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1. Nosocomial infections are an unfortunate complication of hospitalization. All of the following statements regarding nosocomial infections in children are true except.
A.
Hospital acquired infections are generally highest in teaching hospitals
B. Surgical services have the highest rate of nosocomial infections
C. In the pediatric services,
respiratory infection is the most common nosocomial infection D. E. coli is the most common cause of pediatric urinary tract infections
E. Klebsiella is the most common cause of lower respiratory infections in
newborns 2. Which of the
following is least accurate regarding nosocomial upper respiratory infection:
A. When patients with nasotracheal
tubes in place develop maxillary sinusitis, pneumococcus is the most common
organism
B. It has been shown that in acute
sinusitis, culture of the nose or throat do not yield the organisms responsible
for the sinusitis
C. Corneal ulcers, if discovered,
must be treated aggressively to prevent progression to hypopyon, corneal
destruction & perforation.
D. Data suggest that there is little
overall effect of a different physical plant of the hospital, whether new or
old, on the resultant nosocomial infection rate 3. Respiratory borne nosocomial infections are associated with increased
morbidity and mortality, which is likely to increase hospital costs.
Regarding this topic which of the following statements is not true:
A. Patients treated with H2-blockers
are at higher risk of tracheal colonization with gram negative bacilli
B. Ventilators with humidifying
cascades rather than nebulizers have little role in contaminating patients if
the tubing is changed every 48 hours
C. Aspiration occurs more often in
children with an uncuffed endotracheal tube compared to those with a cuffed tube
D. Initial colonization begins in
the stomach or hypopharynx with subsequent spread to the trachea
E. Anaerobes are the dominant organisms that colonize the trachea in
intubated patients 4.
All of the following statements regarding infections associated with
arterial cathererization are true except:
A. Insertion by a surgical cutdown
is associated with a significantly higher risk of
localized and systemic infection compared to percutaneous insertion
B. Catheters in place for greater
than 4 days have a significantly higher risk of being infected C. Local inflammation correlates well with duration of insertion of the
catheter
D. Single patient disposable transducers can be used up to 4 days
without
bacteremia
E. Candida albicans and enterococcus are most common organisms
involved in infection Click here for answer 5. All of the following
statements regarding central venous catheterization are true except:
A. Catheters placed during an active
infection may become colonized with the same organism causing the bacteremia
B.
The proximity of a tracheostomy
tube may be a relative contraindication for a subclavian catheter placement
C. Pulmonary artery catheters have a
significantly higher incidence of positive catheter tip cultures after 72 hours
of insertion
D. Staphylococcus epidermidis and
staphylococcus aureus are the most commons causes of parenteral nutrition
associated infections
E. Fifty percent of parenteral nutrition associated infections are fungal 6.
Select whether the following statements regarding nosocomial infections
in children are true or false:
____ Skin site erythema greater than 4 mm in diameter, fever and positive
skin cultures are predictive of catheter-associated infection
____ Asymptomatic Pseudomonas bacteremia in dialysis patients has been
reported
____ External shunts for
hemodialysis are most commonly infected by Staphylococcus aureus
____ Approximately 10 % of cannulas
placed for extracorporeal life support become infected
____ Coagulase-negative
staphylococci are the most common cause
of catheter-related sepsis 7. All of the following
statements regarding urinary tract infection in children are true except:
A. In the newborn period males outnumber females 3:1 to 6:1 B. In B. In the Pediatric ICU, the cumulative risk of urinary tract infection in catheterized patients approaches 30%
C. In a midstream “clean catch”
specimen, greater than 105 organisms/ml indicates infection
D. Meatal cleansing with providone-iodine
and use of impregnated catheters significantly decreases the incidence of
urinary tract infection
E. Urinary catheters are more likely
to be colonized with gram positive than gram negative bacteria 8. All of the following
statements regarding intracranial pressure devices are true except:
A. Increasing frequency of breaks in the system increases the risk of
infection
B. Prophylactic antibiotic coverage significantly decreases the incidence of
infection
C. Duration of placement is directly related to infection rates
D. Placement either in the intensive
care unit or in the operating room appears to have no relationship to the rate
of infection
E. Intraventricular hemorrhage in
the presence of an intracranial pressure greater than 20 cm H20
increases the rate of infection 9. All of the following statements regarding childhood infections are true except:
A. Common offending organisms during
the first seven days of the life are Group B streotococci, E.coli,and Listeria
monocytogenes
B.
Ampicillin and a third generation
cephalosporin will effectively cover the organisms in Answer A
C. H.
infuenzae, S. pneumoniae and
N. meningitidis are the three most common causes of bacterial meningitis and
pneumonia in children
D.
In the septic child with an
abdominal focus, ampicillin, gentamicin and tobramycin are adequate
E. Avoiding monotherapy with
cephalosporin in the treatment of catheter sepsis decreases the risks of
emerging resistant organisms 10. Match the clinical features with
the corresponding type of Group B-streptococcal infection:
A.
Early onset neonatal Group-B Streptococcal infection
B.
Late onset Group-B Streptococcal infection
____
1.
Higher association with pneumonia
____
2.
Higher association with meningitis
____
3.
Type III isolated 95% of the time
____
4.
Poor correlation with maternal 11. Both
the choice of antibiotics and the population at risk being treated affect
bacterial complications of a disease. Select
whether the following statements are true or false:
____ Ampicillin/gentamicin is a
synergistic combination against Group B Streptococcal infection
____ Ampicillin/chloramphenicol is a
synergistic combination against Group-B Streptococcal infection
____ Low complement levels, poor
opsonization capacity, and decreased immunoglobulin levels account for a
newborn’s susceptibility to Group-B Streptococcal infection
____ Simple and exchange
transfusions improve short-term outcome in Group-B Streptococcal infection
____ Most babies with Group-B
Streptococcal infection are born to mothers who possess antibodies against the
infecting strain
____ Listeria monocytogenes becomes
more coccoid in morphology the longer it stays in culture
____ High risk groups for Listeria
monocytogenes include neonates, pregnant women, and the elderly
____ Listeria monocytogenes has a
bi-modal presentation similar to Group-B Streptococcal infection 12. Regarding sepsis, match the following associated findings with the most
accurate diagnosis A or B:
A.
