CURRENT INFECTIOUS DISEASE ISSUES. 11/2/15 Regina Won, MD

Transcription

1 CURRENT INFECTIOUS DISEASE ISSUES 11/2/15 Regina Won, MD

2 Disclosures None

3 Objectives Discuss common organisms seen on the wards Discuss infection control issues associated with these common organisms Discuss some uncommon organisms and associated infection control issues Discuss infections related to recent global outbreaks

4 Common organisms Staphylococcus aureus Methicillin-resistant Staphylococcus aureus (MRSA) Vancomycin-resistant Enterococcus (VRE) Clostridium difficile Influenza Urinary tract infections

5 Less common organisms Carbapenemase-resistant Enterobacteraciae (CRE) Tuberculosis Ebola Middle East Respiratory Syndrome (MERS)

6 Staphylococcus aureus Common colonizer Ubiquitous pathogen Broad spectrum of disease

7 Staphylococcus aureus Leading cause of skin and soft tissue infections Abscesses Boils Cellulitis Serious infections Endocarditis Bacteremia Pneumonia Septic arthritis Osteomyelitis

8 Methicillin-resistant Staphylococcus Aureus (MRSA) Initially seen with hospitalization or healthcare-associated risk factors (healthcare-associated MRSA) Permanent indwelling devices Residence in long term care facilities Dialysis Increasing number of patients with MRSA without risk factors (community-acquired MRSA) Distinction now blurred Transmission of CA-MRSA in hospital Acquisition of HA-MRSA in community

9 Methicillin-resistant Staphylococcus Aureus (MRSA) Per CDC study, # of invasive MRSA infections on decline Declined 54% in hospital onset infections between w/30,800 infections 28% decrease in healthcare associated community acquired MRSA 9000 fewer deaths between

10 Courtesy of Dan Diekema

11 Staphylococcus aureus Colonization Can commonly live on skin or in nose Can be colonized and not cause infection 25-30% colonized with Staph aureus 1% colonized with MRSA Colonization can last for months to years

12 Transmission of MRSA Direct contact with infected wound or contaminated hands Indirect contact with colonized patients or commonly shared item or surface Adherence to basic infection control practices is key to prevention and control of staph infections in healthcare settings

13 Methicillin-resistant Staphylococcus Aureus (MRSA) Prevention Decolonization Mupirocin ointment (nares and under fingernails) Chlorhexidine baths Contact isolation Hand hygiene Environmental cleaning Inoculation Reduction of exposure to pathogens Central line, device associated infection prevention, surgical site bundles

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16 Vancomycin-resistant Enterococci (VRE) Enterococci commonly found in Gastrointestinal tract Female genital tract Environment Potential infections Urinary tract infections Wound infections Bacteremia Endocarditis

17 Vancomycin-resistant Enterococci (VRE) Vancomycin used to treat enterococci, but can become resistant Can be colonized with VRE without causing infection Usually occurs in hospital Risks for VRE infection Previous treatment with vancomycin and other antibiotics (ceftriaxone implicated) Hospitalization, particularly when receiving prolonged antibiotics Immunocompromised (chemotherapy, transplant) Abdominal surgery Folks with indwelling medical devices VRE colonization

18 Vancomycin-resistant Enterococci (VRE) Transmission Person to person by contaminated hands (from feces, urine, blood) Environment - get from contaminated surfaces with VRE Prevention Contact precautions Hand hygiene

19 Clostridium difficile Bacteria that can cause inflammation of the colon (colitis) Produces spores Produces 2 exotoxins (A and B) Symptoms Fevers Watery diarrhea Abdominal pain/tenderness Nausea

20 Clostridium difficile Most common cause of hospital-acquired infection in US Leading cause of gastroenteritis-associated death Risk factors Antibiotic use PPI use GI surgery/manipulation Advanced age

21 Colonization vs infection Colonization Exhibits no clinic symptoms Tests positive for C.diff organism and/or toxin More common than C.diff infection Infection Clinical symptoms Usually significantly elevated white count Repeat testing not recommended after treatment as patient may remain colonized

22 Estimated U.S. Burden of Clostridium difficile Infection (CDI), According to the Location of Stool Collection and Inpatient Health Care Exposure, 2011.

23 Transmission of Clostridium difficile Shed in feces Spores can live on any surface, device or material contaminated with feces Transferred to patient from hands of healthcare personnel (who has touched contaminated surface or item) Can last in environment for a long time

24 Clostridium difficile Prevention Contact precautions Hand washing with soap and water Alcohol in hand sanitizer does not kill spores Environmental cleaning Daily cleaning of room surfaces Supplemental cleaning with bleach or other FDA spore-killing disinfectant

25 Influenza Acute respiratory infection caused by the influenza virus 3 types of influenza virus A, B, C Type C occurs much less frequently C not included in vaccine Type A further classified into subtypes by viral surface proteins H1N1 H3N2

26 Peak Month of Flu Activity through

27 Symptoms of Influenza Sudden onset of high fevers Cough (usually dry) Myalgias Headaches Malaise Sore throat Runny nose Vomiting* Diarrhea* *more common in children than adults

