RED BOOK 2006

1
RED BOOK 2006
2
Neisseria meningitidis

• 13 serogroups
• Common A, B, C, Y and W-135
• Risk of invasive infection
• Terminal complement def (C5-C9)
• C3 or properdin def
• Anatomic or functional asplenia

3
Clinical manifestation

• Meningococcemia/meningitis
• Fever, chills, malaise, rash
• Macular, maculopapular or petechial
• Waterhouse-Friderichsen syndrome
• Purpura, DIC, shock, coma

4
Diagnosis

• ????? RB 454

5
treatment

• PGS 250,000-300,000 U/kg/day q 4-6 hr (max 12
  million U/day)
• Cefotaxime, ceftriaxone or ampicillin
• Penicillin allergy(anaphylaxis) chloram
• Duration 5-7 days
• Isolation droplet in first 24 hr of Px

6
Chemoprophylaxis

• High risk recommend(close contact)
• Household
• Child care/nursery during 7 d before onset of
  illness
• Direct exposure to index pts secretion 7 d
• kissing, sharing toothbrushes or eating utensils
• Mouth to mouth resuscitation or unprotected
  during intubation 7 d
• Frequently slept or ate in same dwelling 7 d
• Passengers seated directly next to the index case
  during airline flights gt8 hr

7

• Low risk (not recommended)
• Casual contact (school or work)
• Indirect contact
• HCWs non-exposed to pts oral secretion
• Index case
• Chemoprophylaxis not recommend if Px with
  cefo/ceftri

8
Chemoprophylaxis

• Rifampin
• lt 1 mo 5 mg/kg, oral q 12 hr x 2 days
• ? 1 mo 10mg/kg oral q 12 hr x 2 days
• Ceftriaxone
• lt 15 yr 125 mg IM single dose
• ? 15 yr 250 mg IM single dose
• Ciprofloxacin
• ? 18 yr 500 mg oral single dose

pregnant
9
Immunoprophylaxis

• Meningococcal vaccines
• A, C, Y and W-135
• 2 vaccines licensed
• MPSV4 ? 2 yrs
• MCV4 11-55 yrs

10
Recommendation

• RB458

11
ENTEROVIRUS
12
Classification of Enteroviruses
1. Polioviruses ?? type 1-3 2. Coxsachiviruses
A ?? type 1-24 Coxsachiviruses B ?? type
1-6 3. Echoviruses ?? type 1-34 4.
Enteroviruses ?? type 68-71
13
Clinical Manifestations of Enteroviruses
1. Respiratory - cold, pharyngitis, herpangina,
HFMD, pneumonia 2. Skin - exanthem 3.
Neurologic - aseptic meningitis, encephalitis,
paralysis 4. GI - diarrhea, hepatitis 5. Eye -
acute hemorrhagic conjunctivitis 6. Heart -
myopericarditis (Most of the cases are
asymptomatic or nonspecific febrile illness)
14
Risk Factor of EV 71 Encephalitis with Pulmonary
Edema
1. Prolong fever 2. Tempeature gt 39 ?c 3.
Hyperglycemia 4. Leucocytosis 5. Limb weakness 6.
Miscellaneous - headache, vomiting, lethargy,
convulsion
15
Diagnosis of HFMD from EV71
1. Clinical diagnosis (suspicious when
outbreak) 2. Viral identification - - acute
phase - TSC and 1st serum specimen -
convalescent phase - stool culture and 2nd serum
specimen (Department of Medical Science,
MOPH) 3. Polymerase Chain Reaction for EV 71
16
(No Transcript)
17
???????? HFMD
1. ????????????? ???? ????????, xylocaine
??? 2. ?????????????????? ??????? 3. ?????????
MFMD ??????????????????? ???? ?????? ???
??????? ?????????????? ??????? ???????????????
(??? admit ??? investigate ?????) 4.
?????????????? IVIG, ECMO ?? severe life
threatening HFMD (???????????)
18
Possible therapy for Severe EV71

1. Mechanical ventilation for neurogenic
pulmonary edema eg. ECMO 2. Alpha-blocking agents
for counteract of sympathetic reflex activity 3.
IVIG - survived in 10/14 patients 71 (observe
only servived 15/20 patients 75)
(CID 1999 29184)
19
Prevention and Control of EV 71

• Observe and surveillance of HFMD, Herpangina
  patients especially severe case (identified
  etiology)
• Control outbreak by closing the nurseries,
  schools kindergarten, swimming pool, play ground
  etc. for 1-2 weeks
• EV 71 vaccine is ongoing development

20
Clostridium difficile
21

• Spore forming, anaerobic,
• gram positive bacilli
• 2 syndromes
• Pseudomembranous colitis
• Antimicrobial-associated diarrhea

22
Clostridium difficile

• Most commonly antibiotics associated
• Penicillin
• Clindamycin
• Cephalosporin
• Diagnosis
• Treatment

