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78 Cards in this Set

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What percentage of neonates are colonized at birith with GBS and how many actually become sick?
at birth - 50% of babies with colonized mothers will be colonized

2% of those babies will develop early onset GBS Disease - case fatality 2-5%

pre-term infants have case fatality 20-30% with GBS disease
what are risks for GBS colonization?
Young
Sexual activity
tampon use
Poor hand hygiene
diabetes
high temperatures
humidity
In what percent or pregnancies is there GBS bacteruria?
2-4%
What are the associated complications with heavy colonization?
Maternal- UTI, Pyelonephrititis, endometritis, chorioamnionitis, osteomyelitis, endocardiditis

Fetal - Pre-term, TROM (12-24 hrs), chorio - fever in labour
What is early onset GBS disease and what problems that does that entail
Early onset disease <7 days after birth - represents 80% of neonatal disease

- bacteremia - 74%
- Meningitis - 14%
-Pneumonia 12%
-25% of cases are preterm
What is the rate of GBS sepsis in the early stage?
2-3/1000 before prophylaxis and now we've reduced it down to 0.5/1000

Mortality is 5-20%
can get neurological sequelae
when does late onset occur?
>7 day to less than 1 month
0.5 - 2 /1000 --> does really change despite prophylaxis

Usually manifests as meningitis

mortality is less than late onset
Does treating the neonate cure the disease?
no, it only impact disease severity - the best is the prevent it form happening in the first place
What is the reduction of chemoprophylaxis on reducing early onset disease?
30 times!!!!
What is the best screening strategy?
universal screening - can take a risk-based approach, but found to be less effective in reducing early onset disease
in what situation is GBS prophylaxis recommended in this pregnancy?
previous newborn with invasive GBS disease
GBS bacteruria in this pregnancy
Positive GBS culture at 35-37 weeks
if TPROM - prophylax and induce
what if the GBS status is unknown
Delivery <37 weeks
Rupture >18 hours
Intrapartum temperature >38
what is the max time that a culture can be used?
up to 5 weeks - after that we need to re-swab
Write out the GBS antibiotics that you need to give
1. Pen G 5 mil u IV x1, then 2.5 mil U q4h till delivery OR Ampicillin 2 g IV x1, then 1g IV q4h till delivery

2. (low risk pen allergic) - Ancef 2 g IVx1, then 1 g IV q8h till delivery

3. clindamycin 900 IV q8h till delivery or

4. Erythromycin 500 mg IV q6h till delivery (more and more resistance)
What are the vaginal colonization rates per hour after initiation of antibiotics?
1 hour - 46% after loading dose
1-2 hr - 29%
2-4 hours - 3%
>4 hrs - 1.2%
How should you monitor the neonates?
1. received appropriate ABX
2. no ABX but appear well
3. moms with chorio
1. observed for 24 hrs
2. observe for 48 hours
3. do septic work-up
should you treat asymptomatic bacteruria in pregnancy?
if colony counts >100,000 CFU

if colony count less than 100,000 then don't need to treat
what is concerning about asymptomatic bacteruria in pregnancy?
increased risk of :
pyelonephritis
low birth weight infants
BUT no decrease in pre-term birth
what is the definition of recurrent bacteruria, vs. re-infection?
1. recurrent - same strain, high colony counts within 2 weeks of treatment

2.Re-infection - same/different strain with high colony counts MORE than 2 weeks after treatment
what increased the risk of chorioamnionitis in patients?
-No therapy for GBS bacteruria at anytime in pregnancy

-more than 8 vaginal examinations
what are the screening guidelines for ALL women who are pregnant (and don't have GBS bacteruria already?)
All women between 35-37 weeks
Swab needs to go from vaginal to the rectum (THROUGH the anal sphincter)
Should be done in women EVEN if they are going to have an elective C/S because or risk of rupture or labour
what should you do for a woman who is pen allergic and needs an GBS swab?
You need to makes sure they send off for sensitivities
What is the new guidelines by the CDC for PPROM and GBS?
the CDC in 2010 recommended GBS prophylaxis for 48 hours (or less if GBS swab negative) + latency antibiotics
Why do we use Pen G such a narrow spectrum antibiotic?
diminishes the risk of selective pressure on other organisms

decreases the risk of ampicillin resistance
what is the recommendation with term prom and GBS + status?
Need to induce right away with oxytocin for least amount of infection to the neonate
what is the prevalence of hepatitis C in Canada?
0.8%
world incidence is 3%
what are the at risk groups in Canada and its associated prevalence in that population?
IVDU - 70%
Aboriginal populations - 15-20%
Recipients of blood products,organs (1960-92) - 1.5-2.7%
prisoners in correctional facilities 25-40%
What is the transmission rate for sexual transmission?
Vertical transmission?
Sexual transmission - 2.5% for prolonged exposure over 20 years