Early onset Listeria monocytogenes sepsis
B.
Late onset Listeria monocytogenes sepsis
____
1.
Mother has a “flu-like” illness
____
2.
Meningitis
____
3.
Type 4B
____
4.
Mothers are asymptomatic 13. A
full-term infant is born by spontaneous vaginal delivery to a mother with active
herpetic lesions. All of the
following statements regarding Herpes Simplex virus infection are true except:
A.
Contraction during delivery is the most common
B.
Approximately 6% of babies
delivered by Cesarean section within 4 hours of rupture of
Membranes become infected
C.
10-20% of adult genital diseases may be caused by Type I Herpes Simplex
virus
D.
Incubation period is approximately 2 days
E.
Premature babies are more likely to be affected 14. Select whether the following
statements regarding Herpes Simplex virus are true or false:
____ Mucosal or skin lesions are
only present 20-30% of the time in neonatal diagnoses
____ Meningoencephalitis occurs in 75% of neonatal diagnoses
____ Disseminated diagnosis has a mortality rate of 40%
____ Type 2 has an increased rate of
pneumonitis and disseminated intravascular coagulopathy than Type 1
____ Mothers with genital lesions need to beisolated from their babies
____ It may be wise to isolate the
mother from the newborn when the mother has oral lesions 15. A
2 year-old male presents to the emergency department with tachycardia,
hypotension, fever, and ecchymotic lesions on his trunk and lower extremities.
You suspect meningococcemia. All
of the following statements regarding Neisseria meningitis are true except.
A.
The disease caused by Neisseria meningitidis is usually endemic
B.
Ninety percent (90%) of infections occur in children < 2 years of age
C.
Prior infection with influenza A
or B has been associated with increased susceptibility to infection with
Neisseria meningitidis
D.
More common in males
E.
Carriage of the organism in the nasopharynx is very rare 16. Unfavorable prognostic features in meningococcal infection include all of
the following except:
A.
Cerebrospinal fluid, white blood cell count of 3 mononuclear cells/mm3
B.
Presence of petechiae for < 12 hours prior to admission C. Presence of shock
D.
An erythrocyte sedimentation rate of 100 mm/hr
E.
A peripheral white blood cell count of 3000/mm³ 17. Which of the following is true
regarding fulminant meningococcemia:
A.
Rarely fatal
B.
Petechiae are universally absent
C.
Large doses of exogenous corticosteriods always reverses the shock state
D.
Cardiovascular collapse is secondary to endotoxemia
E.
Mortality is approximately 35% in patients with unfavorable pronostic
factors 18. Which statement is true regarding
meningococcal infection:
A.
High dose methyprednisolone always reverses the associated shock state
B.
Myocarditis develops 24-48 hours after presentation in 3-5% of all
patients
C.
Pneumonia is always mild
D.
Rifampin prophylaxis of household and day care center contacts is
recommended 19. Which of the following infections
is associated with petechiae:
A.
H. influenza
B.
N. gonorrhea
C.
N. meningitidis
D.
S. pneumoniae
E.
All of the above 20. Which of the following statements
regarding H. influenzae type b infection is least accurate:
A. Acute sepsis may mimic meningococcemia
B. Adrenal hemorrhage is recognized in fatal cases
C. Death related to overwhelming
sepsis is caused by intractable hypotension and cardiac dysfunction
D. Chemoprophylaxis with Rifampin is recommended for all household contacts
E. Rifampin prophylaxis should be
administered one month after completion of the therapeutic antibiotic course 21. Which of the following statements
regarding meningitis in children is true:
A.
Otitis media has not been associated with H. influenzae meningitis
B.
Contaminated lake water is a recognized source of Neigleria meningitis
C.
Meningitis usually involves the parenchyma of the brain
D.
Virchow-Robin spaces are
continous extensions of the subararchnoid space which prevent bacteria from
infecting the surface of the brain
E.
The process of meningitis rarely includes cerebral edema 22. Regarding the pathophysiology of meningitis, which of the following
statements is/are the most appropriate responses (s):
A. Convulsions in the first 72 hours of the illness carry a grave prognosis
B. Children less than 5 years of age
who attend a day care center are a lower risk of meningitis than the average
child
C. Limitation of ocular movement always indicates increased intracranial
pressure
D. Papilledema that develops within
the first day of presentation is more likely to be due to a ruptured brain
abscess than meningitis itself
E. All of the above 23. Which
one of the following statements is incorrect regarding the clinical
manifestations of bacterial meningitis:
A.
Convulsions occur in 30% of cases during the course of the illness
B.
Convulsions that are limited to
the first 48-72 hours of illness carry a better prognosis
C.
Kernig’s sign is positive when pain is elicited after extension of the
leg
D.
Limitations of extraocular movements are secondary to paresis of cranial
nerve VII
E.
