Micro Phase C 2nd half
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. What would you like to do?
What kind of reduction in diseases have we seen with our regular childhood diseases.
What are the live vaccines we give?
- Measles, Mumps, Rubella, Rotavirus, Varicella
Difference b/n conjugate and non-conjugate vaccines. How can you tell from the name? How does this affect vaccine timing?
-Non-conjugate only have polysaccharide. They have a P in the middle (Pneu-P-23). They need a more advanced immune system, so they only work after patient in 2 years old. Not as long lasting
-Conjugate has polysaccharide attached to protein, which induces higher T-dependent Ab response. Therefore these can be used all the way down to infancy and last longer (better memory). They have a C in the middle of the name (Pneu-C-13)
How do you administer the rotavirus?
Describe what the following are:
- -DTaP-IPV-Hib: Diptheria, Tetanus, acellular Pertussis, Inactivated polio, H. influenza b
- -Tdap: Tetanus primarily, smaller amounts of diptheria and pertussis
- -Measles Mumps Rubella (+/-Varicella)
- -Conjugated meningitis C
Which vaccines do you get at
-4 years (preschool)
-12 years (Gr. 6)
-14 years (Gr. 8)
time range for something to be considered as an adverse event following immunization (AEFI). List 2 common and 4 less common AEFI's.
- -0-7 days after inactivated vaccine
- -0-6 weeks after live vaccines
common: Local reactions (swelling), systemic (fever, headache, anorexia, etc)
Less common: febrile seizures, non-specific rashes, excessive crying (3+ hours), hypotonic-hyporesponsive state (zombie-like)
Rare, but serious AEFI's
- -Guillain-Barre Syndrome
True contraindications to vaccines (5)
- 1) allergy (anaphylaxis) to a component (e.g. eggs)
- 2) Immunodeficient patient and live vaccine
- 3) Pregnancy (defer MMR only)
- 4) Recent IG admin (defer MMR only)
- 5) mod/severe illness +/- fever (defer until it has resolved)
What do we worry about when only part a portion of the population is getting vaccinated?
It actually pushes the disease later into peoples lives (e.g. varicella) because there is less exposure
What are the big reasons people object to vaccines?
- 1) Child experienced mild AEFI (70%)
- 2) Parents had negative info from friends, family, or internet and are unsure about vaccines (25%)
- 3) Patients who strenuously object, armed with "information" (5%)
What are 5 false (NOT) contraindications for vaccination?
- -Low grade fever
- -Hx or FHx of seizures
- -FHx of allergies
- -Previous mild AEFI (does not mean increased risk of one in subsequent vaccinations)
What do you say when someone says that in a recent outbreak, more of the kids who were sick were vaccinated
tell them this is a quirk of math and is only because there have been so many kids vaccinated
Has Thermosol (what Jenny says causes autism) ever been used in canada?
NO! And even after it was removed in the states rates continued to rise
list 6 steps that parents can take to protect their unvaccinated child from disease
- 1) be knowledgable about each Vaccine preventable disease (VPD)
- 2) know when an exposure has occurred
- 3) access physician to manage exposure
- 4) allow Ig (passive) or vaccine (active) to prevent VPD
- 5) keep kid out of school during outbreaks
- 6) advise grown up kid that they are unprotected (they may want to catch up)
What is the only vaccine that does not provide herd immunity?
tetanus -> cannot decrease circulation because it comes from a wound or dog bite.
An example of a vaccine that needs high coverage for herd immunity, low coverage.
- high coverage needed: Measles (92-95% immunization rates)
- Low coverage needed: influenza (50-80%)
Why should you report disease? (6 reasons)
- 1) It's the law!
- 2) Ensure the case is being managed properly (e.g. contact precautions)
- 3) Identify the source of infection to prevent further transmission
- 4) Identify others who were exposed and may start spreading infection
- 5) To monitor communicable diseases in our community
- 6) Identify new, emerging infectious diseases
Describe public health programs that address communicable diseases (7)
- -Positive Living Program (HIV/HCV)
- -Infection prevention and control
- -Sexual health clinics
- -Street health (reduce blood-borne pathogens)
- -TB Prevention and Control
- -Travel medicine
- -Vaccine Preventable Diseases to vaccinate
Compare non-conjugate and conjugate proteins (4 contrasting points)
Difference between active and passive immunization
-active: vaccines, relies on one's own immune system to remember and defend against pathogens
-Passive: IGs, relies on others' immune armament to defend one against infection
Which diseases can we immunize for after exposure (5)? Why?
Measles, varicella, Hep A, Hep B, Rabies
-works because the immune response to the vaccine is rapid and it these viruses have relatively long incubation periods
Indications for Standard IG (SIG) and IVIG
SIG - all antibodies in a donor; pre or post exposure prophylaxis against hep A and measles
IVIG - specific abs against a certain disease or depleted ab in people with AI disease. Also against certain diseases (see other flashcard)
Which of the following can be used for pre-exposure preventions, post-exposure prevention, and/or treatment:
Standard Immunoglobulin; IVIG; Tetanus IG; Equine Diptheria antiToxin; Equine Botulism AntiToxin; Hep B IG; Vari ZIG; Rabies IG; Palivizumab (RSV)
When can you NOT give a vaccine and an IG at the same time?