23
Diagnosis (C.difficile)

• Endoscope suggest
• EIA for toxinA with cell culture cytotoxicity
  assay for toxinB

24
Treatment (C.difficile)

• Metronidazole oral and IV
• Vancomycin oral
• Bacitracin zinc oral
• metro 30 MKD qid x 10 days

25
VARICELLA
26
Varicella infection

• Identify susceptible people
• Isolation day 8-21
• Candidates for VZIG
• Varicella vaccine
• Index case treatment
• lt1 yr 30 MKD q 8 hr x 7-10 days
• gt1 yr 1500 mg/m2/day q 8 hr x 7-10 days

27
Type of exposure

• Household
• Playmate face to face, indoor play
• Hospital
• Varicella same 2-4 bed room, adjacent beds in a
  large ward
• Zoster intimate contact
• NB 5 days before, 2 days after

28
Candidates for VZIG

• Immunocompromised children without Hx. Of
  varicella or varicella immunization
• NB 5 days before, 2 days after
• Hospitalized PT(?28wks) ????????????????
  varicella
• Hospitalized PT(lt28wk or lt1000gm)

29
BIOLOGICAL TERRORISM

• 3 categories A, B, C

30
Category A

• Anthrax
• Smallpox
• Plague
• Tularemia
• Botulism
• Viral hemorrhagic fever
• (Ebola, Marburg, Lassa, Junin)

31
Category B

• Coxiella burnetti (Q fever)
• Brucella species (brucellosis
• Burkholderia mallei (glanders)
• Alphaviruses (Venezuelan equine, eastern equine,
  western equine encephalomyelitis)
• Rickettsia prowazekii (typhus)
• Chlamydophila psittaci (psittacosis)
• Ricinus communis (castor beans) ricin toxin
• Clostridium perfringens epsilon toxin
• Staphylococcus enterotoxin B
• Foodborne/waterborne (Salmonella, Shigella,
  E.coli O157H7, Vibrio cholerae, Cryptosporidium
  parvum)

32
Category C

• Nipah virus
• Hantavirus
• Tickborne hemorrhagic fever viruses
• Tickborne encephalitis viruses
• Yellow fever virus
• MDR M. tuberculosis

33
Malaria
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
Malaria

• Incubation period 6 days - 6 weeks
• Symptoms fever, chill, anemia
• Clinical manifestation
• Mild or uncomplicated malaria
• PF, PV, PM, PO
• Severe or complicated malaria
• PF

41
Complications of Pf in children

• Cerebral malaria
• Severe anemia
• Hypoglycemia
• Metabolic acidosis
• Respiratory distress
• High grade fever
• Hematologic abnormalities
• Jaundice
• Hemoglobinuria
• Shock
• hyperparasitemia

42
???????????????????????????????????????? PF
????????????????

• ???????? 1
• ??????????????????????????????????????????????????
  ????????
• ???????? 2
• ??????????????????????????????????????????????????
  ????????????????????????????? ????????????????????
  ???????????? 1
• ???????? 3
• ??????????????????????????????????????????????????
  ???? ???????????????????????????????? 1 ??? 2

43

• ???????? 1 IV antimalarial drugs
• ???????????????????????????????????????????
• ?????????????????????
• ??????????????????????????????????????
• ?????????
• ???????????????? (???????????)
• ????????? ??????????, mild intercostal retraction
• ??????????? severe intercostal retraction, ??????
• ???????? 2 oral antimalarial drugs
• Hb lt 5 g/dl or Hct lt 15
• Convulsion gt 2 episodes in 24 hrs
• ???????? 3 IV fluid replacement

44
Artemisia annua
Artemisinin (Qinghaosu)
45
Treatment

• Uncomplicated malaria
• Plasmodium falciparum
• Plasmodium vivax / Plasmodium ovale
• Plasmodium malariae
• Complicated malaria
• Supportive care
• Specific antimalarial drugs
• complications

46
Uncomplicated malaria

• Plasmodium falciparum
• Artesunate 4 mg/kg/day OD x 3 days then
  Mefloquine 15 mg base/kg and 10 mg base/kg at
  next 6 hrs
• Quinine sulfate 10 mg/kg/dose q 8 hr x 7 days
• ( gt8 y tetra 5 mg/kg q 6 hr/doxy 3 mg/kg OD x
  7 days)
• Artemether-lumefantrine (CoartemTM)
• Atovaquone-proguanil (MalaroneTM)
• gametocyte primaquine 0.6 mg/kg single dose

47

• Plasmodium vivax / Plasmodium ovale
• Chloroquine 10 mg base/kg stat
  Chloroquine 5 mg base/kg next 6 hrs
  Chloroquine 5 mg base/kg next 24 hrs
  Chloroquine 5 mg base/kg next 48 hrs
• ??? hypnozoite primaquine 0.3 mgbase/kg/day x
  14 days
• Plasmodium malariae
• Chloroquine ?????? PV ????????????? primaquine