Tuberculosis and crypotococcal
meningitis are more likely to present with focal signs and papilledema 24. All of the following statements
regarding laboratory diagnosis of meningitis are true except:
A. Definitive diagnosis is made by cerebrospinal fluid culture
B. The normal opening pressure, by spinal manometer, in the neonate is
90-110 cm H2O
C. The normal opening pressure of older children and adults is up to 180 cm
H2O
D. An acceptable upper limit for
white blood cell numbers of cerebrospinal fluid in the full-term infant, is 32
white blood cells/mm³
E. In newborns, neutrophils may
comprise 90% of the white blood cells in the cerebrospinal fluid and still be
considered normal 25. Cerebrospinal fluid abnormalities can help to determine the etiology of
meningitis. Select whether the
following statements are true or false:
____
Spinal fluid remains clear with up to 500 white blood cells/mm³
____
Red blood cells in the
cerebrospinal fluid may raise the protein by 5 mg/100ml for every 1000 red blood
cells/mm³
____
Abnormal cerebrospinal fluid lactate is > 2mg/100ml 26. Which of the following is true
regarding partially treated meningitis:
A. Clinical course and outcome are
improved when prior treatment (oral antibiotics) has been administered prior to
hospitalization
B. Cerebrospinal fluid becomes
“sterile” within 1 hour of parenteral antibiotic administration
C. Specific antigens of the
bacterial capsule are detectable for up to two weeks after antibiotic therapy
D. Approximately 50% of children receive antibiotics in some form prior to
diagnosis 27. Regarding evaluation and therapy of a child with meningitis, which of the
following statements is least accurate:
A. Tuberculous meningitis is less
likely to present with focal signs and papilledema than other causes of
bacterial meningitis
B. Cryptococcal meningitis is more
likely to present with focal signs and papilledema than bacterial meningitis
C. The presence of retinal hemorrhages suggests cortical vein thrombosis
D. The normal cerebrospinal fluid opening pressure in the neonate is 100 mm
H2O 28. The following statements
regarding complications of meningitis are all true except:
A. SIADH has been noted in > 50% of patients
B. Subdural effusions mostly occur
beyond the first week of the illness and eventually resolve spontaneously
C. Cerebral vasculitis leading to
capillary leakage is the likely pathogenesis of subdural effusions
D. The most common cause of
recurrent fever after initial treatment of meningitis is a nosocomial infection
E. By day 5 of treatment, only 30%
of children with H. influenzae meningitis will be afebrile 29. Select whether the following
statements regarding childhood meningitis are true or false:
____ Fever that persists beyond the
10th hospital day is most likely due to subdural
effusions, drug fever, arthritis, brain abscess and nosocomial infection
(in descending order)
____ Thirty to fifty percent (30% to
50%) of persistent fevers have an unknown etiology despite adequate treatment
for meningitis with negative blood cultures
____ The outcome of children is
directly proportional to the persistence of positive cerebrospinal fluid
cultures
____ Gram negative endotoxin may be
related to the formation of intracranial abscesses, hydrocephalus and
porencephalic cysts in children with gram negative meningitis 30. All of the following statements
regarding therapy of meningitis are true except:
A. Respiratory isolation is required
for 24-48 hours after initiation of antibiotic treatment
B. Hyperglycemia may worsen outcome of children with cerebral ischemia
C.
The American Academy of
Pediatrics recommends dexamethasone as a treatment option for children with
suspected bacterial meningitis
D. Aztreonam, a synthetic monocyclic
b-lactam antibiotic, has been shown to be
effective in the therapy of gram negative infections
E. The child with a
ventriculoperitoneal shunt and suspected meningitis should receive a combination
of ampicillin and clindamycin for adequate antimicrobial coverage 31. Select whether the following
statements regarding childhood meningitis are true or false:
____ Most neonatal meningitis
cases require ³ 21 days of intravenous antibiotics
____ With tuberculous meningitis, a
lymphocytic reaction in the cerbrospinal fluid may mimic a viral etiology
____
In the first several weeks of
tuberculous meningitis, cerebrospinal fluid glucose and protein may remain
normal
____ Acid-fast smear in tuberculous meningitis is positive in > 90% of
patients
____ Long-term sequelae for bacterial meningitis occur in 30-50% of affected
patients 32. Singer
criteria for hospital admission of patients with probable aseptic meningitis
include all of the following except:
A.
Deteriorating clinical condition
B.
Patients < 1year of age
C.
All children who have received antibiotics in the week prior to
presentation
D.
Cerebrospinal fluid: increased protein, decreased glucose, > 1000 WBC/mm³
E.
An older sibling with an upper respiratory infection 33. The following statements are all
true regarding ECHO and coxsackie viruses except:
A.
Typical incubation period is 3-5 days
B.
Group B is most common Coxsackie, and type 9 among ECHO viruses
C.
Peak incidence occurs in late summer
D.
Meningitis is usually benign
E.
Incidence rates increase with higher socio-economic groups 34. Select whether the following
statements regarding meningitis are true or false:
____
Lymphocytic choriomeningitis develops after contact with infected rodents
____
Corticosteriods greatly enhance recovery time of aseptic meningitis 35. All of the following statements
regarding viral encephalitis are true except:
A.
Enteroviruses and Arboviruses are the most common etiologic agents
B.
In 75% of cases, no specific etiology can be established
C.
The hallmark of the disease is a disturbed higher cerebral function
D.
The majority of cases are secondary to hematogenenous spread
E.
With Herpes Simplex virus, the EEG displays abnormalities in the
occipital cortex 36. Which of the following statements
is true regarding arboviruses:
A.
Highest mortality occurs with California equine encephalitis
B.
Transmitted by rodents
C.
Occurs in late autumn and early winter
D.
St. Louis encephalitis is the most common arbovirus infection in the US 37. Match each of the following
arboviruses with its likely clinical presentation:
A.
Eastern Equine Encephalitis
B.
Californian Equine Encephalitis
C.
Western Equine Encephalitis
D.
Venezuelan Equine Encephalitis
____ Midwest: “LaCrosse strain”; school-age children; most recover without
sequelae
____ Abrupt onset: children, 1 year
of age; extensive neuronal death with devastating sequelae
____ California and Texas;
hyperplasia and occlusion of small blood vessels; elevation of
intracranial pressure
____ Affects adults more than children; rare neurologic involvement 38. All of the following statements
regarding Rocky Mountain Spotted Fever are true except:
A.
