Top Curbside Consult Ques7ons in Inpa7ent ID

Transcription

1 Top Curbside Consult Ques7ons in Inpa7ent ID Management of the Hospitalized Pa7ent October 2014 Jennifer Babik, MD, PhD Assistant Clinical Professor Division of Infec7ous Diseases, UCSF Disclosures! I have no disclosures. 1

2 Learning Objec7ves 1. To know the situa7ons in which formal bedside consulta7on is preferred over curbside consulta7on 2. To develop an approach to common ID ques7ons that arise in the inpa7ent sesng Outline! A Brief Word on Curbsides vs Formal Consults! Top Curbside Consult Ques7ons in ID 2

3 Curbsides vs Formal Consults! Recent study of 47 curbsides vs. formal consults! Medicine consult! Curbsided providers were not allowed to look in the chart! Results:! Informa7on in curbside was inaccurate or incomplete in 51%! Formal consult changed management in 60% (36% major changes )! If informa7on was inaccurate/incomplete then a formal consult changed management in 92% (45% major changes ) Burden et al, J Hosp Med 2013, 8:31. Are Curbsides Okay?! Yes, but we need to balance concerns re: efficiency, pa7ent safety, and educa7on! ID gets >10 curbsides per day and this accounts for ~20% of clinical work " would be impossible in most prac7ces to convert all into formal consults! See Bob Wachter s blog on curbsides The Dangers of Curbside Consults and Why We Need Them (hjp://goo.gl/fpjbj3) Denes et al, Med Mal Infect 2014, 44:374. Grace et al, Clin Infect Dis 2010, 51:651. 3

4 When Should a Curbside be a Consult?! The Goldilocks of Curbside Consulta7on! Not too simple (i.e. the answer can be easily looked up)! Not too complicated (i.e. the answer requires nuanced clinical judgment or interpreta7on of a lot of data)! Just right: Hypothe7cal, straighlorward ques7on! What we tell our ID Fellows:! Can you provide the answer without looking it up?! No " Consult! Yes and you trust the data source " Curbside The Special Case of Staph aureus Bacteremia! Benefits of ID consulta7on:! # detec7on of metasta7c foci of infec7on, endocardi7s! # removal of prosthe7c devices! Improved an7bio7c choice and dura7on! $ risk of relapse and $ mortality! No curbsides for Staph bacteremia!! Curbside consult associated with # mortality by > 2- fold compared to bedside consult Forsblom et al, Clin Infect Dis 2013, 56:527. Pragman et al, Infect Dis Clin Pract 2012, 20: 261. Tisot et al, J Infect 2014, 69:226. 4

5 Curbside #1 A 70 y/o M with diabetes is admijed with a severe diabe7c foot infec7on. He had no other symptoms. On admission he was febrile and his wound showed purulence and necro7c 7ssue. He was taken to the OR for wound debridement and culture grew MRSA. His admission blood cultures were nega7ve, but urine culture grew E. coli. UA on admission showed WBC/hpf. Do we need to treat this? Do You Need to Treat This? 1. Yes 2. No 3. I need more informa7on 5

6 Curbside #1(a) A 65 y/o M is admijed with an STEMI. 4 days into his hospitaliza7on he spikes a fever to 39, starts coughing, drops his SaO2 to the low 90s on RA, and becomes altered. He has a foley. He is started on vancomycin and pip/tazo and improves. Work- up reveals:! CXR with a new LLL infiltrate! Blood cultures and sputum culture nega7ve at 48h! UA (from his catheter) shows 30 WBC, Urine cx >100K VRE What Should You Do With His Vanco? 1. D/c vancomycin 2. Con7nue vancomycin 3. Change vancomycin to linezolid 6

