Wright, Disclosures. Objectives. Emerging Infectious Diseases: A Discussion of New and Upcoming Infections

Transcription

1 Emerging Infectious Diseases: A Discussion of New and Upcoming Infections Wendy L. Wright, MS, APRN, BC, FAANP Adult / Family Nurse Practitioner Owner - Wright & Associates Family Healthcare Amherst, New Hampshire Owner Wright & Associates Family Healthcare Concord, NH Partner Partners in Healthcare Education, PLLC 1 Disclosures Speaker Bureau: Novartis, GSK, Sanofi- Pasteur, Merck, Takeda, Vivus Consultant: Vivus, Sanofi-Pasteur, Takeda 2 Objectives Upon completion of this lecture, the nurse will be able to: 1. Discuss various viral and bacterial infectious diseases 2. Identify the most common tests to identify etiology of various infectious diseases 3. Discuss treatment options for various emerging viral and bacterial infections 3 1

2 Influenza 4 Influenza The typical incubation period for influenza is 1 4 days (average: 2 days) Adults shed influenza virus from the day before symptoms begin through 5 10 days after illness onset. Young children also might shed virus several days before illness onset Children can be infectious for 10 or more days after onset of symptoms. Severely immunocompromised persons can shed virus for weeks or months Flu Season Early emergence of influenza in Early strains seen: H1N1 and ph1n1 Flu appears to have good match to the flu strains in this year s vaccine Current estimates suggest approximately 65% of immunized individuals will be protected Those who are immunized and contract influenza, less duration and disease burden 6 accessed

3 CDC Weekly Activity: December 27, accessed Influenza Influenza: 3 different varieties of flu viruses Type B and C affects only humans Type B more serious; more common in children. Doesn t mutate as much as type A Type C doesn t cause much disease in humans Type A: can cause epidemic and pandemic influenza 8 Influenza Type A Influenza A viruses are divided into subtypes based on two proteins on the surface of the virus: the hemagglutinin (H) and the neuraminidase (N). There are 17 different hemagglutinin subtypes and 10 different neuraminidase subtypes. 9 3

4 Type A Zoonotic viruses H1N1 Migratory foul are reservoirs for this virus spread to pigs, then pigs to human Have ability to affect a lot of other species: cats, pigs, horses 10 Influenza Different viruses come together and infect the cell at the same time; genes mix (like shuffling card deck) and a new virus/strain emerges Example: Spanish virus after 1918 lived stable in population until recombination in 1957 to the Asian virus; then 1968 recombination into Hong-Kong influenza leads to next pandemic 11 Mechanism for Influenza Shifts Two mechanisms of shifting Antigenic drift - these are small changes in the virus that happen continually over time Antigenic drift produces new virus strains that may not be recognized by the body's immune system. This process works as follows: a person infected with a particular flu virus strain develops antibody against that virus. As newer virus strains appear, the antibodies against the older strains no longer recognize the newer virus, and reinfection can occur. 12 4

5 Mechanism for Influenza Shifts Second method: Antigenic shift is an abrupt, major change in the influenza A viruses, resulting in new hemagglutinin and/or new hemagglutinin and neuraminidase proteins in influenza viruses that infect humans. Such a shift occurred in the spring of 2009, when a new H1N1 virus with a new combination of genes emerged to infect people and quickly spread, causing a pandemic Influenza Vaccines million doses produced million of these are quadrivalent Trivalent or Quadrivalent A/California/7/2009 (H1N1) A/Victoria/361/2011 (H3N2) B/Massachusetts/2/2012 Quad: B/Brisbane/60/ Influenza: Update CDC alert issued on 12/26/2013 Severe respiratory illness in young/middle age adults Same strain at 2009 pandemic Concern is that more younger individuals will become affected Encourage high risk individuals to seek early evaluation and treatment with antivirals Health.Alert@dhhs.state.nh.us issued

6 Influenza: Update Antiviral treatment indicated for: Those hospitalized Severe, prolonged illness Children < 2 years of age Those 65 years and older Any individual with: pulmonary disorders, diabetes, neuromuscular disorders, immunosuppressed, pregnant or postpartum (within 2 weeks), morbidly obese, long-term care facilities Ideally, begin within 48 hours Health.Alert@dhhs.state.nh.us issued Pharmacologic Therapy Oseltamivir (Tamiflu) Adult dosing: 75 mg bid x 5 days Prophylaxis: 75 mg once daily x 10 days (after household exposure) Dose reduction based upon creatinine clearance: Acute treatment with CrCl 10 30: 75 mg once daily x 5 days Acute treatment with CrCl < 10: not studied 17 accessed Pharmacologic Therapy Oseltamivir (Tamiflu) Pedi dosing is based upon age and weight Be sure to consult recommendations for treatment Available in 30, 45, 60 and 75 mg 18 accessed