It is a tick borne disease
B.
Occurs primarily in the Rocky Mountain area
C.
Complicated by meningoencephalitis in 30% of cases
D.
Ten percent (10%) of cases progress to coma 39. A
6-year-old female presents with a high temperature for 3 days despite negative
blood and cerbrospinal fluid cultures. A
CT scan of the brain reveals a 2 cm ring-enhanced lesion consistent with a brain
abscess. The most likely
predisposing condition is:
A.
Suppurative otitis media
B.
Suppurative mastoiditis
C.
Suppurative frontal sinusitis
D.
An uncorrected Tetralogy of Fallot 40. Which of the following statements
about brain abscess is most accurate:
A. Abscess formation occurs in areas
of the brain with generous blood supply and is therefore most commonly seen in
gray matter
B.
Brain abscess formation very
commonly complicates bacterial meningitis beyond the neonatal period
C. When seizures develop, they are always focal in type
D. Brain abscess formed by
hematogenous seeding is usually in the distribution of the middle cerebral
artery
E. All of the above 41. Regarding the microbiology and chemotherapeutic treatment strategies for
brain abscess, which of the following is most accurate:
A. The overwhelming majority of
brain abscesses are caused by a single organism and polymicrobial etiology is
very rare
B. Suppurative otitis media due to
H. influenza type b is the most common predisposing factor
C. Aminglycosides are the drugs of first choice
D.
In the neonatal period,
Citrobacter diversus and Proteus mirabilis are the most common etiologic agents
E. All of the above 42. Which of the following statements
regarding subdural empyema is true:
A.
The subdural space at the base of the brain is most frequently involved
B.
Is usually restricted from
spreading by the suture lines where the dura is firmly adherent
C.
H. influenzae is the most common etiologic agent in infants
D.
MRI is the diagnostic imaging procedure of choice
E.
All of the above 43. Match the most likely organism
with its disease process:
A.
Brain abscess in a child with a cyanotic congenital heart disease
B.
Subdural empyema
C.
Spinal epidural abscess
____
1.
Staphylococcus aureus
____
2.
Aerobic streptococci
____
3.
Hemolytic streptococci 44. Which
is the following is not a prosposed diagnostic criterion for Toxic Shock
Syndrome in children:
A.
Fever > 39° C.
B.
Diffuse or palmar erythema
C.
Hypotension
D.
Lymphocytosis
E.
Diarrhea or vomiting 45. Which of the following is true
regarding Toxic Shock Syndrome:
A.
Is caused by coagulase negative staphylococci
B.
Neutralizing antibodies are formed immediately by the body against the
toxin
C.
Menstrual cases seen exclusively in African-American
D.
A serum creatinine > 3mg/dl at presentation predicts a prolonged
hospital course
E.
All of the above 46. Which of the following statements
regarding Rocky Mountain Spotted Fever is true:
A. Most victims are adults
B. Dermacentor variabilis is most
common tick involved in the eastern regions of the US, and D. Andersoni is the
most common tick in the West
C. Peaks in winter
D. Incubation period is 24 hours
E. Man is the primary host of R. Ricketsii 47. All of the following statements
are true regarding Rocky Mountain Spotted Fever except:
A. Initial presentation consists of fever, headache, and malaise
B. Rash appears 10 days after the onset of fever and begins on the trunk
C. Erythematous macules become petechial over the course of several days
D. Complement fixation or indirect
fluorescent antibody titers are used to confirm the diagnosis
E. Diffuse vasculitis affects many organ systems 48. All of the following statements
regarding Legionnaire’s disease are true except:
A.
Mostly affects adult males
B.
May present with cerebellar ataxia
C.
Lung disease is lobar
D.
Fever, non-prodcutive cough, hematuria and encephalopathy are presenting
signs
E.
Accounts for 50% of pneumonias in adults 49. Superantigens
are potentially involved in which of the following disorders:
A.
Toxic Shock Syndrome
B.
HIV infection
C.
Kawasaki Syndrome
D.
All of the above
E.
None of the above 50. Toxic Shock Syndrome in:
A.
An adult
B.
A child
____ 1.
Prodromal synptoms of fever, mucosal erythema, vomiting, dizziness almost
always seen
____ 2.
Hypotensions is prominent at admission 51. Match the following:
A.
Brain abscess in a newborn with meningitis
B.
Brain abscess in a child with uncorrected Tetralogy of Fallot
C.
Brain abscess secondary to a penetrating brain injury
D.
Brain abscess in a patient with a compromised immune system
____
Nocardia spp.
____
Citrobacter diversus
____
a-hemolytic streptococci
____
Staphylococcus aureus Answers 1.
E
In pediatric and newborn services,
lower respiratory infections are the most common type of nosocomial infection
followed by bacteremia, urinary tract, cutaneous and surgical wound infection. S.
aureus predominates as the most common cause of lower respiratory infections
in newborns, not Klebsiella. Klebsiella is the most common organism isolated from pediatric
lower respiratory tract nosocomial infections.
Other common lower respiratory pathogens include P.
aeroginosa, Coagulase Negative staph, and E. coli. E.
coli is the most common cause of pediatric, nosocomial, urinary tract
infections. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 976, 997 table 30.2) 2.
A Pneumococcus and Branhamella are
the most common organisms causing sinusitis in the general pediatric population
< 10 years of age. In ICU patients with a nasotracheal tube in place, a
variety of gram-negative organisms, including, P.
aeruginosa, Klebsiella, Proteus, E. coli, Enterobacter and Serratia,
are found. Often, these
infections are polymicrobial. Direct
aspiration and culture of the material should direct therapy. Ocular infections are often caused by P. aeruginosa and may
progress if left untreated. Infection
from environmental contaminants also occurs.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 987-988) 3.