7 What Do These 2 Cases Have in Common?! Asymptoma7c Bacteriuria (ASB) =! Isola7on of bacteria from a urine sample (see criteria below) AND! No symptoms or signs related to UTI! Criteria for ASB: Women Men Catheterized pa7ents (men or women) 10 5 bacteria on 2 separate voided specimens 10 5 bacteria form a single voided specimen 10 2 bacteria from a single specimen Nicolle et al, Clin Infect Dis 2005, 40:643. ASB is Common Pregnant Women Post- menopausal Women Diabe7c pa7ents Elderly pa7ents Long term care pa7ents Spinal cord pa7ents 2-10% 3-9% 9-27% 4-19% 15-50% 23-89% HD pa7ents 28% Short term catheter (<30d) 9-23% Long term catheter (>30d) 100% In hospitalized pa7ents with a posi7ve urine culture (with or without a catheter) 86-91% Nicolle et al, Clin Infect Dis 2005, 40:643. Leis et al, Clin Infect Dis 2014, 58:980. 7

8 ASB Usually Does Not Require Treatment! Why not to treat?! Treatment does not $ the risk of symptoma7c UTI or later ASB! Overtreatment is associated with adverse effects and development of resistant organisms! ASB is not associated with long- term adverse outcomes (HTN, CKD, GU malignancy, mortality)! This has been studied with RCT studies in:! Premenopausal women, diabe7c women! Pa7ent with spinal cord injuries! Elderly men and women in the community and in long term care sesngs! Pa7ents with short term and long term catheters Nicolle et al, Clin Infect Dis 2005, 40:643. Excep7ons: Who With ASB Should Be Treated?! Pregnant women! Treatment decreases risk of pyelo, premature delivery, low weight infants! Pa7ents undergoing GU procedures with mucosal bleeding! High rate of post- procedure bacteremia (60%) and sepsis (up to 10%)! RCTs support treatment to reduce these complica7ons! Timing of treatment?! Hasn t been studied start shortly before the procedure (night before is ok)! Stop a{er procedure or con7nue un7l catheter is removed! Immunosuppressed/transplant pa7ents?! Very lijle data, not addressed in most transplant guidelines or by IDSA! Many centers treat ASB in renal transplant pa7ents in the first 3 months! We also treat in neutropenic pa7ents because of the risk of invasive disease Nicolle et al, Clin Infect Dis 2005, 40:643. 8

9 The Heart of the Problem! It s Hard to Ignore a Posi7ve Culture! Proof of concept study:! Mount Sinai stopped repor7ng the posi7ve urine cultures on non- catheterized inpa7ents (a{er admission)! The percentage of ASB that was treated dropped from 48% to 12%! There were no untreated UTIs and no pa7ents developed sepsis Leis et al, Clin Infect Dis 2014, 58:980. The Million Dollar Ques7on! How do I dis7nguish between ASB and UTI? 9

10 Does the UA Help?! Pyuria is very common in pa7ents with ASB! 30% of young women! 70% of diabe7c women! 90% of elderly ins7tu7onalized pa7ents! 90% HD pa7ents! 30-75% of pts with short- term indwelling catheters (<30d)! % of pts with long- term indwelling catheters (>30d)! PPV only 32-36% for catheterized pa7ents!! Bojom line:! The presence of pyuria is not helpful and does not signify UTI! But the absence of pyuria suggests an alterna7ve diagnosis Nicolle et al, Clin Infect Dis 2005, 40:643. Tambyah et al, Arch Intern Med 2000, 160:678. Does the Organism Help?! Microbiology of ASB:! GNRs:! E. coli (most common organism isolated from women wth ASB)! Klebsiella! Indwelling devices: Proteus, Pseudomonas, Providencia, Morganella! GPCs:! Enterococcus (55% ASB, 45% UTI)! Group B Strep! Coag nega7ve Staph! Bojom line: NO, the same bugs cause both ASB and UTI Nicolle et al, Clin Infect Dis 2005, 40:643. Lin et al, Arch Int Med 2012, 172:33. 10