7 Pharmacologic Therapy Zanamivir (Relenza) 5 mg/blister Dry powder inhaler Dosage: 2 puffs inhaled every 12 hours x 5 days 7 years and older Prophylaxis: 2 puffs inhaled every 24 hours x 10 days 5 years and older accessed Summary of Antivirals 20 accessed Importance of Improving Influenza Protection in the Older Adult Of all infectious diseases, influenza is foremost in its association with an agerelated increase in serious consequences leading to hospitalization, debilitating complications, and death. 1 Reference: 1. McElhaney JE, Dutz JP. J Infect Dis. 2008;198(5):

8 Influenza-related Hospitalizations a and Deaths b Increase with Age a Hospitalization rates are for b Mortality rates are for Reference: 1. Thompson WW, et al. J Infect Dis. 2006;194(suppl 2):S82-S91. Efficacy Study on High Dose vs. Standard Dose Influenza Vaccine High dose vs. standard dose in individuals > 65 years of age 24.2% more effective in preventing flu and complications than standard dose flu vaccine Studied more than 30,000 individuals accessed Hot Off the CDC Press First H5N1 flu identified in North America Severe illness Fulminant pneumonia Encephalitis, sepsis and multi-organ failure Consider in individuals returning from Asia within previous 10 days Known to circulate in animals High mortality rate 24 8

9 H7N9 Since March 2013, > 150 cases confirmed 33% death rate All except one, confirmed to have poultry exposure 1 case believed to be result of person-person exposure 25 accessed H7N9 Also produces flu symptoms Isolated to China at this time No commercially available vaccination however, CDC has serum available for vaccination should this become needed CDC and WHO encourages travel precautions: avoiding poultry, eating fully cooked poultry accessed Flu-like Illnesses 27 9

10 Coronavirus Coronaviruses are named for the crown-like spikes on their surface. They are common viruses that most people get in their lifetime. These viruses usually cause mild to moderate upper-respiratory tract illnesses. Most of these coronaviruses usually infect only one animal species or, at most, a small number of closely related species. However, SARS coronavirus can infect people and animals, including monkeys, Himalayan palm civets, raccoon dogs, cats, dogs, and rodents accessed Middle Eastern Respiratory Syndrome Coronavirus MERS-CoV Remains isolated to Arabian peninsula and surrounding countries Majority develop severe adult respiratory infections 50% have died as a result of this virus No US cases to date Spread person to person but not sustaining in community 29 accessed Important New ID. Coronavirus Two index cases: June 2012; 2 nd case Qatari citizen visiting Mecca in September 2012 Now confirmed person-person transmission Can cause a variety of symptoms including simple URI to as severe as SARS Highest risk: Arabian Peninsula but cases now identified in UK; none in US to date Important: Severe acute lower respiratory infection in individuals travelling within past 10 days to Arabian peninsula should be reported 30 accessed

11 Confirmed MERS -CoV 31 accessed Statistics and Important Information As of 12/2/ cases confirmed 71 fatalities Virus has an affinity for human kidney cells which may explain why acute renal failure has been seen in many Link has been found to camels and bats accessed Miscellaneous Emerging Infections 33 11

12 Measles January 1 August 24, 2013 Increase in reported measles cases within United States Total of 159 cases of measles were reported during this period Most cases were in persons who were unvaccinated (131 [82%]) or had unknown vaccination status (15 [9%]) 34 accessed Measles: As of August accessed CDC Vaccine Recommendations All persons aged 6 months without evidence of measles immunity who travel outside the United States should be vaccinated before travel with 1 dose of MMR vaccine for infants aged 6 11 months and 2 doses for persons aged 12 months, at least 28 days apart Routine MMR vaccination is recommended for all children at age months, with a second dose at age 4 6 years accessed