E Gram negative organisms, not
anaerobes, are the dominant organisms that colonize the trachea in patients who
are intubated. Colonization is
increased in those patients receiving cimetidine or antacids. Respiratory equipment, including nebulizers, medications and
hand ventilators may also become contaminated and contribute to respiratory
infections. Uncuffed endotracheal tubes contribute to the aspiration of oral
secretions. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 989) 4.
C Local inflammation does not
correlate with the duration of arterial catheter insertion and is not predictive
of catheter tip colonization. All
other responses are true. Catheters
placed by surgical cutdown have twice the incidence of infection and nine-fold
increase in septicemia. Disposable
transducers used for 4 days had no higher risk of infection than those used for
2 days. At 8 days, the prevalence
of contamination was significantly higher for the transducers (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp 981-982)
5.
E Approximately 30% of TPN
infections are caused by fungi with C.
albicans, candida species, and Torulopsis
being primarily responsible.
All of the other statements are true.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 984) 6.
T, T, T, F, T In spite of the
inherently invasive nature of ECMO, few reports of infectious complications have
risen. Approximately 5% of the
cannulas placed for extra-corporeal life support became infected. (Rogers MC, et
al. Textbook of Pediatric Intensive Care, 3rd Edition; pp 986-987) 7.
D Cleansing with providone-iodine or
the use of antibiotic impregnated catheters have not been shown to significantly
lower the incidence of urinary tract infections in the intensive care unit. Gram
positive isolates predominate in UTI in both sexes.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 991-992) 8.
B
The prophylactic use of
antibiotics does not significantly decrease the incidence of infection
associated with intracranial pressure monitoring devices, and therefore, use of
prophylactic antibiotics in this setting is not indicated.
Increasing the frequency of breaks into the system, such as obtaining
samples or flushing the catheter with saline, does increase the risk of
infection. However, placement of
these catheters either in the intensive care unit or the operating room, has not
been shown to make a substantial difference in terms of the rate of infection.
The presence of blood within the ventricular system does increase the
risk of infection. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 993-994) 9.
D Ampicillin and an aminoglycoside
alone will not be adequate coverage for intraabdominal infection. It is necessary to cover for anaerobic bacteria as well.
Therefore, a combination of ampicillin, gentamycin and clindamycin, is
one approach the child with abdominal sepsis.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1012-1013) 10.
A, B, B, B Early onset neonatal
group B streptococcal infections are usually seen within the first week of
birth. Early onset disease is
primarily a disease of premature infants < 35 weeks gestation and weighing
<2500 g at birth. Late onset
infection can be delayed up to three months after birth.
There is a poor correlation between the late onset group B streptococcal
infection and maternal colonization, 95% of the isolates are Type III, and there
is a higher association with meningitis, as opposed to association with
pneumonia that is seen with early onset group B streptococcal infection.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1016-1017) 11.
T, F, T, T, F, T, T, T
The initial
antibiotic therapy of the sick neonate generally consists of ampicillin and an
aminoglycoside. While the
combination of ampicillin and gentamicin is synergistic against group B
streptococcal infection, the addition of chloramphenicol to ampicillin is of no
additional benefit. The immaturity of immunologic system of the newborn
predisposes this group of patients to susceptibility to group B streptococcal
infection. It is the deficiency in
complement, antibodies and plasma components that is thought to be responsible
for the short-term outcome improvement in simple and double volume exchange
transfusions. Listeria monocytogenes generally affects extremes of age and
pregnant women, and it has a bi-modal presentation similar to group B
streptococcal infection (i.e., early onset and late onset). (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp 1019-1020) 12.
A, B, B, B
Late onset Listeria
monocytogenes infection is usually seen in healthy full-term infants who are
born to mothers who are asymptomatic at the time.
The vast majority of infections are due to Type 4 B and there is a higher
association with meningitis. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1020-1022) 13.
D The majority of infections in
which a source is identified are related to maternal genital infections.
The incubation period for neonatal Herpes is usually longer than seven
days. The likelihood of the neonate
contracting the disease is correlated with a prolonged rupture of membranes
(> than 6 hours) in a mother with active genital infection.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1023-1024) 14.
T, F, F, T, F, T Herpetic
meningoencephalitis occurs in approximately 50% of neonatal diagnoses. Mothers with genital lesions need not be isolated from their
babies, in contrast to mothers with oral or perioral lesions who should be
preferably isolated from their newborn babies.
The prognosis for babies with disseminated infection is approximately
90%. HSV-2 has an increased rate of pneumonitis and DIC, which may relate to its
poorer outcome when compared to HSV-1. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1023-1024) 15.
E Neisseria meningitidis is usually
endemic and is commonly carried in the nasopharynx of the healthy population.
The infection is more commonly in males. Influenza A and B are associated
with an increased susceptibility to infection.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1025-1027) 16.
D
Several attempts at classifying
meningococcal disease severity and prognosis have occurred.
The characteristics that are associated with a worsened outcome represent
failure of the child’s organ systems to adequately compensate for the disease.
A low leucocyte count in the periphery or in the CSF may represent a
failure of the host’s neutrophils to mount an adequate response.
Similarly the presence of shock, petechiae, and thrombocytopenia, are
unfavorable. The elevation of the
sedimentation rate is, in part, due to elevation of the acute phase reactants,
which includes fibrinogen, and this will take at least 24 hours. A sedimentation rate of 100mm/hr (as stated in the question)
would suggest that the infection has been going on for more than several hours,
and it would constitute a good prognostic feature. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1026-1027, Tables 31.13, 31.14, 31.15, 31.16, and 31.17) 17.