When you are giving a live vaccine, Also Hep A
When can you give live vaccines to an immunocompromised patient?
- Can give MMR when:
- -Isolated Ig deficiency
- -Neutropenic patient
- -Well controlled HIV
- -asplenic patients
- Varicella can be given when
- -ALL is well controlled and chemo can be witheld
- -give Varizig if exposed
What are asplenic patients especially at risk for?
- encapsulated bacteria like:
- -S. pneumonae
giving abx when there is NO infection present, but there is a high probability of future exposure to conditions that would put people at risk.
For example, penicillin post splenectomy
the 3 basic tenets of abx prophylaxis
- 1) potential infection severity greater than side effects of abx
- 2) abx should be given for the shortest time possible to prevent target infection
- 3) abx should be given before period of risk or as soon after exposure as possible
Describe infection suppression
giving abx to when infection is present but with the goal of disease amelioration, not eradication.
Describe the abx prophylaxis for the following clean procedures: cardiac, ortho, neuro, vascular
Worried about staph/strep wound infections
Therefore, cefazolin vs vancomycin
Describe the abx prophylaxis for the following clean-contaminated procedures: H&N, upper GI, uterus stuff
again, worried about staph/strep: cefazolin or clindamycin
DEscribe the surgical prophylaxis for the following clean-contaminated procedures: High risk GU surgery
worried about staph-strep and endogenous flora
Surg prohylaxis for clean-contaminated procedures: colorectal surgery or appendectomy
endogenous flora + staph/strep
cefazolin with metronidazole
Surgical prophylaxis for the following DIRTY procedures: ruptured viscous
mixed anaerobes and aerobes
clindamycin+gentamycin or monotherapy with a carbapenem or pip-tazo
3 abx you can give to meningitis contacts
want to cover meningococcus and pneumococcal
Prophylaxis for animal bite wounds
Cover for staph, strep, pastuerella
prophylaxis for necrotizing pancreatitis
mixed flora infection inevitable
Prophylaxis for spontaneous bacterial peritonitis (worry about this in people with liver cirrhosis)
What is the 'window period' after a needle stick?
the time between when a person becomes infected and tests show that they are infected
What steps do you take when exposed to blood and body fluids
- 1) immediate care: wash wounds and skin with soap and water, flush mucous membranes
- 2) inform resident or attending
- 3) Call incident line for the health region you are in
- 4) Go to emerg
- 5) assess: exposure, source, and exposed (you)
Describe the stuff you would want to know to assess a blood and body exposure
- 1) exposure itself: date and time, type of exposure, type and amount of fluid exposed
- 2) assessment of source: known infection, hx of risk taking behaviour, current sx, PMHx
- 3) assessment of the exposed (you): immunizations, risk taking behaviours, meds, PMHx
Describe the window period for HIV, HBV, and HCV. 4 things you must do until the window period is over
HIV and HBV: negative test at 3 months means not infected
HCV: negative test at 6 months means not infected
- Until it is ruled out:
- 1) condoms or abstinence
- 2) no bodily fluid donations
- 3) no breastfeeding
- 4) pregnancy precautions
What is the management plan for someone you think may get infected with HIV, HBV, or HCV due to a body fluid contact
Get baseline serology of the exposed and the source
HIV: HIV post-exposure prophylaxis (PEP), need ID consult to get the full 28 days. ED MD can start
HBV: either HBIG or HBV vaccine. ED MD's call.
HCV: nothing available, hope you didn't get it.
Risk of transmission in an HIV+ source in a:
-percutaneous needle stick
- Blood transfusion: 90%
- Percu needle stick: 0.3%
- mucocutaneous exposure: 0.1%
Would you give HIV PEP in the following source conditions?
-unknown/unavail for testing
- +ve: offer PEP
- -ve: consider window period and source risk factors
- unknown: consider type of exposure and source risk factors
When do you have to give HIV PEP by
in the first 72 hours, preferrably in the first 2 hours
Risk of HBV transmission with a transcutaneous needle stick
Efficacy of pre and post exposure measures to prevent HBV infection
- Pre: HBV vaccine (90-95% effective)
- post: HBIG (within 48/24) 70-75%; vaccine (3 doses) 70-75%; both combined (75-95%)
Need to make sure they have protective levels of HBsAb from vaccine. Give HBIG if there is a HIGH risk they will contract disease (e.g. HBV +ve carrier)
Risk of HCV transmission with an HCV+ source and a percutaneous needle stick
How long does it take to get back a stat HIV test? Window period for this test?
