably within 6h-12h; efficacy likely lost when started > 72 h
45
Formula or BF for HIV infected mothers?
Exclusive formula feeding
- if HIV (+) F found to be BF urgently refer to peds HIV expert and clarify mother's understanding of transmission
46
How do you R/O HIV infection in HIV-exposed infants and kids?
- <18 month= qualitative or quantitative HIV DNA +/- RNA PCR
- R/O w/ 2 separately timed (-) PCR; 1 beyond 1 month of age and 2nd > 2 month of age
- HIV status of exposed finalized using serological assay btwn 18-24 months of age
47
List Zidovudine side effects (used for HIV tx)
reversible anemia
| reversible neutropenia
48
HIV rate of vertical transmission: with and without intervention.
- 25-40% without tx
| - < 2% with tx
49
Infectious contraindications to BF:
- Mastitis and breast abscess:
pump and dump unless obvious pus then continue with other breast
- TB:
EBM during 1st 2 wks (to avoid airborne transmission risk)
If active TB, delay until 2wk of appropriate anti-TB therapy + prophylaxis for infants.
- Brucellosis:
d/c BF with untreated maternal brucellosis; infection can pass through BF
- Human T-cell lymphotrophic virus type I or II
50
T or F: You cannot BF with CMV
False.
Continue BF with latent or active maternal CMV infection.
Note: latent CMV reactivate in BF during postpartum period and can be transmitted to infant w/ BF but transmittal dose do not pose risk to term b/c serious dx prevented by placental transferred maternal antibody.
51
What BF precautions do you need to take for mothers w/ herpes simplex virus ?
- continue BF
- hand hygiene
- cover oral labial lesions w/ a mask
- if lesions on breast/HSV mastitis, verify it is HSV and not varicella-zoster virus
- interrupt direct BF until lesions crusted over; use EBM
52
Is EBM contraindicated with HIV mothers?
Yes. BF and EBM both contraindicated.
53
Which meds are contraindicated in BF?
- TMP/Sulfa- caution if nursing or G6PD deficiency
- high dose metronidazole (d/c BF x 12h-24h to allow excretion of dose)
- Antimalarials (primaquine, quinine) safe in BF unless BB has G6PD deficiency
54
T or F: Autistic spectrum disorder associated with MMR vaccine or thimerosal containing vac.
False
55
List counselling on safe food handling:
- use safe foods (i.e. avoid unpasteurized milk, wash fruit + veg)
- sep raw from food that will be cooked (i.e. sep chopping boards)
- wash hand before prep
- use safe water for prep
- cook meat, egg, poultry, seafood thoroughly
- eat food soon after cooked
- store appropriately
- reheat appropriately
- keep kitchen clean (i.e. food debris sustain microbial proliferation)
- protect from insect, rodent, pets
56
List food safety tips for immunocompromised pt:
- avoid undercooking
- avoid raw or undercooked food
- avoid soft cheese
- wash, peel, cooked fresh fruit + veg
- avoid raw fruit + veg that can't be peeled or washed well
- avoid raw seed sprouts
57
How syphilis acquired?
Mainly: sex (vaginal, anal, oral)
Rarely: blood, kiss, sharing needles
58
What does risk of syphilis vertical transmission depend on?
Stage of maternal dx
i. e. < 10% risk = late latent syphilis
vs. 70-100% if untreated primary or secondary syphilis during pregnancy
*most infected in utero after 4th mo. GA or via contact at time of delivery
59
T or F: syphilis serology should routinely be performed at T3?
False.
- Routine performly at T1
- prescreen @ 28-32 wk GA and at delivery in high-risk F OR if outbreak in that area
60
Name the two types of Syphilis serology testing:
Most= RPR is initial and confirm via treponemal test.
1. Non treponemal test
- RPR (rapid plasma reagin)
- VDRL (venereal dx research lab test)
2. Treponemal test
- detect treponemal specific antibodies
e. g. FTA-ABS, or trep pallidum particle agglutination (FTA-PA)
61
Interpret Syphilis BW:
| - Non reactive RPR + reactive TP-PA or FTA-ABS
- usually treated syphilis OR early infection (early primary syphilis) OR late latent OR person from endemic nation
62
Interpret Syphilis BW:
| - Reactive RPR + Non reactive TP-PA or FTA-ABS
False (+)
63
Interpret Syphilis BW:
| - Non reactive RPR + Non reactive TP-PA + Reactive FTA-ABS
Primary syphilis
64
Interpret this Syphilis B/W:
- Non reactive Non -treponemal (RPR)
- Indeterminate Treponemal (TP-PA, INNO-LIA)
positive
| - early primary syphilis OR late latent/tertiary syphilis OR previously treated or from endemic nation
65
Why is watching the decrease in RPR important?
- Treponemal test usually reactive for life so unless very early in infection you watch for decrease in RPR
i. e. drop 4X at 6 mo. w/ treatment, 8X fold at 12 month etc.
66
T or F: neonates with congenital syphilis are usually symptomatic at birth?
False.
| - Usually asymptomatic at birth; dx rely on B/W
67
Does a mother's negative VDRL R/O congenital syphilis if BB has features?