D The cardiovascular collapse and
instability associated with meningococcal infection was originally thought to be
due primarily to adrenal dysfunction. However
large doses of exogenous corticosteroids were not always effective in reversing
the shock state, and therefore, the more recent prevailing theory is that the
cardiovascular collapse is actually secondary to endotoxemia with its effect in
inducing multiple organ dysfunction syndrome. Fulminant menigococcemia has an
estimated mortality rate of 85%. Petechiae
are frequently present in this disease and are related to a failure of the
hematopoietic system and DIC. Corticosteroids
were a promising intervention that have not been demonstrated to universally
reverse the shock state. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1026-1029) 18.
D Myocarditis which is believed to
be a form of vasculitis generally develops a 4-7days after onset of infection,
and pneumonia can be very severe and require mechanical ventilatory support.
The recommendation of using Rifampin prophylaxis for household and
day-care contacts is universally agreed upon. Corticosteroids were a promising
intervention that have not been demonstrated to universally reverse the shock
state. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp1029-1032) 19.
E Petechiae and ecchymosis may be
noted with any of the infections mentioned although they are typically
associated with Neiseria infection. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1032-1034) 20.
E
H. influenzae infection may mimic
meningococcemia. Adrenal hemorrhage
has been noted in 55% of the fatal cases of Hemophilus influenzae sepsis.
Intractable hypotension and cardiac dysfunction usually lead to death in
affected patients. Rifampin
prophylaxis should be initiated immediately after diagnosis of the H. influenzae
type B infection, in household contacts. It
should be incorporated into the therapeutic antibiotic regimen of the index case
in the last few days of therapy, and should not be delayed until one month after
completion of antibiotic therapy. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1032-1034) 21.
B A history of freshwater lake
swimming is an important etiologic risk factor for Neigleria meningitis.
Otitis media is often seen in association with H. influenzae meningitis.
Meningitis in the vast majority of cases does not actually involve the
parenchyma. It is limited to the
three layers of the meninges. The Virchow-Robin spaces are a continuous extension of the
subarachnoid space, which will allow the bacteria to gain access into the
subarachnoid space, and maybe to the most superficial surface of the brain.
Meningitis, when severe, is often associated with cerebral edema. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1040-1060) 22.
D
Even in the absence of an index
case within the day care setting, children who attend day care centers are at
higher risk of developing meningitis. Convulsions occurring within the first
24-72 hours of meningitis may represent febrile seizures and therefore have a
better prognosis. Convulsions that develop beyond this period carry a less
favorable prognosis. Limitation of
ocular movement may be due to abnormalities in the 3rd cranial nerves
and does not always indicate increased intracranial pressure.
When papilledema is noted on the first day of admission of meningitis,
other etiologies should be sought, particularly an intracranial mass lesion,
such as a brain abscess. (Rogers MC, et al. Textbook of Pediatric Intensive
Care, 3rd Edition; pp 1047-1060)
23.
D Limitation of ocular movements may
result from irritation of cranial nerves III, IV, or VI. Convulsions do occur in
at least 30% of meningitis cases. Those
convulsions that are limited to the first 24-72 hours carry a better prognosis.
See response to question 22 above. (Rogers MC, et al. Textbook of
Pediatric Intensive Care, 3rd Edition; pp 1047-1049) 24.
E
Bacterial culture of the CSF is
considered the gold standard. The
presence of any neutrophils in the cerebrospinal fluid in the newborn period
should be treated with a high degree of suspicion.
This may be one of the early manifestations of meningitis. However, in newborn infants polymorphonuclear leukocytes may
comprise up to 60% of the total CSF white cell population and still be
considered normal. The opening pressure in the neonate is between 90 and 110 mm
H2O, whereas in the older child and adult it may be as high as 180 mm
H2O. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp 1049-1051,
Table 32.4) 25.
T, F, F Spinal fluid remains clear
with up to 500 WBCs/mm3. Erythrocytes
raise the CSF protein concentration by about 15mg/dl for every 1000 RBCs/mm3.
A cerebrospinal fluid lactate level of more than 14 mg % is considered abnormal.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1049-1047) 26.
D
Children who are diagnosed and
admitted to the hospital for meningitis have commonly received some form of
antibiotic, usually oral, prior to presentation. This form of antibiotic usually
is not sufficient to treat meningitis, and therefore, it does not improve the
outcome in these patients. Several
hours after the administration of an appropriate antibiotic, it is certainly
possible to inhibit bacterial growth in the spinal fluid.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1051-1052) 27.
A
Tuberculous meningitis, which is
usually a basal form of meningitis, is more likely to present with focal
neurologic signs and papilledema, particularly cranial nerve palsies such as
cranial nerves VII, VIII and IX. Cryptococcal
meningitis may present only with behavioral changes , or it may present with
symptoms of a space occupying lesion. The
opening pressure in neonates may be as high as 110 mm H2O. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1052-1060; American Academy of Pediatrics.
Cryptococcus neoformans infections. In: Pickering LK, ed.
2000 Red Book: Report of the Committee on Infectious Diseases. 25th
Ed. Elk Grove Village, Il) 28.
E By day 5 of treatment with
antibiotics, 85% of children with H. influenzae meningitis will be afebrile.
The syndrome of inappropriate anti-diuretic hormone secretion (SIADH) has
been noted in more than 50% of patients with meningitis.
Under these circumstances, restriction of fluid and close monitoring of
fluids and electrolytes are a necessary part of the management of these
patients. Subdural effusions which are a recognized complication of
meningitis, generally resolve spontaneously and do not require surgical
intervention in the vast majority of cases.
Nosocomial infection is a common cause of recurrent treatment after
initial treatment for meningitis. (Rogers MC, et al. Textbook of Pediatric
Intensive Care, 3rd Edition; pp 1052-1054) 29.