11 What if the Pa7ent has a Catheter?! Asymptoma7c CA- bacteriuria is common:! 9-23% of pa7ents with short- term (<30d) catheters! CA- bacteriuria usually represents ASB and NOT infec7on! Of all posi7ve urine cultures in catheterized pts, ~90% are ASB!! So how do we define a true CA- UTI? 1. Symptoms or signs c/w UTI! New or worsening fever, rigors, AMS, malaise and no other clear cause! Flank pain, CVAT, pelvic discomfort! Acute hematuria! Spinal cord injury: #spas7city, autonomic dysreflexia, sense of unease 2. No other source of infec7on (i.e., diagnosis of exclusion) Hooton et al, Clin Infect Dis 2010, 50:625. Leis et al, Clin Infect Dis 2014, 58:980. What if I Can t Assess Symptoms?! 2 main scenarios where it is difficult to ask about classic UTI symptoms: 1. The pa7ent has a catheter 2. The pa7ent doesn t have a catheter but is altered or otherwise unable to communicate! How to define UTI in these pa7ents? " use same criteria as for CA- UTI: 1. Symptoms or signs c/w UTI (as per last slide) 2. No other source of infec7on (i.e., diagnosis of exclusion) Nicolle et al, Clin Infect Dis 2005, 40:

12 How to Interpret Urine Studies in a Pa7ent Without Classic UTI Signs/Sx (e.g., with a Catheter) Alternate Diagnosis Likely? (Signs/ sx of other illness present) Yes No Do not order U/A, urine cx Send U/A, urine cx U/A, urine cx (- ) U/A (- ), urine cx (+) U/A (+), urine cx (+) U/A (+), urine cx (- ) Do not treat for UTI Asymptoma7c bacteriuria - No treatment* (unless pregnant, urologic procedure, neutropenia) - Look for alternate dx Treat for UTI - If no alternate dx iden7fied On abx No abx Do not Rx for UTI Slide courtesy of Catherine Liu. ASB vs. UTI: Take- Home Points! ASB and pyuria are common, especially in pa7ents with catheters! Pyuria UTI, but absence of pyuria strongly points to an alterna7ve source! ASB does not require therapy except for:! Pregnancy! Urologic procedures! Neutropenia, renal transplant <3 mo! To diagnose a UTI in a pa7ent with a catheter or who cannot report symptoms, the pa7ent must have:! Signs and symptoms compa7ble with UTI! No other source for infec7on (i.e., diagnosis of exclusion) 12

13 Curbside #2 I can ignore Candida in the urine, right? Can you ignore Candida in the urine? 1. Yes, in most cases 2. No, Candida is a frequent cause of UTI 13

14 Candiduria: Who Needs Treatment?! Candiduria is very common in pa7ents with catheters! Candiduria is usually asymptoma7c! In general, don t treat!! Change the foley: can eliminate candiduria in 20-40%! Excep7ons: Pa7ents at high risk of dissemina7on! Neutropenia! Pa7ents undergoing urologic procedures! (Pregnancy)! Symptoma7c candiduria (uncommon)! Same symptoms as bacterial UTI! Treat Pappas et al, Clin Infect Dis 2009, 48:503. Candida UTI: Treatment Op7ons! 1 st line: Fluconazole! Excellent urine levels, 10- fold higher than serum levels! Can get concentra7ons in the urine that are higher than the MIC for organisms that are intermediate or resistant (like C glabrata)! mg PO daily Fisher et al, Clin Infect Dis 2011, 52:S

15 Fluconazole- Resistant Candida UTI! Can try fluconazole and re- check Ucx (if not systemically ill)! Other op7ons all have poor efficacy or side effect profile:! Flucytosine! Amphotericin B (conven7onal formula7on)! Ampho bladder washes: Resolve candiduria in >90% but high number of relapses! Other azoles?! Vori, posa, itra have poor urinary penetra7on! Echinocandins?! Poor urinary penetra7on, but use if suspect systemic disease Fisher et al, Clin Infect Dis 2011, 52:S457. Candiduria: Take- Home points! Most o{en asymptoma7c and does not require treatment! Fluconazole is the drug of choice for C. albicans, and can o{en be used for non- albicans species as well! Echinocandins and the other azoles have poor urinary penetra7on 15

16 Curbside #3 A 75 y/o F with neurogenic bladder and history of prior UTI is admijed with confusion and low- grade fever. Her daughter reports a 2 day history of suprapubic pain and dysuria. UA shows >50 WBC/hpf and urine culture grows E. coli. Blood cultures were nega7ve. She improves on empiric ertapenem and is ready for discharge. Suscep7bili7es come back and the E. coli is an ESBL producer. Do I need to send her home on ertapenem or are there any oral op7ons? Which Oral ABx Has the Best Data for ESBL UTI? 1. Fosfomycin 2. Nitrofurantoin 3. Minocycline 16