Vertical transmission - wide range - roughly 7.9%
What are the risk factors associated with vertical transmission? what about breast feeding?
vertical transmission - dependent on HCV RNA
Breast feeding - HCV does get secreted in breastmilk, but NO transmission detected before
is there any possibility with Rh immunoglobulin of getting Hep c?
no
Who is considered high risk for Hep C infection? (20%)
IVDU (30% of those who have ever used)
Recipients of unscreened blood products prior to 1990
Who is considered moderate risk for Hep C infection? (1-20% risk)
Newborns - mom known to be infected
Chronic hemodialysis
organ transplant patients
recipients of blood from unscreened donors
Medical/Dental procedures - inadequate sterilization
What is a low risk of hep C infection (<1%)
multiple sex partners
partner infected
tatoos, body piercing
Household contacts --> inadvertant blood exposure
Rituals - circumscision, scarification, excision, traditional medicine (blood letting), skin breaking activities - ear and body piercing
what is the relationship between HepC and HIV co-infection?
both HIV and Hep C progress faster
What is the time course of Hepatitis C infection?
1-3 weeks - HCV RNA detected
7 weeks - Raised ALT
3 months - Anti HCV detectable
6 months- development of peristance HCV and chronic infection
10 years - clinically overt hepatitis
20 years - cirrhosis (20% of chronically infected pts)
30 years - hepatocellular carcinoma (1-5% of chronic infections)
What percentage will actually clear the disease? and how can you tell?
15% will clear the disease and you can tell by doing HCV RNA
Is there correlation with LFTS and the severity of the disease?
NOPE
there can be very severe pathology with normal LFTS
are all patients symptomatic with their first infection?
50-75% are asymptomatic

25% are jaundiced
What are some extra-hepatic manifestations that may trigger an immune response?
1. membraneous glomerulonephritis
2. porphyria cutanea tarda
3. aplastic anemia
4. cryoglobinemia
5. ITP
6. Thyroiditis
what are co-factors that affect natural history?
Viral load/ viremia
HIstology - more fibrosis
HIV co-infection
Alcohol
Gender - male increasing disease severity
Age
Pregnancy - DOES NOT CHANGE course
What people should you screen? - there is no universal screening
1. injection drug user - ever used drugs
2. hemodialysis
3. persistenlyl elevated AST
4. recipient of clotting factors before 1988
5. recipients of blood components or solid organs before 1992
6. recipients of blood components or solid organs from HCV+ person
7. person with significant exposure to HCV + person - or that of high risk
8. prisoners
9. infants of hcv mothers
10. older childrent of hcv mothers - if reason to believe vertical transmission may have occurred
11 - HIV+
12 tattoos - especially prison tattoos
13. aboriginal population
what will give a false + for HCV?

what gives a false negative?
those with positive rheumatoid factor

Those who were tested too early - seroconversation takes 3 months
what do you to when you get a positive test?
Repeat ELISA x1, then run a confirmatory test (RIBA or PCR)
Who should be treated?
those with ALT >1.5x normal for 3 consecutive months
other associated conditions: glomerulonephritis etc.
End stage liver disease
what is the most common treatment. Can you use it in pregnancy?
Ribavirin + interferon

Ribavirin - emryocidal and teratogenic
avoid in pregnancy and for 6 months after
NO breastfeeding
women on ribaviran NEED good contraception
what are some behavioural recommendations?
MUST avoid alcohol - <2 units/day if necessary, but should be avoided

MUST immunize against hep A and B
What role HCV have on pregnancy what about pregnancy on HCV?
HCV is not worsened by pregnancy, may even improve slightly

HCV doesn't make pregnancy worse either - no worse obstetrical outcomes (IHCP may be more common)
What is the vertical transmission risk for pregnancy?
5%

if you are HIV + HCV then 15% transmission up to 44%
What factors affect transmission and how does that impact on transmission?
Viral load + RNA --> 10% transmission
Prolonged ROM , FECG
you have decreased transmission with elective C/S

Breast feeding is controversial but no transmission to date
what happens if patients with hepatitis C also contract hepatitis A?
41% will have fulminent hepatitis and possible death
What is the vaccination schedule with Twinrix?
0, 1month, 6 months

Accelerated:
0, 1 week, 3 weeks, 1 year
what are risk reduction behaviours that you can advise people to partake in?
1. Needle exchange programs, avoid needle sharing
2. avoid alcohol consumption
3. recommend vaccine against hepA and B
4. Support Group
5. Safer Sex practices
6. no blood,organ, tissue, or semen donation
7. shouldn't share razors or toothbrushes
8. Tattoing in unlicensed parlours
What are baseline labs you would order for moms with Hep C?
HbsAG
Anti-HepA igG
HCV RNA