- No; mother incubating syphilis at time of delivery can have (-) serology in mom + BB thus any infant w/ compatible findings require investigation!
68
List features of congenial syphilis?
- spontaneous abortion/stiibirth/hydrops fetalis
- necrotizing funisitis (barbershop pole umbilical cord)
- rhinitis/snuffles
- rash (diffuse maculopapular)
- HSM
- lymphadenopathy
- neurosyphilis
- osteochondritis or perichondritis, pseudo paralysis
- heme: anemia, thrombocytopenia, other changes w/ heme malignancy
69
List late feature of congenital syphilis?
- interstitial keratitis
- frontal bossing, poorly developed maxilla, saddle nose, winged scapula
- 8th nerve deafness (sensory neurodeafness)
- Hutchinson's teeth (occur when permanent dentition erupts)
- Mulberry molars (dwarfing of cusps and hypertrophy; age 13-19 month)
- recurrent arthropathy and painless knee effusion (Clutton's joints)
70
What do you do if mother was treated for primary, secondary or early latent syphilis during preg > 4 wk before delivery w/ adequate fall in RPR titre and evidence of relapse?
0-3 mon= baseline + monthly assessment for signs
0, 3, 6, 18 mon= serological tests (RPR, TT) w/ clinical assessment
NO= XR, CBC, CSF, ophtho, audiological
NO= tx for congenital syphilis
71
Mother untreated, treponemes detect on direct examination from infant, infant RPR 4X or greater (higher than mother's at birth), or 4X rise in infant titre?
0-3 mon= baseline + monthly assessment for signs
0, 3, 6, 18 mon= serological tests (RPR, TT) w/ clinical assessment
Yes= XR, CBC, glucose, CSF, ophtho, audiological
Yes= tx for congenital syphilis
72
Do you always have to test at 12 or 18 month for syphilis?
No- not if RFR and TT nonreactive at 6 mo. of age
Infant RPR titre decline by 3 mo. of age + non reactive by 6 mo. in absence of congenital syphilis.
73
How do you treat congenital syphilis?
10 d x IV Pen G 50 K units/kg
NOTE: b/c tx do not cure every cause F/U serology to see loss of treponemal antibodies by 18 mo. of age for infants (if no congenital syphilis or very early tx) OR sustained 4X or greater drop in RPR
74
Indications for Prophylaxis to reduce risk of infective endocarditis.
Prophylaxis IF:
- previous IE
- prosthetic valve or material valve
- congenital HD
= unprepared cyanotic CHD (include palliative shunts + conduits)
= w/in 6 mo. post-op of complete repair
= repaired CHD w/ residual defect adjacent to prosthetic patch or device
- cardiac transplant who get valvulopathy
75
IE prophylaxis not indicated in:
- ASD
- VSD
- PDA
- MV prolapse
- previous KD
- hypertrophic cardiomyopathy
- previous coronary a. bypass graft sx
- cardiac pacemakers (intravascular and epicardial) and implanted defibrillator
- bicuspid aortic valves
- coerce.
- Ca2+ aortic stenosis
- pul stenosis
76
Assuming they meet indications, which procedures need Abx prophylaxis?
- All dental procedure w/ gingival tissue manipulation
- resp procedure if invasive (incision, bx of mucosa like T&A)
Do not need prophylaxis IF: routine anesthetic injection through noninflected tissue, dental XR, bleeding from mucosa
77
Which Abx do you give if prophylactic Abx for IE indicated ?
- single dose (before or up to 2h after procedure)
- Amoxicillin or Ampicillin
- If allergic = Cephalexin, Clindamycin, Azithro or Clarithro
78
Are GI/GU tract prophylaxis required patients indicated with IE prophylaxis?
No
| - no longer required
79
what are the most common ppt of invasive group A streptococcal dx?
- necrotizing fasciitis
- myositis
- bacteria with no septic focus
- pneumonia
80
RF of invasive GAS in kids?
VARICELLA
Adult RF include: HIV infection, CA, heart dx, DM, lung dx, alcohol abuse, IVDU, preg related RF
81
T or F: Is invasive GAS a reportable dx?
YES
82
What is a confirmed case of invasive GAS?
Lab confirmation +/- clinical evidence
83
Clinical Dx of streptococcal toxic shock syndrome?
Low BP
min. 2 signs of:
- renal impairment
- coagulopathy
- liver f'n abN
- ARDS
- generalized erythematous macular rash
84
How do you define a close contact in invasive group A streptococcal disease?
- only offer if exposed during 7d before onset to 24h after starting ABX
- household- spent min. 4h per day on avg in last 7d or 20h per week
- non household who share same bed/sexual relation
- direct MM contact with oral or nasal secretions
- IVDU who share needle
85
How do you manage severe GAS?
- supportive: fluids, lyte
- Abx: penicillin
- minimize/neutralize toxin= clindamycin
- IVIG may be considered in strep TSS or severe toxin-mediated dx without shock
86
What do you use for chemoprophylaxis for invasive GAS?