17 Oral Op7ons for ESBL E. coli in the Urine An7bio7c Ciprofloxacin TMP- SMX Amoxicillin/Clavulanate Nitrofurantoin Fosfomycin % Sensi7ve in vitro Suscep7bili7es for ESBL Klebsiella are lower for fosfomycin (~58-80%) and nitrofurantoin (14%) Suscep7bili7es are similar for community- acquired and hospital- acquired infec7ons Prakash et al, An7microb Agents Chemother 2009, 53:1278. Liu et al, J Micro Immunol Infect 2011, 44:364. Kumar et al, Infect Dis Res Treat 2014, 7:1. Meier et al, Infect 2011, 39:333. Kresken et al, Int J An7microb Agents 2014, 44:295. Fournier et al, Med Mal Infect 2013, 43:62. Rodriguez- Bano, Arch Intern Med 2008, 168:1897. Clinical Data for Oral ABx in E.coli ESBL Cys77s! Fosfomycin! Several studies, mostly in outpa7ent cys77s! Course: either single dose or 3 doses qod! 94% clinical cure rate, 78% micro cure rate! Nitrofurantoin! 1 study in outpa7ent cys77s! Course: 14 days! Clinical cure rate 69%, Micro cure rate 68%! Amoxicillin- clavulanate! 1 study in outpa7ent cys77s! Course: 5-7 days! 93% clinical cure rate Falagas et al, Lancet Infect Dis 2010, 10:43. Rodriguez- Bano, Arch Intern Med 2008, 168:1897. Pullukcu et al, Int J An7microb Agents 2007, 29:62. 17

18 Reminder About These Old New An7bio7cs Fosfomycin! Does not achieve good renal/serum levels so cannot use for pyelonephri7s/bacteremia! MIC not rou7nely done in most micro labs! Recommend dosing at 3gm PO qod x 3 doses (or un7l clinical improvement) Nitrofurantoin! Does not achieve good renal/serum levels so cannot use for pyelonephri7s/bacteremia Avoid in renal failure (CrCl<60) due to inadequate urinary levels and poten7al for toxic serum levels Reffert and Smith, Pharmacotherapy 2014, 34:845. What if the Pa7ent has Pyelonephri7s?! Small study in community- acquired pyelonephri7s showing that use of non- carbapenem was equivalent to a carbapenem:! Non- carbapenems were: Amox/clav (7), Fluoroquinolone (12), TMP- SMX (5), Aminoglycoside (30), Pip/tazo (6)! Bacteremia 15% in non- carbapenem group c/w 50% in carbapenem group! Bojom line: can use in very select circumstances without bacteremia but there is limited data Park et al, J An7microb Chemother 2014, 69:

19 Oral Op7ons for ESBL UTI: Take- Home points! Most data is for E. coli ESBL (limited data for Klebsiella)! For mild- moderate cys77s:! Oral ABx choice dictated by suscep7bili7es! Consider suscep7bility tes7ng for fosfomycin if possible! Cau7on with nitrofurantoin given poor clinical cure rates! Would not use orals if the pa7ent is clinically ill, has bacteremia, or cannot be followed closely! In very selec7ve cases of mild pyelonephri7s, can consider orals (but not fosfomycin or nitrofurantoin) if no bacteremia, but data is very limited Curbside #4! A 55 y/o woman with ESRD on HD through a tunneled right IJ line is admijed with fever and abdominal pain and is found to be bacteremic on both line and peripheral cultures with Klebsiella pneumoniae. Do we have to take out the line? 19

20 Do You Need to Change the Line? 1. Yes 2. No 3. I need more informa7on What Informa7on Would Be Most Helpful? 1. Abdominal CT scan 2. Talk to micro and get the differen7al 7me to posi7vity 3. Examine the exit site for inflamma7on 20