2 hours, window period is 2 weeks
How does Dm predispose you to infection? (3)
- 1) Leukocyte function: defects in chemotaxis, phagocytosis and intracellular killing
- 2) hyperglycemia may reduce complement levels
- 3) Organism factors: C. albicans adhesion proteins are induced by glucose
RF's for diabetic foot ulceration and infections
- 1) peripheral neuropathy (motor, sensory, and autonomic)
- 2) arterial insuff
- 3) foot deformities or limited joint mobility
- 4) inappropriate footwear
How do you know if an infection is present in a diabetic foot? (5)
- 2+ of the following:
- -local swelling or induration
- -local tenderness or pain
- -local warmth
- -purulent discharge
What is the progression of pathogens in a diabetic foot infection?
gram +ve -> gram -ve -> anaerobes
What should you NOT do with regards to culturing a specimen from a diabetic foot? (3)
- 1) dont culture a clinically uninfected lesion
- 2) dont obtain a specimen without first cleaning and debriding a wound
- 3) Don't get a culture by swabbing! Use a sterile needle or curette
What test should you do if you suspect that an infected ulcer has spread to become osteomyelitis?
Do a probe to bone test.
You should suspect this in any large ulcer, or an ulcer that overlies a bony prominence
Abx treatment for diabetic foot ulcers
- mild: amox-clav
- moderate (MSSA): ampcillin-sublactam
- Moderate (psuedomonas): pip-tazo
- severe (MRSA): vanco
How can you prevent diabetic foot ulcers? (4)
- -preventative foot care (podiatrist)
- -proper footwear
- -daily visual self-foot exam
- -physician screening (monofilament test)
Major resp infection in diabetics
mucormycosis (fungal infection of resp tract)
What are your chances of surviving mucormycosis (zygomycosis). Fungal infection in diabetics. 5 scenarios
- Sinus/cutaneous: about 90%
- Lungs: 24%
- Disemminated: 4%
- GI: 15%
What usually causes malignant otitis externa (diabetic ear infection). How to diagnose and treat
Dx: culture, elevated ESR but normal WBC, CT for bone involvement
4 signs you see in sepsis
- tachypnea or need mechanical ventilation
- temp >38.5 OR <36
- Leukocytosis or leukopenia OR >10% bands and other immature forms
Most common bacterial (3) and viral (2) causes of neonatal sepsis, important to remember what when thinking of neonatal sepsis
Bacterial: E. Coli > GBS > Listeria
viral: HSV > enteroviruses
DONT FORGET TO THINK ABOUT INBORN ERRORS OF METABOLISM!!!
Timing of early and late onset newborn sepsis, difference in etiology, bugs usually responsible
- -Sx < 7/7 days of age
- -usually infected maternal genital tract
- -Sx at > 7/7 days of age to 3/13 of age
- -usually non-maternal genital source
- -E. coli>GBS>Listeria>HSV
Empiric tmt for bacterial (2 regimins) and viral neonatal sepsis
Bacterial: ampicillin+Cefotaxime OR Ampicillin+Gentamicin
Viral: start empiric IV acyclovir
How long do you need to give antimicrobials in bacteremia and meningitis
bacteremia: 10-14 days for the three bacteria, 14 days of acyclovir for HSV
meningitis: abx for 2/52 in GBS and Listeria; 3/52 in E coli and other gram negatives; 3/52 for HSV
Steps for prevention of early onset GBS sepsis in neonates. when is it indicated? (4)
give IV pen G Q4h from start of labor until baby is delivered. maximal effectiveness if 2+ doses are given.
- indicated when:
- 1) previous infant with GBS
- 2) GBS bacturia in current preg
- 3) +ve GBS swab in this pregnancy (unless she is getting a C/S before ROM)
- 4) unknown GBS status and ANY of the following:
- -Delivery <37/52
- -amniotic rupture for >18 hours
- -intrapartum temp > 38 C
What should you think if they see a gram +ve bacilli
List 5 common errors in ID
- 1) Over-diagnosing UTI
- 2) Under treating S. Aureus bacteremia
- 3) Over-treating aspiration pneumonia
- 4) Slow treatment of meningitis
- 5) Under and over treatment of soft tissue infections
What are the 2 most common urine isolates. What should you think if you see S. aureus in the urine?
E. Coli (85%) and S. saprophyticus (15%)
Think bacteremia if you see S. aureus
How do you treat S. aureus bacteremia?
2/52 of IV cefazolin
Why would you want to use Cloxacillin (keflex) over vancomycin? (2)
Cloxacillin sterilizes the blood faster
vanco is an independent RF for recurrence
2 important points in meningitis treatment
- 1) abx should be given within 20 minutes regardless of CT or LP plans
- 2) Blood cultures should be drawn before abx are given
What should you know about steroids (dex) and meningitis? (3)
- 1) only use if S. pneumonae
- 2) NEED to give before abx for benefit
- 3) will have to give vanco intrathecally if dex is on board because it screws with CSF uptake from blood stream
What should you use for an anaerobic (aspiration) pneumonia?
Pip-tazo, not clindamycin
clinda can cause C. diff overgrowth and has no gram negative coverage
What should you keep in mind about erysipilis and septic bursitis? What if there is no improvement after 5-7 days?
- -They get worse before they get better. Stay the course on the clindamycin that you initially prescribe
- -If n improvement, think of an underlying osteo or septic arthritis.
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