Download HIV Infection in Children and Adolescents

Infectious Disease Part 1
 I’m going to Jazz Fest this weekend!
 A. True
 B. False
 Epidemiology, diagnosis, prevention
and treatment of HIV/AIDS has changed
dramatically over the past 25 years
 Rates of new infections in infants has
plummeted
 Effective screening and prevention strategies
 Children born with HIV are surviving into young
adulthood
 Adolescents acquiring HIV at an alarming rate
 Worldwide:
 33.2 million people living with HIV
 2.5 million are children younger than 15
 In 2007, 2.1 million AIDS deaths occurred
 330,000 were children
 In the US:
 In 2006, 2181 cases of AIDS were reported among
children and adolescents through age 24
 Only 38 cases were in children <13yo
 Pediatric burden of infection now rests in the adolescent
population!
 Lentivirus in the retrovirus
Family
 Infection occurs when the
virus enters the body and
binds to the CD4 receptors
on host T lymphocytes
 Binding fusion of HIV envelope with lymphocyte
cell membrane viral RNA and enzymes (RT) enter
host cell viral RNA reverse transcribed into DNA
viral DNA enters host cell nucleus integration into
host cell genome activation of host cell virion
production and release spread to other cells
 This viremic phase preceeds antibody response and is
the period of HIGHESET INFECTIVITY!!
 A 17 yo honor student comes to your office with a
maculopapular rash on his face, trunk, palms, and soles.
He also c/o a sore throat and fever. He states that he has
been sexually active with women for 2 years and men for 6
months. He does not use condoms with either. He denies
any sick contacts or substance abuse, including injection
drug use. You are strongly considering early HIV infection
in this patient. The most accurate test to confirm the
diagnosis at this time would be:





A. Western Blot
B. EIA
C. HIV RNA PCR
D. Rapid test- blood
E. Rapid test- saliva
 Viremic phase corresponds with the acute retroviral
syndrome:
 Fever, LAD, rash, myalgias/ arthralgias, HA, diarrhea,
oral ulcers, leukopenia/ thrombocytopenia,
transaminitis
 During this “window period” between host cell
infection and antibody response:
 HIV antibody test negative
 HIV RNA positive
 Seroconversion occurs b/t 10-14 days and 6 months
after infection
 All of the following are effective ways to decrease the
risk of transmission of the HIV virus from mother to
child EXCEPT:
 A. C/S before the onset of labor in persistently viremic




women
B. ART during pregnancy
C. Neonatal AZT
D. Intrapartum AZT
E. Breastfeeding the infant
 *Transmission by two principal modes
 *Mother-to-child
 Antepartum: transplacental transfer
 Intrapartum: exposure to maternal blood, amniotic fluid or
cervicovaginal secretions during delivery
 Postpartum: Breastfeeding
 Behavioral
 Unprotected sex
 Traumatic sex
 Active genital ulcer disease
 Douching before sex
 Injection drug use
 So what do we do?!
 *Mother-to-child
 ART
 Intrapartum zidovudine
 Neonatal zidovudine
 Safe replacement feeding
 Elective C/S before the onset of labor in women with
persistent viremia
 Behavioral
 *COUNSEL, COUNSEL, COUNSEL!!
 Abstinence
 Consistent and correct use of condoms
 A 20 mo F presents to your clinic, because her mother
was recently diagnosed with HIV. Mom did not
receive PNC during her pregnancy and is unsure if any
HIV testing was performed at delivery. She is very
concerned and would like the child tested. Of the
following, the most appropriate test to order (on the
child) would be:
 A. HIV DNA PCR
 B. HIV RNA PCR
 C. HIV antibody titer
 D. No testing is required in this patient
 *Remember that all infants
Born to HIV-positive mothers
Will test positive for the HIV
Antibody due to maternal
Transfer of Ig
 A 4 mo M presents to your office for a WCC. Past medical
history includes HIV exposure in utero. Mom was treated with
ART through the pregnancy and AZT at delivery. The child also
received AZT and is formula fed. At his 2 week visit and 2 month
visits, HIV DNA PCRs obtained were negative. Of the following,
you are most likely to counsel Mom that:
 A. HIV is definitively excluded in her son
 B. An HIV antibody titer should be performed at this visit and if
negative, HIV is definitively excluded
 C. An HIV DNA PCR should be performed at this visit and if
negative, HIV is definitively excluded
 D. An HIV antibody titer should be performed at 18 mos to
definitively exclude HIV
 E. Even though the past 2 tests have been negative, there is still a
high likelihood her son is infected with HIV
 HIV-exposed infants
 HIV DNA/RNA PCR at 2 weeks, 2 months, and 4
months
 Definitive exclusion of infection
 Negative results for two virologic tests
 First at age 1 month or older
 Second at 4 months of age or older
 Confirmatory antibody test at 12-18 mos optional
 HIV-positive mothers and BF
 Testing should continue throughout period of BF and 6
months after
 Children and adolescents
 All children of HIV-positive mothers should be screened
 Adolescents should be screened as a part of routine
health care
 Age 13 and older
 High-risk adolescents should be screened yearly!