21 For Uncomplicated Klebsiella HD- line Infec7on, IDSA Recommends: 1. Line removal 2. Op7on for line reten7on or guidewire exchange CLABSI: Diagnosis! Clinical findings unreliable:! Inflamma7on at the exit site is extremely insensi7ve (<3%)! Posi7ve peripheral bcx and > 15 CFU/plate of same organism from catheter 7p! 79% sensi7ve, 92% specific! But >80% of catheters withdrawn b/c of clinical suspicion of CLABSI are removed unnecessarily! Quan7ta7ve blood cultures (line vs peripheral) may be most sensi7ve/specific, but not rou7nely available Mermel et al, Clin Infect Dis 2009, 49:1. Safdar and Maki, Crit Care Med 2002, 30:

22 CLABSI: Differen7al Time to Posi7vity! Allows for diagnosis without removing the line! Draw culture from line + peripheral blood at the same 7me! UCSF protocol: must be drawn within 15 minutes of each other! CLABSI = blood culture drawn from central line turns posi7ve at least 2 hrs before peripheral culture turns posi7ve! Test characteris7cs! 85-95% sensi7ve! 83-90% specific Liñares, Clin Infect Dis 2007, 44:827. Bouza et al, Clin Infect Dis 2007, 44:820. Bouza et al, Clin Microbiol Infect 2013, 19: E129. Safdar et al, Ann Intern Med 2005, 142:251. CLABSI: Possible Scenarios Line (+) and peripheral (+) Line (+) and peripheral ( ) DTTP 2 hrs CLABSI DTTP < 2 hrs Look for another source Possibili7es Line coloniza7on Contaminant Bacteremia from other source with 1/2 posi7ve cultures 22

23 General Principles of Line Management! The line should be removed in complicated infec7ons:! Severe sepsis! Persistent bacteremia (>72 h of appropriate ABx)! Sep7c thrombophlebi7s! Exit site infec7on/abscess! Evidence of metasta7c infec7on: endocardi7s, osteomyeli7s! Line salvage ok in certain cases (see next slide)! Studied primarily in long- term catheters! Treat with ABx lock therapy + systemic ABx for 7-14 days! ABx lock therapy: only if no signs of exit site/tunnel infec7on! Give ABx through the line? " good in theory but no data Mermel et al, Clin Infect Dis 2009, 49:1 Line Management By Line Type + Organism (IDSA) Organism Staphylococcus aureus PICC/Short- term CVC Tunneled Cath/Port HD Catheter Remove Remove Remove Pseudomonas Remove Remove Remove Candida Remove Remove Remove Mermel et al, Clin Infect Dis 2009, 49:1 23

24 Line Management By Line Type + Organism (IDSA) Organism Staphylococcus aureus PICC/Short- term CVC Tunneled Cath/Port HD Catheter Remove Remove Remove Pseudomonas Remove Remove Remove Candida Remove Remove Remove Coag- nega7ve staphylococci Remove or retain Remove or retain Retain or guidewire exchange Enterococcus Remove Remove or retain Retain or guidewire exchange (or remove) Other GNRs Remove Remove or retain Retain or guidewire exchange (or remove) Mermel et al, Clin Infect Dis 2009, 49:1 Line Management: Take- Home Points! Differen7al 7me to posi7vity (line posi7ve at least 2 hours before peripheral) allows for diagnosis of CLABSI without line removal! All lines should be removed for any complicated infec7on or for Staph aureus, Pseudomonas, or Candida! Line management for other organisms depends on line type (lower barrier to remove line for short term catheter > long- term catheter > HD catheter) 24

25 Curbside #5 A 65 y/o woman with a prosthe7c joint infec7on on vancomycin and ce{riaxone is admijed with diarrhea and found to have C. difficile infec7on. She was started on PO vancomycin 125mg qid and has not yet had improvement of her diarrhea a{er 4 days. Should we add metronidazole or change to fidaxomicin? What is the Best Course of Therapy at this Point? 1. No change 2. Add IV metronidazole 3. Switch to fidaxomicin 25

26 When Should My Pa7ent Get Bejer? Symptoms can be prolonged by 1-2 days in the presence of concomitant ABx Al- Nassir et al, Clin Infect Dis 2008, 47:56. Cornely et al, Lancet Infect Dis 2012, 12:281. C. difficile Therapy: General Principles 1. Treat with an7- C. difficile an7bio7cs 2. Stop other ABx if possible 3. Other general points:! Avoid an7- peristal7cs! Hold PPI if possible (associated with # severity of disease) 26