48
Complicated malaria

• Artesunate-mefloquine
• Artesunate 2.4 mg/kg IV stat
• 1.2 mg/kg IV at 12 hr
• 1.2 mg/kg IV at 24 hr then
• 1.2 mg/kg IV OD 3-5 days
• Mefloquine 15 mg base/kg stat
• 10 mg base/kg next 6 hr
• Artemether-mefloquine
• Artemether 3.2 mg/kg stat then 1.6 mg/kg OD 3-5
  days
• Mefloquine same as above

49

• Quinine
• 20 mg/kg IV drip in 4 hr stat
• 10 mg/kg IV drip in 2 hr q 8 hr x 7 days

50
Management of complication

• Convulsion
• Anemia
• Hypoglycemia
• Acidosis
• Hemoglobinuria
• Shock
• Pulmonary edema
• Acute renal failure
• Hyperparasitemia

51
ISOLATION PRECAUTIONS

• Standard precautions
• Transmission-based precautions
• Airborne
• Droplet
• Contact

52
Droplet transmission

• Adenovirus
• Diphtheria(pharyngeal)
• Haemophilus influenzae type b (invasive)
• Influenza
• Mumps
• Mycoplasma pneumoniae
• Neisseria meningitidis (invasive)
• Parvovirus B19
• Pertussis
• Plague (pneumonia)
• Rubella
• Streptococcal pharyngitis, pneumonia, or scarlet
  fever

53
Contact transmission

• MDR bact (MRSA,VRE)
• Clostridium difficile
• Conjunctivitis
• Diphtheria(cutaneous)
• Enteroviruses
• Escherichia coliO157H7
• Staph (cutaneous)
• Major abscess, cellulitis
• Viral hemorrhagic fever
• (Ebola, Lassa, Marburg)

• Impetigo
• Parainfluenza virus
• Pediculosis
• RSV
• Rotavirus
• Scabies
• Shigella
• HAV
• HSV
• HZV

54
(No Transcript)
55
Vaccine

• Toxoid
• Killed vaccine
• Live attenuated vaccine

56
Live attenuated vaccine

• BCG
• OPV
• MMR
• Typhoid (oral)
• Varicella vaccine
• Rota virus vaccine

57

• ??????????????????????????????????????????????????
  ????????????
• live attenuated vaccine ??????????????????????????
  ??????????????? ??????????????????????????????????
  ?????????????????? 1 ?????
• ????????????????? anaphylaxis ?????????
  ??????????????????????????????? ????
  ????????????????? ?????????????-??????????-??????
  ???????????????????????????? anaphylaxis
  ??????????????????????????????????????????????????
  

58

• ??????????????????? ??? whole cell pertussis
  ??????
• - ?????????? 40.5 ???????????? ????? 24
  ??????????????
• - ????????????????????? 3 ??????? ????? 48
  ???????
• - Hypotonic-hyporesponsive episode (HHE) ????
  shock-
• like state
• - ???????? 48 ????????????????????
• ??????????????????????????????????????????????????
  ???? DTPw ???????????????? DTPa ???

59

• ????????? DTP ???????? encephalopathy ????? 7 ???
  ??????? acellular ???? whole cell pertussis
  ??????????????????????????? DT ???
• vaccine-associated polio paralysis VAPP

60

• Preterm ???????????????????????????
  ????????????????????????????? 2,000 ????
  ??????????????????? HBsAg-positive ?????? HBV ???
  HBIG ????? 12 ???????????????
• ????????????????? admit ???????????? OPV ??? BCG

61
Pregnant women

• Live attenuated vaccine
• MMR 1 month

62
Immunocompromised patient

• Killed vaccine, toxoid OK
• Live attenuated vaccine
• HIV
• BCG ???????????????????????????
• Varicella ???????? CDC class C ???? 3
• MMR ???????? CDC class C ???? 3
• Immunosuppressive drug
• ?????????????????? 3 ?????
• corticosteroid

63
corticosteroid

• Toxoid or killed vaccine OK
• Live attenuated vaccine
• Topical steroid and local injection
• Systemic corticosteroid
• Physiologic dose
• Low or moderate dose OD or EOD
• High dose (2 MKD OD or EOD ???? gt20 mg/d in child
  gt10 kgs
• lt 2 weeks ?????????????????????????? 2 weeks
• ? 2 weeks 1 month

64
(No Transcript)
65

• Influenza vaccine
• Varicella vaccine

66
Recommendation for use of IVIG(US FDA and NIH)

• Primary immunodeficiencies
• Kawasaki disease
• Pediatric HIV infection
• Chronic B-cell lymhocytic leukemia
• Recent stem cell transplantation in adults
• Immune-mediated thrombocytopenia
• Chronic inflammatory demyelinating polyneuropathy