 First step: referral to an HIV specialist!
 Antiretroviral therapy
 Goals: (maximize quality and longevity of life)
 Complete suppression of viral replication
 Preservation or restoration of immunologic function
 Prevention of or improvement in clinical disease
 Antiretrovirals
 What to start?
 ART should be planned and monitored in collaboration with
an HIV specialist
 Triple-drug combination ART
 3 drugs from 2 categories: one non-nucleoside reverse
transcriptase inhibitor (NNRTI) OR protease inhibitor PLUS two
nucleoside or nucleotide reverse transcriptase inhibitors
 Viral load to monitor adherence
 Non-detectable viral load within 3-6 months
 Failure to achieve this goal strongly suggests suboptimal
adherence rather than resistance
 Prevention of Opportunistic Infections
 Pneumocystis jiroveci pneumonia (PCP)
 Most common OI
 Bactrim prophylaxis for:
 All HIV-exposed infants until infection is reasonably excluded
 All HIV-infected infants <12mos
 All HIV-infected children and adolescents with severe immune
suppression
 CD4 percentage< 15% or CD4 count< 200 cells/mm3
 Mycobacterium avium complex
 Azithromycin prophylaxis for:
 Age≥ 6yo with CD4 count <50 cells/mm3
 Ages 2-5yo with CD4 count <75 cells/mm3
 Ages 1-2 yo with CD4 count <500 cells/mm3
 Age< 1yo with CD4 count <750 cells/mm3
 Prevention of opportunistic infections
 Toxoplasmosis
 Less common in children
 Bactrim prophylaxis in:
 Toxoplasma IgG positive individuals with severe
immunosuppression (CD4%< 15% or CD4 count < 100
cells/mm3)
 Immunization schedule same as for healthy children
with a few small exceptions:
 CD4 percentage< 15% or CD4 count< 200 cells/mm3=
NO VARICELLA OR MMR
 Only killed, injectible formulations of the influenza
vaccine
 Coping with the diagnosis and prognosis
 Offer hope and reassurance about the
availability of effective treatment
 *Disclosure of HIV Infection status
 Planned disclosure to family and friends can increase
support for the HIV-positive person
 Sexual partners can make informed decisions about how
to protect themselves
 Adherence to Care and Treatment
 Requires 90-100% adherence to drug regimens to avoid
the development of resistance
 School and sports participation
 HIV-infected children and adolescents can participate
fully in the educational and extracurricular activities at
school
 *No obligation to notify school personnel of student’s
HIV infection status
 Some experts advise athletes with a detectable viral load
to avoid high-contact sports (boxing, wrestling)
 Transition to adult health care
 Complete and coherent medical record
 Advance care planning and palliative care
 Which of the following statements regarding EBV
epidemiology is TRUE?