T, T, F, T The causes of fever that
persists beyond the 10th day in the setting of meningitis are
subdural effusions, drug fever, arthritis, brain abscess and nosocomial
infection. Thirty to fifty percent
of fevers are idiopathic. Persistence
of a positive cerebrospinal fluid culture would be a poor prognostic feature in
patients with bacterial meningitis. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp1053-1060) 30.
E The frequency of shunt infections
varies between 2 and 30% and is influenced by a variety of factors.
Children suspected of having a shunt infection or meningitis should
receive coverage with antibiotics for gram positive organisms including
staphylococcus species as well as gram-negative organisms.
Staphylococcal species are the most common.
Initial therapy should include vancomycin because the frequency of
methicillin resistant staphylococci is high. Respiratory isolation of the
patient for the initial 24hours of antimicrobial therapy is an important
epidemiologic consideration. The data regarding the use of dexamethasone in
meningitis are controversial. (Rogers MC, et al. Textbook of Pediatric Intensive
Care, 3rd Edition; pp 1061-1062) 31.
T, T, F, F, T The CSF cytology in
tuberculous meningitis mimics the lymphocyte predominance found in viral
meningitis. CSF glucose is
classically reduced and the protein level is elevated.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1050-1061) 32.
E Aseptic meningitis is an
inflammatory process of the meninges that results from a number of different
etiologies. An elevated protein, a
pleocytosis and the absence of organisms on gram stain and culture characterize
it. The etiologies associated with
this diagnosis are rather large and include viral, bacterial, and fungal causes.
Admission of the patient to the hospital depends upon the certainty of
the diagnosis. To the extent that the patient is stable and the likelihood
of a partially treated bacterial etiology is ruled out, outpatient management
may be acceptable. (Mandell ML, et
al. Principles and Practice of Infectious Diseases, 3rd Edition; pp 1367-1379) 33.
E
Enteroviral infections are higher
in lower socioeconomic groups, have a 3-5 day incubation, and are typically seen
in the latter part of the summer. The meningitis associated with these
infections usually has a benign course. (American Academy of Pediatrics.
Enterovirus infections. In: Pickering LK, ed.
2000 Red Book: Report of the Committee on Infectious Diseases. 25th
Ed. Elk Grove Village, Il)
34.
T, F
(Mandell ML, et al. Principles
and Practice of Infectious Diseases, 3rd Edition; pp
1367-1379) 35.
E With Herpes Simplex virus
infection, particularly with meningoencephalitis, the electroencephalogram
displays abnormalities typically in the frontal and temporal lobe area of the
brain. All of the other responses are true
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1064-1066) 36.
D
Arboviruses are arthropod borne
viruses and are a common cause of encephalitis.
These infections are usually seen in late summer and spring, and they are
transmitted by arthropods. St.
Louis encephalitis is the most common Arbovirus infection in the US, and is
generally a mild disease. The
highest mortality usually occurs with Eastern equine encephalitis.
California encephalitis is usually a mild disease.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1062-1064) 37.
B, A, C, D St. Louis encephalitis
virus is distributed throughout most of the United States and causes major
epidemics that peak later than other arboviruses.
Most infections are asymptomatic, and less than 1% have overt neurologic
disease. Western equine
encephalitis is the usual cause of arbovirus encephalitis and California
encephalitis viruses occur in the central and eastern United States and cause
diseases with a fulminant and mild course, respectively. (Rogers MC, et al.
Textbook of Pediatric Intensive Care, 3rd Edition; pp 1063-1065) 38.
B Interestingly, in spite of the
name, Rocky Mountain Spotted Fever occurs primarily in the eastern US, including
the Ohio valley area. The disease is a tick-borne illness. See Question 47
below. (Rogers MC, et al. Textbook
of Pediatric Intensive Care, 3rd Edition; pp 1106-1109) 39.
D Over the past 30 years, cyanotic
congenital heart disease has replaced suppurative otitis media or mastoiditis
and suppurative sinusitis as the most common predisposing factor for brain
abscess. This is true for the
industrial nation, but even in developing nations, it is the most likely
predisposing factor. Overall, a
predisposing factor can be determined in approximately 85% of all patients with
brain abscess, and therefore, a meticulous evaluation for a predisposing factor
is warranted in these patients. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1071-1073) 40.
D Brain abscesses formed by
hematogenous seeding tend to develop at the junction of gray and white matter
and usually in the distribution of the middle cerebral artery; hence the
predominant location in the temporal and parietal lobes. Beyond the neonatal
period, meningitis is a rare form of brain abscess.
Seizures, when they occur, are more typically generalized. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1071-1074) 41.
D Normal brain parenchyma is highly
resistant to invasion by micro-organisms and therefore, abscess formation seems
to occur only in areas of the brain with focal ischemia, necrosis, or marginal
perfusion. Poor vascular supply in
the white matter or at the junction of the gray and white matter makes these
areas the most likely to be affected by brain abscess. With the exception of the neonatal period, abscess
infrequently complicates a course of bacterial meningitis.
In the neonatal period, meningitis, particularly due to Citrobacter
diversus and Proteus mirabilis are the most common etiologic agents which
usually cause meningitis and are subsequently complicated by brain abscess.
When seizures develop in association with brain abscess, they are most
commonly a generalized seizure. In
up to 30% of brain abscess cases, the microbiology is polymicrobial, which could
be a combination of aerobic and anaerobic organisms. Suppurative complications of otitis media or sinusitis are
becoming less and less common as an etiologic agent or predisposing factors for
brain abscess. Due to poor
penetration into the abscess cavity, aminoglycosides are not effective for
treatment of brain abscess. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1073-1075) 42.
D
Unlike the epidural space, the
subdural space is not limited by attachment of the dura to the skull sutures,
allowing extension and the spread of the subdural empyema over a wide area of
the cerebral hemispheres. The
potential subdural space is restricted at the base of the brain and therefore
involvement of the base of the brain is rare with subdural abscesses.