27 IDSA Guidelines for C. difficile Treatment Mild to moderate WBC <15 Cr <1.5x baseline Severe WBC 15 Cr 1.5x baseline Severe + Complica7ons Hypotension Ileus Toxic megacolon Metronidazole 500mg PO 7d x 10-14d Vancomycin 125mg PO qid x 10-14d Vanco 500mg PO qid + Metronidazole 500mg IV q8 +/- Vanco 500mg PR qid (ileus) Cohen et al, Infect Control Hosp Epi 2010, 31:431. The Benefit of Adding Intravenous Metronidazole?! Part of the IDSA guidelines for severe, complicated disease (C- III)! To ensure drug levels in the colon in the case of ileus (when PO vanc may not transit to the colon)! No clinical data for combina7on therapy (with or without ileus)! Anecdotally, some pa7ents get bejer a{er addi7on of metronidazole, but this has not been studied systema7cally Cohen et al, Infect Control Hosp Epi 2010, 31:431. Brown et al, Am J Med 2014, 127:

28 Guidelines Concordance for C. difficile! Concordance with IDSA guidelines for C difficile resulted in significant:! $ mortality (5.4% vs 21.8%)! $ infec7on recurrence (14% vs 35.6%)! Guidelines were followed in 80% of mild, 35% of severe, and only 20% severe complicated infec7ons! Why discordance?! Mild disease: Trea7ng recurrent disease inappropriately! Severe disease: Trea7ng with metronidazole or trea7ng recurrent disease inappropriately! Severe complicated disease: Trea7ng with metronidazole alone or PO vanco alone (without IV metronidazole) Brown et al, Am J Med 2014, 127:865. Fidaxomicin! General points:! First- in class macrocyclic an7bio7c! Minimal absorp7on from the GI tract! Treatment dose: 200mg PO bid x 10 days! Efficacy:! Equivalent to vancomycin for cure rate in ini7al episode (~85-90%) and may have slight advantage if pa7ent is on concomitant ABx! Lower recurrence rate than PO vanco (15% vs 25%)! Issues:! Not as much experience with fulminant disease! No data for switching from vanco to fidaxomicin in case of failure! $$$$ ($2600 for a treatment course vs ~$15 for compounded PO vanc) Louie et al, NEJM Cornely et al, Lancet ID Mullane et al, CID Cornely et al, CID

29 C. difficile: Take- Home Points! ~25% of pa7ents s7ll have diarrhea a{er 4-6 of therapy (longer for PO metronidazole and if on concurrent ABx)! Refer to the IDSA guidelines, as concordance has been shown to $ mortality and recurrence! The addi7on of intravenous metronidazole to oral vancomycin in pa7ents without ileus is common in the sesng of prolonged symptoms, but its benefit is unclear! The main benefit of fidaxomicin is in its lower risk of recurrence (rather than ini7al treatment efficacy) Curbside #6! A 45 y/o woman presents to the ER with fever. Upon screening, she says she has just returned from Ethiopia where she was visi7ng a non- profit organiza7on. She has no gastrointes7nal symptoms and no other travel history. She is febrile to 39.3 and the rest of her exam is normal.! Could she have Ebola? 29

30 Could She Have Ebola? 1. No, wrong symptoms 2. No, wrong epidemiology 3. I m not sure call for help This Pa7ent Had 30

31 10/25/14 Word on Ebola Curbsides If you think your pa7ent might have Ebola, this should probably be a FORMAL CONSULT!!! Ebola: A Global Update! Widespread transmission! Liberia! Guinea! Sierra Leone! Travel- associated cases!!!! Nigeria Spain United States Senegal! As of October 19:! 9936 cases! 4877 deaths! 49% mortality rate 31

32 Ebola in the United States! 8 adults with EVD managed in the U.S.! 5 evacuated from West Africa (to Emory, Nebraska)! 1 imported (Dallas, TX)! 2 secondary cases (Dallas, TX)! Pa7ent outcomes! 4 discharged! 3 hospitalized! 1 death Could It Be Ebola? Risk Factors in Last 21 Days! Travel to an area of ac7ve transmission (Liberia, Guinea, Sierra Leone)! Contact with someone with suspected/confirmed Ebola Compa7ble Symptoms! Fever! Headache! Weakness! Muscle pain! Vomi7ng, diarrhea! Abdominal pain! Unusual bleeding or bruising 32