 A. Immunocompetent persons who have been infected
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


shed more virus than immunosuppressed persons
B. Infectious mononucleosis caused by EBV occurs most
commonly in infants and toddlers
C. Most people who become infected with EBV are
symptomatic for life
D. The risk of transmission is highest from persons who
have had recent infections
E. The virus is only transmitted through oral secretions
 EBV results in spectrum of diseases
 Infectious Mononucleosis
 Aggressive non-malignant proliferations
 Hemophagocytic syndrome
 Post-transplant lymphoproliferative syndrome (PTLS)
 Lymphoid interstitial pneumonitis
 Oral hairy leukoplakia
 Human malignancies
 Nasopharyngeal carcinoma
 Burkitt lymphoma
 Hodgkin disease
 Leiomyosarcoma
 *Host immune response plays a key role in
determining clinical manifestations
 *Know the epidemiology of EBV
 *Mode of transmission: oral contact
with saliva
 Handling of toys
 Kissing among adolescents
 Also found in genital secretions
 *Incubation period: 30 to 50 days
 Onset of illness is insidious over 1 to 2
weeks
 *Period of communicability
 Shed at high concentration for 6
months following acute infection, and
then low concentration for life
Herpesvirus
Type 1 and Type 2
 Infection of B cells in the lymphoid-rich areas of the
oropharynx
 Dissemination throughout the lymphoreticular system
including the liver and spleen
 Like all herpesviruses, EBV establishes persistent
latent infection for the life of the host
 Memory B-cells
 Reactivation is asymptomatic (second attacks have not
been documented)
 *Classic infectious
mononucleosis
 Fever
 Pharyngitis
 Adenopathy (90%)
 Peaks in 1st week
 Fatigue
 Headache
 Nausea, vomiting, and
anorexia are frequent
 Reflect hepatitis
 A 15-year-old male comes to the ER because he has had a
sore throat and fever for the past week. On physical exam
he has cervical lymphadenopathy, his spleen edge is palable
3cm below the costal margin, and he has a generalized
maculopapular rash with several scratch marks. Upon
further questioning, he tells you that his PCP gave him
some antibiotics a few days ago but he can’t remember the
name.
 The MOST likely medication to cause the patient’s new
symptom is:





A. Amoxicillin
B. Cefdinir
C. Ampicillin
D. Bactrim
E. Ciprofloxacin
 Splenomegaly in 50 to 60%
 Can cause upper quadrant discomfort
 2 to 3 cm below the costal margin
 *Know the significance of rash following
ampicillin in patients with mono
 3 to 15% of all patients
 Maculopapular
 Following administration of ampicillin or
amoxicillin in 70 to 90%
 Immune mediated
 Discontinue antibiotic
 Gianotti-Crosti syndrome
 Papular acrodermatitis on cheeks, extremities, and
buttocks
 Can last for 15 to 50 days
 *Know the range of clinical manifestations of EBV
infection in children of various ages
 Infection in young children is usually asymptomatic
 Or produces symptoms indistinguishable from other febrile
infections
 Infectious mononucleosis is rarely recognizable in children
under 4
 Among adolescents the clinical syndrome is classic
 Infectious mononucleosis is rare in adults older than 30
to 40, when most people are already infected with EBV
 Heme
 Total WBC 12,000 to 18,000
 Lymphocytosis (>60%)
 Atypical lymphocytes (20-40%)
 Thrombocytopenia (usually self-limited)
 Liver function tests
 Elevated aminotransferases in 50% of patients
 Asymptomatic without jaundice
 You are evaluating a 3-year-old girl who has fever for 10
days, pharyngitis, and cervical lymphadenopathy. You
suspect she has an infection caused by EBV. Which of
the following tests is MOST likely to confirm your
diagnosis?
 A. CBC
 B. Heterophile antibody
 C. IgM early antigen test
 D. IgM viral capsid antigen test
 E. Viral culture
 Heterophile antibodies
 Monospot is a latex agglutination assay using horse
erythrocytes
 Stays positive for 2 years after infection
 Detects antibody in 90% of cases
 Does not have same specificity and sensitivity in young
children
 They do not produce antibodies
 80% by age 4
 Diagnostic choice
 If + monospot and compatible syndrome, no further testing
 If EBV infection still suspected, test for specific antibodies
 *Distinguish (by serologic tests) between acute and
past EBV infections
 EBV-specific antibodies
 Viral capsid antigen (VCA)
 IgM and IgG are present at onset
 IgM wanes over 3 months
 Confirms the diagnosis of acute EBV infection
 IgG persists for life
 Nuclear antigen (EBNA)
 IgG to EBNA begins to appear 6 to 12 weeks after onset of
symptoms
 Early antigen
 IgG to EA present at onset of illness
 You are seeing a long-time patient of yours who is a 16 year-
old male with sore throat, fever, and fatigue for the past
week. He is a varsity football player, but has felt too tired to
practice this week. On physical exam he has mild
hepatosplenomegaly. You do a Monospot in the office and
it is positive.