LFTs qtrimester
Any specific recommendations regarding labour?
c/s said to be protective but not full data, so wouldn't recommend at this time

avoid ROM, scalp sampling, FECG, episiotomy
What are the fetal considerations?
HCV RNA - at 3 months
RNA and Antibody - at 1 year

all babies will be positive from Maternal IgG crossing through the placenta - but will clear by 12-15 months

vaccinate at birth - Hep B, HepA at one year
What gynecologic issues may Hep C women face?
1. significant liver disease - an ovulation, infertility
2. Cirrhosis - get estrogen excess predisposing to endometrial hyperplasia/cancer
3. cirrhosis, HCC, hepatic failure are contraindications to OCP
4. NO contraindications to progestin only, IUD, barrier contraception - should recommend
5. if you are going on ribavirin - NEED effective contraception --> recurrent yeast infections are common on this therapy
what are some conditions for use for a screening test?
-disease must have public health importance
-sensitive and specific test must exist for its detection
-therapeutic and preventative measures must be available
-direct and indirect screening costs must be acceptable to society
what type of virus is Hepatitis B?
DNA virus - all other hepatitis viruses are RNA viruses
what is the incubation time for hepatitis B?
1-6 months
what are the structural proteins in hepatitis?
HbsAg - surface antigen
HbcAg - core antigen
HbeAg - e antigen
what is the transmission risk of HepB?
IVDU
vertical transmission - accounts for most cases worldwide
Sexual contact - 25% between long term sexual partners
Blood and blood products
what is the most efficient transmission method for HepB?
Serum - saliva, vaginal secretions, semen
Who is at risk for transmission of hepatitis B?
MSM
Multiple sexual partners
Sex workers
IVDU
HBV carrier in family
sex with HbV + person
Healthcare workers
low SES
Infected with HIV or HCV
Previous or other STIs
What is the overall prevalence of hepatitis B?
0.5 - 1%
what is primary and secondary prevention?
primary - Hepatitis B vaccine
secondary - HBIG to all needlestick or mucosal exposure- followed by vaccine (transmission rate is 30% if HepeAg +)

HBIG immediately to neonate and vaccine 12 h later
what percentage of people actually clear an acute HepB infection? what percentage becomes chronic carriers?
85-90% will clear the disease
10-15% will be chronic carriers
what about perinatal infection?
90% of those with perinatal infection will develop a chronic infection
What do the different viral serology testing mean?
HbsAg - appears before symptoms, used to screen blood donor and pregnant women
HbeAg - evidence of viral replication - high infectivity
HbCAg - present only in hepatocytes and does not circulate

anti-HbC IgM - first antibody to appear - indic...
HbsAg - appears before symptoms, used to screen blood donor and pregnant women
HbeAg - evidence of viral replication - high infectivity
HbCAg - present only in hepatocytes and does not circulate

anti-HbC IgM - first antibody to appear - indicated acute infection --> can be the only marker during 'window period' where hbsAg is negative and anti-hbs not yet positive

Anti-Hbc igG - indicated previous infection (hbsAg-) or ongoing infection (hbsAg+)

Anti-HbE - indicated waning viral replication and low infectivity

Anti-HbS - indicates resolution of acute disease and immunity (sole marker for vaccination)

HBV DNA - presence in serum correlates with active viral replication in the liver
Should you treat hepatitis B?
not for acute infection
Lamivudine and 3TC for chronic infections
what are the basic treatment parameters?
- screen for other STIS and hepatitidies
report the disease
HPV vaccine
what is the role of pregnancy on HBV?
What is the role of HBV on the pregnancy?
Pregnancy doesn't effect HBV

with HBV in pregnancy - 15% transmission without prophylaxis - vertical transmission more likely if HBeAG+ (90% if e antigen or high levels or circulating DNA)
what is the risk of transmission in pregnancy if you have an acute infection?
T1 - 10% babies infected
T3 - 80-90% babies infected
intrapartum - 85-90% ingestion of infected placental fluid
what percentage of patients will die from their disease?
25% will die for sequelae of their disease

90% perinatal transmission will be chronic carriers

usually not transplacental - its peripartum
how does post-natal prophylaxis help transmission?
transmission decreases from 2.5% from 15%
should give HBIG and vaccine
IM injection at different sites on the neonate

will need the full course with 2 follow-up injections within next 6 months

Okay to immunize in pregnancy - 45% seroconversion?
How do you transmit hepatitis A?
fecal-oral transmission in contaminated food or water

4 week incubation - shed in faces, blood is infectious during viremia
how do you diagnose HepA?
IgM and IgG
how do you treat hepatitis A?
can give immunoglobulin within 2 weeks of exposure - vaccine is safe in pregnancy and equally effective
what risks are present with HAV infection?
HAV not teratogenic, vertical transmission is negligible

may have increased PTB and IHCP