33 Ebola: Clinical Presenta7on! Incuba7on 2-21 days (average 8-10 days)! Starts as a non- specific febrile illness (1 st 3-4 days)! Fever, malaise, myalgias, anorexia! Gastrointes7nal phase (usually lasts 5-8 days)! Nausea/vomi7ng, abdominal pain! Severe watery diarrhea! Can have 4-12 L stool output PER DAY! Watch for hypovolemia, electrolyte abnormali7es CDC Ebola Virus Disease Informa7on for Clinicians in U.S. Healthcare SeSngs, October Ebola: Clinical Presenta7on Common Signs/Symptoms Fever 87% Fa7gue 74% Loss of appe7te 65% Vomi7ng or diarrhea 68% Headache 53% Abdominal pain 44% Joint or muscle pain 39% Chest pain 37% Difficulty swallowing 33% Cough 30% Difficulty breathing 23% Sore throat 22% Conjunc7vi7s 21% Hiccups 11% Bleeding is Uncommon GI bleeding 4-6% Vaginal bleeding 3% Hemoptysis 2% Gum bleeding 2% Epistaxis 2% Bleeding at injec7on sites 2% Hematuria 1% Petechiae/Bruising 1% WHO Ebola Response Team, NEJM 2014, 371:

34 Ebola: Clinical Course! Fatal disease! More severe symptoms early in infec7on! Usually die between 6-16 days (mean 8 days) from mul7- organ failure, sep7c shock! Non- fatal disease! Pa7ents usually improve by day 6 CDC Ebola Virus Disease Informa7on for Clinicians in U.S. Healthcare SeSngs, October EVD: Diagnosis! Basic Labs:! Leukopenia, thrombocytopenia! Elevated transaminases (AST>ALT, can be >1000)! Elevated amylase! Abnormal coagula7on studies c/w DIC! Virus- specific tes7ng by RT- PCR! Can be nega7ve in first 3 days a{er symptom onset! Arrange tes7ng at CDC through your local DPH CDC Ebola Virus Disease Informa7on for Clinicians in U.S. Healthcare SeSngs, October CA- DPH Ebola Virus Informa7on, October

35 Ebola: Transmission! Ebola is spread through broken skin or mucous membranes in direct contact with:! Blood or body fluids (urine, saliva, sweat, feces, vomit, breast milk, semen) of a person with Ebola! Surfaces and materials contaminated with these fluids! Infected fruit bats or primates! People are infec7ous only once they start having symptoms CDC, Review of Human- to- Human Transmission of Ebola Virus, October CDC Guidelines for the Use of PPE! New CDC Guidelines as of 10/20/14! Key principles of PPE Guidelines:! Repeated training for HCWs on donning/doffing PPE! No skin should be exposed! All steps of PPE donning/doffing should be supervised by a trained observer CDC, Guidance on Personal Protec7ve Equipment To Be Used by Healthcare Workers During Management of Pa7ents with Ebola Virus Disease in U.S. Hospitals, Including Procedures for PuSng On (Donning) and Removing (Doffing), October 20,

36 Ebola: Treatment! Aggressive suppor7ve care is the mainstay! Experimental therapies:! Convalescent whole blood or plasma! Monoclonal an7bodies (e.g., ZMapp)! Vaccines! Brincidofovir Ebola: Take Home Points! Think of Ebola if the pa7ent has risk factors for exposure within the last 21 days and compa7ble symptoms! Remember that Ebola starts as a non- specific febrile illness and bleeding manifesta7ons are uncommon! PCR tes7ng can be falsely nega7ve in the first 3 days of symptoms! Watch out for and aggressively manage severe hypovolemia and electrolyte abnormali7es 36

37 Top ID Curbsides 1. Asymptoma7c bacteriuria 2. Candiduria 3. Oral op7ons for ESBL UTI 4. Line management in CLABSI 5. Escala7on of therapy for persistent C. difficile 6. (Ebola) Thank You For Your Ajen7on!! Ques7ons: 37