 Of the following, the BEST way to manage this patient is:
 A. Start a course of corticosteroids
 B. Supportive care and advise him to avoid contact sports for 3
to 4 weeks and until his splenomegaly has resolved
 C. Supportive care and advise him to avoid contact sports for
6 months
 D. Supportive care and he can return to practice immediately
 E. A 7 day course of Acycolvir
 *Plan the management of a patient with
uncomplicated infectious mononucleosis
 Observation and symptomatic treatment
 Acetaminophen, NSAIDS, bed rest
 Return to sports
 Want to avoid splenic rupture
 Most likely to occur within 2 to 21 days after onset of
symptoms
 Avoid sports in initial 2 to 3 weeks or while splenomegaly is
present
 All of the following are indications for corticosteroid
use in the treatment of EBV infection EXCEPT:
 A. Seizures
 B. Worsening fatigue
 C. Upper airway obstruction
 D. Hemolytic anemia
 E. Thrombocytopenia with bleeding
 *Know the indications for the use of corticosteroids in
treatment of infectious mononucleosis
 Upper airway obstruction
 Thrombocytopenia complicated by bleeding
 Autoimmune hemolytic anemia
 Seizures
 Meningitis
 Prednisone 1 mg/kg/day x 7 days then taper x 7 days
 Should not be used on routine basis due to unknown
hazards of immunosuppression for a virus that has
oncogenic complications
 Uncommon in healthy persons
 Splenic rupture (<0.5% in adults)
 Tonsillar swelling that causes airway obstruction
 Drooling, stridor, difficulty breathing
 Indication for hospitalization
 IV hydration, humidified air, steroids
 Headache (50%)
 Seizures and ataxia (1 to 5%)
 Meningitis, facial nerve palsy, transverse myelitis, GBS
 “Alice-in-Wonderland synrome” (metamorphopsia)
 Hemolytic anemia
 Aplastic anemia
 Myocarditis
 Interstitial pneumonia
 Pancreatitis
 Parotitis
 Orchitis
 HLH
 *Understand that host factors are important in the
outcome of EBV infection
 Immune response is essential for controlling EBV
replication during primary infection as well as latent
infection
 Immunocompromised people are at increased risk for
EBV-associated malignancies
 HIV, organ transplant anti-immune therapy, congenital
immunodeficiencies
 Excellent with symptoms typically lasting 2 to 4 weeks
 Some have debilatating fatigue and malaise that can wax
and wane for 6 months
 Second attacks are not documented
 One of your patients recently had a positive TST. He
was subsequently sent for a CXR which was normal.
He is otherwise well and has no known TB contacts or
travel. By definition, this patient has:
 A. Active TB disease
 B. No TB disease
 C. Latent TB infection (LTBI)
 D. Had the BCG vaccine
 TB exposure: persons exposed to someone who has
TB but whose status is not yet clear
 *Latent TB (LTBI): positive TST without symptoms,
physical findings, or radiologic anomalies c/w TB
 *TB disease: positive TST with clinical or radiologic
manifestations of TB disease
 Multidrug-resistant (MDR) TB: TB resistant to 2
first-line TB meds (INH and rifampin)
 One third of the global population has LTBI (!)
 Of all persons with untreated LTBI, 5-10% will
ultimately develop TB disease
 90% of the burden of TB disease is in the developing
world
 In the US:
 13,000 new cases of TB disease in 2007
 820 children <15yo
 Control of TB in children has often been neglected b/c
children are ineffective transmitters of the bacillus
 However, much of the morbidity and mortality occurs
during childhood!
 *Specific groups with high LTBI and disease
rates include:
 Immigrants
 International adoptees
 Travelers to countries with endemic infection
 Homeless
 Residents of corrections facilities
 Refugees from high prevalence regions
 Increased risk of progression to TB disease:
 HIV co-infection (and other immunocompromising
conditions)
 Recent LTBI
 IV drug use
 Medical conditions
 DM
 Renal failure
TB is transmitted by
expulsion of nasal droplets
from an infected human
individual to an uninfected
one.
Nasal droplets, which contain tubercle
bacilli and are no larger than 2 um in
diameter, are able to penetrate to
the alveoli of the respiratory tract
of the uninfected individual.