13 Meningitis Type B First outbreak reported at Princeton University with 2 nd outbreak at University of California Santa Barbara 4 cases: UCSB These outbreaks are caused by two different strains: 8 cases Princeton: ST409, UCSB: ST32 37 Annual US Deaths from Meningococcal Disease, 0-24 Years of Age, All Serogroups, Age Group (Years) Reference: 1. Cohn AC, et al, CDC. Clin Infect Dis. 2010;50(1): Clinically Significant N meningitidis Serogroups 1 Serogroup Characteristics A B C Y Leading cause of epidemic meningitis worldwide Most prevalent serogroup in Africa and China Rare in Europe and the Americas A major cause of endemic disease in Europe and the Americas No vaccine commercially available in US A major cause of endemic disease in Europe, North America Multiple outbreaks in schools and/or community Associated with pneumonia Increasing problem in the United States, affecting all age groups W-135 Small percentage of infections worldwide Recent outbreaks associated with Hajj pilgrims Reference: 1. Granoff DM, et al. Meningococcal vaccines. In: Plotkin SA, et al, eds. Vaccines. 5th ed. Philadelphia, PA: Saunders Elsevier, 2008:

14 FDA Allowing 2 dose vaccination for individuals on these campuses Vaccine is NOT licensed in US but is approved for use in Europe, Canada and Australia Prophylaxis administered to close contacts: Rifampin 10 mg/kg 600 mg bid x 2 days or Ciprofloxacin 500 mg as single dose 40 Carbapenem-resistant Enterobacteriaceae CRE Escherichia coli and Klebsiella pneumoniae are examples of this family Some have become carbapenem-resistant Healthy individuals do not generally get these infections Have been seen in individuals who are hospitalized, on ventilators or who have indwelling catheters Difficult to treat with up to 50% of those infected, dying from these infections 41 accessed cdc.gov From November 7, 2011, to February 29, 2012, CDC received reports of 63 persons with signs and symptoms of HFMD or with fever and atypical rash in Alabama (38 cases), California (seven), Connecticut (one), and Nevada (17). Coxsackievirus A6 (CVA6) was detected in 25 (74%) of those 34 patients Rash and fever were more severe, and hospitalization was more common than with typical HFMD. Signs of HFMD included fever (48 patients [76%]); rash on the hands or feet, or in the mouth (42 [67%]); and rash on the arms or legs (29 [46%]), face (26 [41%]), buttocks (22 [35%]), and trunk (12 [19%]) Of 46 patients with rash variables reported, the rash typically was maculopapular; vesicles were reported in 32 (70%) patients Of the 63 patients, 51 (81%) sought care from a clinician, and 12 (19%) were hospitalized. Reasons for hospitalization varied and included dehydration and/or severe pain No deaths were reported

15 Hand, Foot, and Mouth Disease A accessed Another Case 44 accessed Malaria CDC has reported largest number of malaria cases in United States in 40 years 1925 cases in 2011 Most cases occur in individuals who have travelled to areas where malaria transmission is common 45 MMWR 2013;62(5):1-17 accessed

16 Malaria Transmission 46 accessed Malaria Treatment Dependent upon particular species See link to treatment regimen tmenttable.pdf accessed Also.CDC has on-call providers 24 hours per day for suspected malaria 47 CA - MRSA 48 16

17 CA-MRSA 49 CA-MRSA Current estimates: 25 30% of people carry colonies of staphylococci in their noses < 2% are colonized with MRSA 50 IDSA Published Information 51 17

18 CA-MRSA Most CA-MRSA infections are not usually severe or associated with deaths although the CA strains are believed to be more virulent than the hospital strains However, current yearly estimates are: 95K invasive infections 19K deaths 52 CA - MRSA meca gene This is where the resistance originates with MRSA PCN can t bind at its target A lot of cross resistance to beta lactam antibiotics: PCN and cephalosporins particularly in the USA300 strain which is the CA-MRSA strain 53 CA-MRSA 2002 handful of cases of the bacterium which is resistant to vancomycin 54 18

19 Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin Resistant Staphylococcus aureus Infections in Adults and Children: Executive Summary Liu, Catherine et. al. MRSA Treatment Guidelines CID 2011:52 (1 February) Treatment for Uncomplicated CA-MRSA No significant risk factors for adverse outcomes I&D is the treatment of choice Antibiotics are not necessary 56 Antibiotics Indicated Abscesses associated with the following: Severe or extensive disease Rapid progression in presence of cellulitis Signs and symptoms of systemic illness Associated comorbidities or immunosuppression Extremes of age Abscess in area unable to be drained Lack of response to I&D alone 57 19