28 Transmission of Influenza Droplets made when people w/flu cough, sneeze or talk Can land in mouths or noses of people or possibly be inhaled Can spread to others up to ~6 feet away Symptoms can start 1-4 days after infected with virus Able to infect other people beginning 1 day before symptoms start and to up to 5-7 days after becoming sick

29 Prevention of Influenza Droplet precautions Hand washing Vaccination Ideally prior to onset of influenza season Can still be protective as long as virus circulating Takes 2 weeks for antibodies to develop

30 Influenza vaccination Trivalent vaccines H1N1 H3N2 B influenza High doses trivalent vaccine Recommended in >=65 year old Egg-free trivalent vaccine Quadrivalent vaccine 2 influenza A virues and 2 influenza B viruses Nasal vaccine (weakened live virus)

31 Influenza vaccination Contraindication to trivalent vaccination Children <6 months old Severe, life-threatening allergies to flu vaccine or vaccine ingredient (gelatin) Contraindication to nasal spray vaccine Children <2 years old Adults >50 years old Pregnant women Immunocompromised HCW who care for severely immunocompromised patients whom require protective environment (i.e. bone marrow transplant)

32 Urinary tract infections Foley catheter IDSA provide guidelines for when to obtain urine cultures in adults with an indwelling catheter Recommended Local findings suggestive of CAUTI (pelvic discomfort or flank pain) Part of evaluation of sepsis without clear source Prior to urologic surgeries where mucosal bleeding anticipated Early pregnancy Not recommended Urine quality (color, smell, sediment, turbidity) does not constitute signs of infection Asymptomatic elderly or patients with diabetes Repeat urine cultures to document clearance of bacteruria Based on pyuria seen on urinalysis in asymptomatic patient

33 Tuberculosis Caused by Mycobacterium tuberculosis (MTB) Transmission Droplet nuclei containing MTB expelled in air when infected individual coughs or sneezes One can become infected if they inhale air containing these droplets Not everyone infected with MTB becomes sick Latent TB

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36 Symptoms of Tuberculosis General symptoms Unexplained weight loss Night sweats Fevers Loss of appetite Fatigue Symptoms with lung involvement Cough (usually >3 weeks) Hemoptysis Chest pain Can also infect other organs (kidneys, spine, brain)

37 Cavitary lesions of pulmonary TB

38 Tuberculosis Airborne precautions Ventilated room PAPR or N95 mask for any staff entering room Fit testing for N95 masks

39 Tuberculosis Testing Tuberculin skin test Interferon gamma release assay (IGRA) QuantiFERON Gold T-spot

40 Latent Tuberculosis Infected with MTB but not sick Positive reaction to tuberculin skin test or TB blood test Chest x-ray usually obtained after positive test and is negative Not considered infectious and cannot spread TB infection to others 5-10% of infected persons will develop TB during their lives without treatment for latent TB

41 Carbapenemase-resistant Enterobacteriaciae (CRE) Enterobacteriaciae are family of bacteria that are part of our normal GI flora E.coli Klebsiella Carbapenems (meropenem, imipenem, ertapenem) can treat Can develop resistance through production of enzymes Recent outbreaks linked to duodenoscope infections Los Angeles, CA Seattle, WA Pittsburgh, PA Chicago, IL

42 NDM-producing Carbapenem-resistant Enterobacteriaceae (CRE) isolates reported to the Centers for Disease Control and Prevention (CDC) as of January 2015, by state

43 Carbapenemase-resistant Enterobacteriaciae (CRE) Usually occurs in hospitals or healthcare settings Associated with high mortality rate and can spread widely Transmission Contact with infected or colonized persons Infected wounds or stool Prevention Contact precautions

44 Middle East Respiratory Syndrome (MERS) Caused by MERS coronovirus Most cases seen in Arabian Peninsula Outbreak in South Korea in healthcare setting

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46 Middle East Respiratory Syndrome (MERS) Symptoms Early symptoms nonspecific Fevers Cough Shortness of breath Diarrhea, sometimes Median incubation period is 5 days Range from 2 to 14 days

47 Middle East Respiratory Syndrome (MERS) Transmission Respiratory secretions Exact way not completely understood Isolation/Precautions Standard Contact Airborne

48 Ebola Update World Health Organization declared Liberia free of Ebola virus transmission on 9/3/15 (42 days after 2 nd negative test) Enhanced entry screening discontinued for travelers arriving from Liberia Sierra Leone will be declared free of Ebola transmission on November 7 if no new cases reported As of 10/28/15, 3 new confirmed cases in Guinea (same household, was already being monitored as high risk contacts) Enhanced travel screening still in place for travelers arriving from Sierra Leone and Guinea

49 Summary Contact MRSA VRE CRE Clostridium difficile (wash hands with soap) MERS Droplet Influenza Airborne Pulmonary tuberculosis MERS

50 Questions?

51 Resources Centers for Disease Control and Prevention. Minnesota Department of Health. National institute of Allergy and Infectious Diseases. Calfee D, Salgado CD, Classen D, et al. SHEA Compendium: Strategies to Prevent MRSA Transmission in Acute Care Hospitals Infect Control Hosp Epidemiol 2008; 29:S62-S80. Hidron AL, Edwards JR, Patel J, et al. NHSN annual update: antimicrobialresistant pathogens associated with healthcare- associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, Infect Control Hosp Epidemiol; 2008:29: Hooton et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: :