 Includes intrathoracic LAD and parenchymal
disease
 Most common site of TB infection
 Incubation period 4-12 mos
 Three time frames for pulmonary involvement
with TB
 Primary parenchymal
 Progressive primary
 Reactivation disease
 One of the most common manifestations of
disease
 Infants and adolescents more likely to be
symptomatic than 5-10 yo children
 Become symptomatic when enlarging LN
compress adjacent airways collapse
consolidation pattern
 Radiographic features: hilar/mediastinal
LAD
Right –sided hilar LAD, narrowing of the right mainstem bronchus and
collapse-consolidation of the RLL
*Courtesy of UTD*
 Results from poor containment of the initial
infection
 Young infant or immunocompromised host
 LN erosion into the airways aspiration of
bacilli
 Development of adult-type cavitary disease
in children >10yo
 Associated with lung tissue destruction and
cavity formation
Progressive
Primary TB
in a toddler
Extensive hilar LAD
with collapseconsolidation in the
left lung and miliarylike presentation of
the right lung
*Courtesy of UTD*
 More common in adolescents, especially in areas
that have high rates of co-infection with HIV
 Reactivation disease more common in the apices of
lungs in adults (while primary disease occurs in the
bases)- NOT SO FOR CHILDREN
 Radiographic findings in reactivation overlap
considerably with the other two types of
pulmonary disease
Cavitary TB
Infiltrate and cavity along R horizontal fissure. Absent hilar LAD c/w
adult-type or reactivation TB in adolescents.
*Courtesy of UTD*
Symptom
Infants
Children
Adolescents
Fever
Common
Uncommon
Common
Night sweats
Rare
Rare
Uncommon
Cough
Common
Common
Common
Productive cough
Rare
Rare
Common
Hemoptysis
Never
Rare
Rare
Dyspnea
Common
Rare
Rare
Rales
Common
Uncommon
Rare
Wheezing
Common
Uncommon
Uncommon
Decreased BS
Common
Rare
Uncommon
Pulmonary
Common
Common
Common
Pulmonary+
Extrapulmonary
Common
Uncommon
Uncommon
Sign
Location of disease
 Most common extrapulmonary form of TB
 Hematogenous spread
 Incubation period: 4-12 mos
 LN involvement: anterior cervical > posterior
triangle > submandibular > supraclavicular
 Usually measure 2-4 cm and lack the classic
inflammatory findings of a pyogenic node
 May be overlying violaceous skin discoloration
 Untreated lymph nodes: may caseate, spread to
contiguous structures and lead to formation of
a sinus tract
 Surgical node excision not
curative but may be necessary
to establish the diagnosis
 Rare
 Develops in fewer than 2% of all cases of TB
 50% of all patients are younger than 2 years of age
 Incubation period: 2-6 mos
 (In parts of the developing world, TB is the
primary cause of subacute meningitis and
tuberculomas are common causes of mass
occupying CNS lesions)
 Tuberculomas
 Conglomerate caseous foci within the brain that develop
from deep seated tubercles acquired during recent or
remote hematogenous bacillemia
 Single rim enhancing lesions ranging from 1-5cm.
 TB Meningitis
 When a subependymal tubercle progresses and
ruptures into the subarachnoid space
 CSF : lymphocytes, low glucose, and high protein
 Highest morbidity and mortality rate
 Due to lymphohematogenous spread
 So, it can pretty much go ANYWHERE!
 Disease of the younger or
immunocompromised child
 Clinical presentation highly variable
 Acute disease: may be fulminant including
multiorgan system failure, septic shock, or ARDS
 Subacute or chronic disease: may present with
FTT without fever, fever of unknown origin, or
with dysfunction of one organ system
 Clinical manifestations
 Fever, constitutional symptoms
 HSM on exam
 CNS involvement in 20%
 A child with miliary TB should ALWAYS be
evaluated for meningitis
Extensive
miliary
pulmonary
lesions
*Courtesy of UTD*
 Skeletal disease
 Disease of the older child
 Spondylitis (Pott’s disease), arthritis,
osteomyelitis
 Pleural disease
 Also a disease of the older child
 Can occur in isolation from or concomitantly
with pulmonary disease
 Sx: CP, fever, dyspnea, cough, anorexia
 Congenital disease
 Occurs in infants born to mothers with
endometrial or disseminated TB
 Abdominal disease
 Renal disease
 Cutaneous disease
 Who to screen?