20 Statistics/Treatment in My Community 37% of staph infection at DHMC MRSA Nationally, approximately 31% are MRSA CA-MRSA antibiotic susceptibility 50% will be resistant to clindamycin Bactrim has best coverage/sensitivity: 96-98% Important for clinicians to obtain own antibiogram for communities in which you service 58 IDSA Recommendations 59 Rifampin No longer recommended as a single agent or for adjunctive therapy for the treatment of skin and soft tissue infections 60 20

21 Treatment and Eradication Strategies: Recurrent infections GOOD handwashing Treatment with Bactrim,clinda, TCN, Linezolid Bathe with disinfectants Hibiclens, phisodex, clorox bleach Utilize topical disinfectants Purell Mupirocin seeing resistance 61 IDSA: Decolonization Regimens No role for oral antimicrobials 62 Preoperative Screening Study 1,200 primary total hip arthroplasty or total knee arthroplasty patients underwent preoperative Staphylococcus nasal screening between January 2009 and July ,100 patients who underwent elective TJA between July 2008 and December 2008 served as the control group Nasal swab at least 14 days before their procedure; those who tested + were treated with mupirocin bid x 5 days intranasally and chlorhexidine baths daily x 5 days Reduced surgical site infections by 82% 63 accessed

22 More Natural Options Stay tuned Vaccine in development Lemongrass essential oil has been shown to inhibit all MRSA colony growth Tea tree oil has also been shown effective French clay is also being studied 64 Who Should Be Hospitalized? Two or more of the following: Fever > Wbc count: > 13,000/uL Bands > 10% Hand cellulitis Facial cellulitis Immunocompromise Failing outpatient therapy Age > 70 years of age 65 Tick Borne Illnesses 66 22

23 Two Sets of Guidelines IDSA ILADS 67 Erythema Chronicum Migrans Etiology Caused by a spirochete called Borrelia Borgdorferi Transmitted by the bite of certain ticks (deer, white-footed mouse) 1st cases were in 1975 in Lyme, Connecticut Affects many systems Children more often affected than adults 68 This is NOT a Lyme Bearing Tick 69 23

24 Lyme Bearing Tick 70 Erythema Chronicum Migrans Symptoms 3-21 days after bite Rash (present in 72-80% of cases)-slightly itchy Lasts 3-4 weeks Mild flu like symptoms (50% of time) Migratory joint pain Neurological and cardiac symptoms Arthritis, chronic neurological symptoms 71 Erythema Chronicum Migrans Signs Rash: Begins as a papule at the site of the bite Flat, blanches with pressure Expands to form a ring of central clearing No scaling Slightly tender Arthralgias: Asymmetric joint erythema, warmth, edema Knee is most common location 72 24

25 Erythema Migrans 73 Erythema Migrans 74 Erythema Chronicum Migrans Signs Systemic symptoms Facial palsy Meningitis Carditis 75 25

26 Erythema Chronicum Migrans Plan Diagnostic: Sed rate: usually normal Lyme Titer IGM: Appears first: 3-6 weeks after infection begins IGG: Positive in blood for 16 months High rate of false negatives early in the disease Lyme Western Blot 76 Per ILADS Diagnosis of Lyme disease by two-tier confirmation fails to detect up to 90% of cases and does not distinguish between acute, chronic, or resolved infection The Centers for Disease Control and Prevention (CDC) considers a western blot positive if at least 5 of 10 immunoglobulin G (IgG) bands or 2 of 3 immunoglobulin M (IgM) bands are positive. However, other definitions for western blot confirmation have been proposed to improve the test sensitivity. In fact, several studies showed that sensitivity and specificity for both the IgM and IgG western blot range from 92 to 96% when only two specific bands are positive Lyme specific bands: 31, 34, and 39 Accessed Erythema Chronicum Migrans Plan Therapeutic: Per CDC Amoxicillin 500mg tid x days Doxycycline 100 mg 1 po bid x days If in endemic area and tick is partially engorged, may treat with doxycycline 200 mg x 1 dose with food 78 26

27 ILADS Believe in Chronic Lyme Disease Treatment may be continued as long as needed to treat symptoms Alternative recommendations are made: Doxycyline mg bid or TCN 500 mg 1 bid Clarithromycin 500 mg 1 po bid along with hydroxychloroquine 200 mg 1 two times daily Azithromycin 500 mg once daily 79 Additional Tick Borne Illnesses 80 Anaplasmosis Formerly referred to as ehrlichioiss Transmitted by blacklegged tick or Lonestar tick 81 27