- first generation cephalosporin (e.g. cephalexin)
- alternative: 2nd or 3rd gen (cefuroxime, cefixime)
- if beta allergy: macrolide (erythro, clarithro, azithro)
87
Is invasive GAS chemoprophylaxis recommended for kids + staff in institutional child care centres or preschool?
NO
| - generally not recommended
88
Should you Cx for contacts receiving ABx chemoprophylaxis?
Routine culture NOT required
89
When do you test HIV testing + viral load response w/ tx?
2-4 weeks post-tx start
90
Describe HIV related symptoms.
- recurrent URTI, sinusitis, AOM
- parotitis
- lymphadenopathy
- HSM
- dermatitis
BW: anemia, neutropenia, thrombocytopenia
Dx: meningitis, pneumonia, sepsis
CMV before 1 month
Prolonged thrush (>2 mo. in kids min. 6 mo.)
Recurrent HSV stomatitis (>2 episodes w/in 1 yr)
91
List some opportunistic infections in HIV kids?
- Recurrent multiple bacterial infections
- Candidiasis of bronchi, trachea, lungs
- CMV dx (other than HSM or nodes) w/ age > 1 mo.
- Pneumocystis jirovecii pneumonia
- Kaposi sarcoma
- Lymphoma, Burkitt or immuoblastic
- Invasive cervical cancer
92
How do you prevent opportunistic infections in kids with HIV children?
1. review vaccinations
2. routine ABX for prevention NOT recommended
3. IVIG if hypogammaglobulinemia (IgG < 400 mg/dL)
HIV infected kids whose immune sys not seriously compromised + no neutropenia = tx the same as other kids
93
What are the current recommendations for the pneumococcal conjugate vaccine?
1. PCV-13 as per routine immunization schedule
2. Four dose routine
3. All healthy 12-35 mo. get one dose after 2
4. If high risk of invasive: get pneumo 13 and pneumo-23 polysacch. pneumococcal vac once > 2 y.o.
94
List RF for community-associated MRSA:
- overcrowding
- frequent/close skin-to-skin contact btwn people
- poor hygiene
- sharing possible contaminated items
- activities that abrade or compromise skin surface (opening of skins, cuts, abrasions)
- challenges in personal cleanliness and hygiene
- limited access to HC
Population RF: aboriginal, athlete, daycare attendees, military recruit, IVDU
95
How do you manage infected scratches or impetigo due to MRSA?
- wet warm compresses
- washing w/ warm water + soap
- consider topical Abx
If abscess: incision and drainage
96
List ways to prevent MRSA infections?
- reduce unnecessary Abx use
- hand hygiene
- encourage flu shot
- monitor resistance and monitor patterns
- build awareness among HC staff
- educate families on how to manage (keep wounds covered w/ clean bandages, dispose used dressing, hand hygiene, bathe regularly, avoid sharing items)
- engage in community level intervention
97
Management of skin abscess while Cx pending:
- skin abscess
- child < 1 mo
- 1-3 mo.
- 3 mon older
abscess: IV
child < 1 mo: IV (usually vanco). PO clinda if abscess small
1-3 mo. w/ no other systemic features: TMP/SMX
3 mon +: observe after I&D
3 mo. + w/ cellulitis but only low gr. fever: TMP-SMX
98
What is amphotericin B products?
- broad spectrum anti fungal agent
- IV
- AE: nephrotoxicity, infusion related AE (fevers, chills, rigors)
99
What are indications for tuberculin skin test in children?
1. Contacts of known cases of active TB
2. Pt w/ suspected active TB dx
3. Pt w/ known RF for progression of infection to dx
4. Kids travel or residing x 3 mo. or longer in area of high incidence of TB
5. Kids who arrived from nation w/ high TB within previous 2 years
100
List RF of developing active TB among persons infected w/ mycobacterium TB:
- AIDS
- HIV
- transplant (related to immunosuppressive tx)
- silicosis
- chronic RF requiring hemodialysis
- carcinoma of head + neck
- recent TB (2 yr or less)
- abnormal CXR -fibronodular dx
101
Describe TB testing:
- TST
- IGRA
TST: poor sensitivity (false neg. in very young, infant < 3 mo, immunocompromised)
IGRA: Interferon-gamma-released assay
- measure in vitro production of interferon gamma by sensitized lymphocytes in response to Tyco Tuberculosis specific antigens
- more specific than TST
- AAP: can't use routine if < 5 y.o. or immunocompromised b/c lack of data about utility in this group
Combo of these two tests increase sensitivity for latent and active TB in situation where TST unreliable (very young or immunocompromised)
102
T or F: you can use IGRA in isolation to dx TB?
False.
- CANNOT
- (-) IGRA or TST does not R/O in all ages
103
T or F: routine mass screening for ALL immigrant kids for latent TB via TST or IGRA.
NO- target screen for RF for reactivation of LTBI.
104
When should you use IGRA in TB testing?
- use to confirm (+) TST if low pre-test (suspected false + TST)
- use w/ TST to dx Latent TB infection in immunocompromised (can have initial neg TST so do IGRA if still concerned)