 Screening tests
 TST
 IGRAs
 Confirmatory tests
 Sequential sputum sampling
 Early AM gastric aspirates
 Specimens from an extrapulmonary site
 CT scan
 TST
 Comprises antigens not all specific to M.
tuberculosis
 Antigens trigger a delayed hypersensitivity
reaction to persons who have come in
contact with TB bacilli
 Becomes positive 3 weeks to 3 months after
infection and should remain positive for life
 One of the nurses on the 5th floor asks you to read her
TST that was placed ~60h ago. You appreciate an area
of induration approximately 11 mm in diameter. What
is the most appropriate next step for this nurse?
 A. INH for 9 mos
 B. CXR to screen for active TB disease
 C. Reassurance
 D. Repeat TST in 3 mos
 E. RIPE therapy for 6 mos
 You are doing a WCC on a 7 yo F who recently moved to the
US from India. Since there were 2 positive responses on
the TB risk factor-based questionnaire
(+lived out of the US, +BCG vaccine), you place a TST.
When the patient returns in 48h, the TST is positive with a
12 mm area of induration. The mother asks you what needs
to be done next. You respond:
 A. Nothing, the TST was likely positive because she received




the BCG vaccine
B. Induced sputum for AFB gram stain and culture
C. INH therapy
D. CXR
E. RIPE therapy
False Positive Results
False Negative Results
 Children exposed to
 Age<6mos
nontuberculosis
mycobacteria
 Recent administration of
the BCG vaccine**
 Improper administration
or interpretation of TST
 Disseminated forms of
TB can induce anergy
(miliary and meningitis)
 Recent measles infection
 High-dose corticosteroid
treatment (or other
forms of
immunosuppression)
 Irradiation
 Measures patient’s ability to produce
interferon gamma after their lymphocytes
are stimulated by 2 or 3 antigens on M.
tuberculosis
 Greater specificity than TST but similar
sensitivity
CXR
Detailed
contact and
symptom
history
Physical
Exam
Latent or
Active
TB
• 3 samples
collected on
different days
before the child
eats or ambulates
• Induced vs.
Expectorated vs.
BAL
• Pleural fluid,
CSF, lymph node
biopsy, etc…
Sequential
sputum
sampling
Gastric
aspirates of
early AM
secretions
Specimens
from an
extrapulmonary
site
CT scan
• If CXR findings
are equivocal
 *Healthcare worker:
 +TST (≥10mm) CXR
 CXR negative offer to treat for LTBI weighing
risks and benefits
 CXR positive further evaluation and Rx
 Contact investigations
 *Child with an adult household contact with
TB disease:
 TST and CXR for ALL children in the household
 Children <4yo (or immunocompromised)
empiric INH
 The mother of a 2 mo breastfed infant comes to your
clinic very concerned, because she recently had a
positive TST. She reports that her doctor sent her for a
CXR, which was normal, and then put her on a single
medication. She asks you what needs to be done to
keep her baby from contracting the illness?
 A. No intervention is required for the infant
 B. Cessation of breastfeeding
 C. Separation of mother and baby
 D. Empiric INH in the infant
 E. Multidrug therapy in Mom
 Infant whose mother has TB:
 Mom with +TST, -CXR (LTBI) no
intervention for infant
 Mom with +TST, +CXR (TB disease)
evaluation for congenital TB; separation from
Mom until infant is receiving INH and Mom
is on multidrug therapy
 Children who have TB should be seen monthly while
receiving therapy
 Medication tolerance and adherence
 Weight gain
 Achieving appropriate milestones (esp with TB
meningitis)
 Look for disease spread
 Pulmonary TB
 Repeat CXR after 1-2 months of therapy
 TB meningitis:
 Often require sequential CNS imaging by CT scan or
MRI
 Appropriate chemoprophylaxis of children who
have been exposed to TB or have LTBI
 BCG vaccination
 Should only be considered for children who are HIV
negative, have a negative TST and who are
continually exposed, and cannot be separated from,
adults who:
 Are untreated or ineffectively treated for TB disease
(if the child cannot be given long-term treatment for
infection)
 Have TB caused by strains resistant to isoniazid and
rifampin
 Infection control and contact investigation
 Hospital infection control
 Most younger children do not have a sufficiently forceful
cough or high enough organism burden in the airways to
be infectious EXCEPT FOR children with:
 Cavitary or extensive pulmonary involvement
 AFB smear-positive TB
 Laryngeal TB
 Procedures with high risk of aerosolization of bacteria (BAL,
entubation)
 If any of the above criteria met personally fitted and
sealed particulate respirators should be used by all patient
contacts and patient should be placed in airborne
infection isolation
 Infection control and contact investigation
 Hospital infection control (con’t)
 Major concern is household contacts that may be the source
case
 Visitation should be limited to those who have had a CXR that
excludes contagious TB
 Return to child care and school
 Children with TB disease can attend school or child care if:
 Effective therapy has been instituted
 Adherence to therapy has been documented
 Clinical Sx have diminshed substantially
 Children with LTBI can participate in all activities whether they
are receiving treatment or not
 Children with a positive TST should be a
“starting point for epidemiologic
investigation by the local health department”
 Reporting of suspected and confirmed cases of TB is
mandated by law in all states
 Physicians should assist local health department in the
search for the source case and others infected by the
source case
 New Orleans Health Department 504-658-2500
LTBI
TB Disease
TB
meningitis
• 100% effective in preventing TB disease
• Adherence must be EXCELLENT!