28 Locations of Blacklegged Tick ution.html#blacklegged 82 Anaplasmosis (Ehrlichiosis) Clinical picture Fever, chills, headaches, muscle aches Occurs 1-2 weeks after a tick bite Additional clues: thrombocytopenia, leukopenia, or elevated liver enzyme levels are helpful predictors of anaplasmosis, but may not be present in all patients Testing: may be negative for first 7-10 days; PCR assay test Treatment: doxycycline 100 mg 1 pill two times daily x 7-14 days (continue for minimum of 3 days after fever subsides) Alternative: rifampin accessed Babesiosis Babesiosis Parasite which invades, infects, and kills the red blood cells (Babesia microti) Babesia microti is spread in nature by Ixodes scapularis ticks (also called blacklegged ticks) Symptoms: flu-like symptoms, such as fever, chills, sweats, headache, body aches, loss of appetite, nausea, or fatigue. Babesiosis can cause hemolytic anemia (from destruction of red blood cells) 84 28

29 Babesiosis Babesiosis Treatment: atovaquone (Mepron) PLUS azithromycin; OR clindamycin PLUS quinine (this combination is the standard of care for severely ill patients) Length: 7-10 days 85 Babesiosis accessed Bartonella Bartonella (cat-scratch) Explanation: Bartonella spp. Bacterium Diagnosis: B. henselae DNA may be detected by PCR Symptoms: Fever, chills, headache, lymphadenopathy, and severe pain in the tibia, weight loss, sore throat, rash Treatment: Azithromycin: For adults and children > 45.5 kg: 500 mg on day 1, followed by 250 mg for 4 days For children < 45.5 kg: 10 mg/kg on day 1, followed by 5 mg/kg for 4 days ILADS consider Levofloxacin 87 accessed

30 Emerging Tick Borne Illness Powassan virus Tickborne illness: Northeast and Midwest 50 cases in US in past 10 years Symptoms: fever, headaches, progressive neurologic abnormalities Cranial nerve palsies, seizures, confusion, altered consciousness Incubation: 1 week 1 month 88 accessed Emerging Tick Borne Illness Diagnosis: CSF as other diagnostic testing may be negative Clue on CSF: Lymphocytic pleocytosis of less than 500 white blood cells/mm3 in the majority of POW virus encephalitis cases Granulocytes can predominate early in the disease CSF protein is generally normal or mildly elevated, while glucose concentration is normal POW virus IgM tests are not commercially available but can be requested through state health department laboratories and CDC accessed Emerging Tick Borne Illness Treatment: No known treatment 10% of cases are fatal Most symptomatic patients need hospitalization for respiratory support, IV antiviral medications and medications to reduce brain swelling and reduce seizures accessed

31 Herpes Simplex Virus HSV 1 and 2 Spread in 3 manners Respiratory droplets Contact with an active lesion Contact with fluid such as saliva 70-80% of infected individuals are asymptomatic and have no history of outbreaks Incubation period: 3-7 days with range 1day to 3 weeks 1-2% this virus asymptomatically; may be as high as 6% 91 Statistics By age of 30 years 50-80% of individuals are seropositive for HSV % seropositive for HSV2 1-2% shed this virus asymptomatically but may be as high as 6% 92 Herpes Simplex Virus Physical Examination Findings Grouped vesicles on an erythematous base Gingivostomatitis: Erythematous, edematous gingiva that bleed easily with small, yellow ulcerations Yellowish-white debris develops on mucosa Halitosis Lymphadenopathy 93 31

32 Herpes Simplex Virus 94 Herpetic Gingivostomatitis 95 Textbook Presentation of Primary Genital Herpes 96 Reproduced from Handsfield HH. Color Atlas and Synopsis of Sexually Transmitted Diseases. 1992, with permission. 32

33 Outbreak Presenting as Erythema Photo courtesy of Jeffrey Gilbert, MD. 97 Outbreak Presenting as an Excoriation Photo courtesy of Jeffrey Gilbert, MD. 98 Herpes Simplex Virus Plan Diagnostic Viral Culture HSV IgG & IgM serum antibodies Most accurate: HerpeSelect Therapeutic Antiviral Pain reliever Cool rinses Oragel 99 33

34 Herpes Simplex Virus Plan Educational: Prevent contact with infected individuals Discussion regarding asymptomatic shedding Prevent recurrences Call for worsening of symptoms (I.e. inability to drink, no urination x 8 hours) 100 Thank you for your time and attention. Wendy L. Wright, MS, APRN, BC, FAANP WendyARNP@aol.com