In infants, subdural empyema generally complicates acute meningitis and
therefore, is caused by the organisms commonly implicated in causing meningitis.
Because the incidence of H. influenza type b as a cause of meningitis in
infants has decreased dramatically in the US, this organism is becoming less and
less an etiologic agent for subdural empyema.
The MRI is the diagnostic imaging procedure of choice for subdural
empyema. Advantages of MRI over CT
scan include the lack of bone artifact, the ability to detect the smaller
extracranial fluid collection, and improved ability to differentiate
extracranial collection of fluid from other differential diagnoses such as
cerbritis, cerebral edema, and venous thrombosis.
MRI can also detect the density difference from elevated protein
concentration and therefore distinguish a subdural abscess from other sterile
collections such as subdural effusions. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1071-1077) 43.
C, B, A
In the child and young
adult, the most common organism causing localized para-meningeal infections such
as a subdural empyema, are the various aerobic streptococci, such as
streptococcus pnemoniae, staphylococci either the epidermidus or the aureus
species. a-Hemolytic streptococci are the most
frequently isolated organisms from brain abscesses in patients with cyanotic
congenital heart disease. Staphylococcus
aureus is the usual organism causing spinal epidural abscess and accounts for
80% of cases. See response to Q51 below.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1072-1079) 44.
D Proposed and simplified diagnostic
criteria for toxic shock syndrome in children include: fever equal to or greater
than 39° C, lymphopenia, rash, shock, diarrhea and
vomiting, and irritability. CDC has
not adopted these simplified criteria, however. Toxic shock syndrome can also be
caused by streptococci, and the streptococci toxic shock syndrome is one from of
severe Group A streptococcal disease. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1103-1106) 45.
D Staphylococcal Toxic Shock
Syndrome is caused by a coagulase postive staphylococcus that liberates an
exoprotein known as TSST-1. The
host does not form neutralizing antibodies to the toxin for at least 2 years
after infection. This, in addition
to the noninvasiveness of the organism, may help to explain the recurrent nature
of disease, especially in menstrual cases. Menstrual cases are seen exclusively
in the white Caucasion population. patients who present with elevated serum
creatinine, particularly when the serum creatinine is greater than 3 mg/dl tend
to have a prolonged hospital course.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1103-1106) 46.
B See Response to Question 47
(Rogers MC, et al.Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1106-1109) 47.
B Rocky Mountain Spotted Fever is
caused by R. rickettsii. In the
eastern regions of the US, Dermacentor variabilis is the most common tick
involved, whereas in the western region, the Dermacentor andersoni is the most
common tic involved. The disease is
usually prevalent in the summer months, and the highest incidence of disease
among children age 5-9 years. More
than half of all cases appear in persons younger than 19 years of age. The incubation period is 2-14 days, with an average of 7
days. Man is only incidentally
involved when bitten by an adult tick. The
initial presentation consists of headaches, malaise, myalgias.
The rash generally appears within 2-4 days after the fever, and has been
noted in nearly all children with the disease.
The eruptions begin as discrete macules, first observed on the ankles and
feet, and shortly thereafter on the wrists and hands.
Regardless of the progression of the rash, the rash is almost always most
pronounced over the extremities and almost always involves the palms of the
hands and the soles of the feet. Over
a period of several days, the rash becomes petechial and purpuric.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp 1106-1109) 48.
E Legionnaire’s disease was first
recognized in 1976 after an outbreak of pneumonia in Philadelphia. The organism,
L. pneumophila, accounts for only
about 15% of pneumonia in adults, but it causes acute pulmonary disease, mostly
among adult males. The disease has
also been noted in infants and children and the prevalence of elevated titers in
children is quite high in some communities.
The presenting complaints are usually fever, non-productive cough,
encephalopathy and seizures; cerebeller signs may be markedly severe in these
patients. The lung disease is
usually lobar in nature, hepatic and renal abnormalities are often also noted.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1109-1110) 49.
D Super antigens are antigens that
are derived from either bacteria or viruses which interact with the major
histocompatibility class II proteins and activate T-cells by binding to the
variable region of the beta chain of the T-cell receptor.
Stimulation of the T-cell receptors leads to polyclonal T-cell activation
which results in release of massive amounts of tumor necrosis factor alpha and
interleukin 6. These cytokines are
most likely the elements responsible for the shock and multi-organ dysfunction
seen in these diseases. Super
antigens differ from conventional antigens mainly in the manner in which they
are processed and presented to the T-cell receptors.
The polyclonal activation generally results in a reduction of the number
of circulating CD4+ lymphocytes; however, this reduction is usually reversible
and transient. Super antigens are
potentially involved in all the three disorders mentioned in the question. (Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd
Edition; pp1103) 50.
B, A Some differences have been
noted between children and adults with toxic shock syndrome.
While only a small percentage of adults have had a prominent prodromal
illness, nearly all children have between 1-6 days of symptoms preceding the
illness. These symptoms include
fever, mucosal hyperemia, erythroderma, vomiting, diarrhea, dizziness, and
myalgias. The vast majority of adults admitted to the hospital have hypotension
at presentation. This finding is
not prominent in children at the time of admission, although it may develop
later during the hospitalization. (Rogers
MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition; pp
1103-1106) 51.
D, A, B, C Brain abscesses are the
most frequently encountered form of localized intracranial infection in
children. Death usually occurs with
rupture of the abscess and spread of the infection into the ventricular system
or herniation secondary to mass effect. Citrobacter
and Proteus are the most common etiologic agents in the newborn period.
In patients with congenital heart disease, a-hemolytic
streptococci are common. Patients
who have traumatic injuries are affected by S. aureus.
Imunocompromised patient are at risk for Nocardia brain abscesses.
(Rogers MC, et al. Textbook of Pediatric Intensive Care, 3rd Edition;
pp 1071-1076)
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