• 95-100% cure in drug-susceptible disease
• Overall mortality low
• Highest rates of mortality and long-term sequelae
• 33% die and 50% have residual defecits
 Designed to prevent the spread of microorganisms
among patients, health-care personnel, and visitors
 Standard precautions and “cough etiquette” should be
used for all persons in and out of the health-care
setting
 3 components
 Source
 Patient, health-care worker, visitor
 Acutely ill with symptoms
 Colonized/infected but no symptoms
 Inanimate objects and toys
 Susceptible host
 Means of transmission
 Direct contact (infected person to host)
 Indirect contact (fomite)
 Droplet (large particles going < 3 feet)
 Airborne (small particles suspended in air and dispersed)
 *Know the recommendations for standard precautions
 All patients
 Hand hygiene before and after each patient contact
 Single most important practice to reduce transmission
of microorganisms
 Alcohol-based preferred (superior activity and
adherence)
 Soap and water if visible soil or with spore-forming
organisms (C. diff)
 No artificial nails for workers in ICU, OR, or oncology)
 Assoc. with gram-neg bacillary and candidal infections
 Use of protective equipment when needed
 Respiratory Hygiene
 “Cough etiquette”
 For staff, patients, families (everyone!)
 Covering one’s mouth and nose during a cough or sneeze
 Dispose of tissues
 Follow with hand hygiene
 If no hand hygiene available → direct cough into antecubital
fossa
 Those with respiratory illness who cannot be separated
from others by 3 feet, should wear a mask
 You are on night float for Purple team and a 7 month
old male comes in with rhinorrhea, cough, and
increased work of breathing. The viral panel comes
back positive for RSV.
 Which of the following will you include in your order
set?
 A. Droplet precautions
 B. No precautions necessary
 C. Airborne precautions
 D. Standard precautions
 E. Contact precautions
 *Know the recommendations for contact precautions
 Gloves and gown when direct patient contact
 Patients in single rooms or cohorted
 *Identify when contact precautions are required
 Organisms
 C. diff
 Enteroviruses
 RSV
 Multidrug-resistant organisms
 Draining abscesses, cellulitis, decubitus ulcers
 Supplies should be available outside the patient rooms
 A few hours later, you are admitting a 4-year-old male for
Silver team who is a know asthmatic with symptoms of
cough, fatigue, and increased work of breathing. His viral
panel comes back positive for influenza. Being the stellar
resident that you are, you order droplet precautions prior to
sending this patient to the floor.
 Which of the following BEST describes droplet
precautions?
 A. Single room and surgical mask required
 B. Shared room and no personal protective equipment
required
 C. Single room and gown and gloves required
 D. Cohort room and good hand hygeine
 E. Negative pressure room and surgical mask required
 *Know the recommendations for droplet precautions
 A surgical mask is required
 Single room or cohort (with 3 feet and curtain) for patients
 When patients leave the room → mask, cough etiquette
 *Identify when droplet precautions are required
 Influenza
 Rhinovirus
 Bordetella pertussis
 Neisseria meningitidis
 Strep pyogenes
 Keep precautions in place until pt. has been receiving
antimicrobial therapy long enough to prevent transmission
 *Know the recommendations for airborne precautions
 Negative pressure airborne infection isolation room
 Before entering the room, clinicians should use a fit-
tested N95 or similar sealing mask
 *Identify when airborne precautions are required
 TB
 Measles
 Varicella
 *Understand that office and hospital staff should
receive an annual influenza immunization
Have a great weekend!