2018 Tuberculosis Clinical Intensive: Infection Prevention & Control. > No disclosures

Transcription

1 2018 Tuberculosis Clinical Intensive: Infection Prevention & Control > No disclosures 1

2 Objectives By the end of today s session, hopefully you will be able to: > Recognize potential TB exposures in healthcare settings > Find recommendations to guide a response to an exposure > Develop a basic response plan to an exposure GLOBAL VERSUS LOCAL Does it matter? > Prevalence of people with tuberculosis > Prevalence of people with an immunocompromised status > Status of facility 2

3 Case Part 1 > 53 year old woman with recent h/o RUL nodule, but had trouble getting recommended chest CT > Presented to HMC with melena, no cough, weight loss, fever > Chest x-ray with nodule right upper lobe > Admit note: known opacity RUL, defer to outpatient.. Case Part 2 > On Day 2 developed a fever and tachycardia > Chest x-ray and CT showed bilateral upper lobe opacities and cavities > Sputum 4+ AFB, later grew M. tuberculosis > Had been in ED and 2 acute care floors > Missed opportunities. 3

4 Harborview Medical Center Community Off site Clinic Harborview Medical Center Specialty Clinic Morgue/Medic al Examiner Pharmacy Emergency Room Front Door Radiology Laboratory EMS/helicopters 4

5 Resources > CDC TB and Infection Control > CDC TB Infection Control Guidelines > WHO TB Infection Control > Curry Center TB Infection Control Manual Response Plan You should have a plan in place > Early detection of patients with TB > Airborne precautions > Treatment of patients with TB > Administrative Measures > Environmental Controls > Respiratory PPE 5

6 Administrative Measures > Assigning someone the responsibility for TB infection control in the health care setting; > Conducting a TB risk assessment of the setting; > Developing and implementing a written TB infection-control plan; > Ensuring the availability of recommended laboratory processing, testing, and reporting of results; > Implementing effective work practices for managing patients who may have TB disease; > Ensuring proper cleaning, sterilization, or disinfection of equipment that might be contaminated (e.g., endoscopes); > Educating, training, and counseling health care workers, patients, and visitors about TB infection and TB disease; > Testing and evaluating workers who are at risk for exposure to TB disease; > Applying epidemiology-based prevention principles, including the use of settingrelated TB infection-control data; > Using posters and signs to remind patients and staff of proper cough etiquette (covering mouth when coughing) and respiratory hygiene; and > Coordinating efforts between local or state health departments and high-risk health-care and congregate settings. Environmental Controls > Primary environmental controls consist of controlling the source of infection by using local exhaust ventilation (e.g., hoods, tents, or booths) and diluting and removing contaminated air by using general ventilation. > Secondary environmental controls consist of controlling the airflow to prevent contamination of air in areas adjacent to the source airborne infection isolation (AII) rooms; and cleaning the air by using high efficiency particulate air (HEPA) filtration, or ultraviolet germicidal irradiation. 6

7 Respiratory Protection > Implementing a respiratory protection program; > Training health care workers on respiratory protection; and > Educating patients on respiratory hygiene and the importance of cough etiquette procedures. Healthcare Workers > TB education > TB screening with onboarding (IGRA, TST, symptoms) > Depending on risk assessment, regular rescreening > PPE training Low risk = PAPR/CAPR Medium risk = PAPR/CAPR +/- N95 7

8 Space Airborne Infection Isolation Room Attributes of an AIIR > Negative pressure (>0.01 WG), with regular confirmation > 6 ACH for old space, >= 12 ACH for new space > Air exhausted outside/via HEPA filter > ~Anteroom Space - Reality > A clinic room > A room in the Emergency Department > No inpatient AIIR/older facilities 8

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10 Practice/Operations > Awareness front desk/triage screening Do you have a cough? mask How long have you had a cough? mask + room > Evaluation ARNP, PA, MD, DO Is TB on the differential? Upgrade precautions? Specimen collection plan? Does this patient need to be admitted? Patient Evaluation > Risk factor evaluation every time* Social history Sexual history > If story, signs and symptoms support possible TB: Precautions and PPE Test *every time likely infectious disease 10

11 TB Testing from the IPC Perspective > Depends on what lab testing is available: 3 smears separated by at least 8 hours and mycobacterial cultures Nucleic acid amplification tests (e.g. Gene Xpert) > CDC recs are to obtain all 3 smear, culture, NAAT Nucleic Acid Amplification Tests > Xpert MTB/RIF assay > Fully automate cartridge-based system > Detects MTB and RIFAMPIN resistance > <2 hrs > Preferable performed on 1 st sputum > Can be paired to run automatically with first smear Resource: CDC The Xpert MTB/RIF Assay 11

12 What to do with the data? > Smears have a SN of 50-80% > Possibly lower in pauci-bacillary cases (30% in people with HIV?) > 1 NAAT Sn 98% smear+/ Sn ~30-50% smear-* > 2 NAATs increase sensitivity > NAATs increase dx ~50-70% *Low prevalence setting Source: Nature Microbiology 12

13 Test Interpretation Chida, N. & Shah, M. Open Forum Infect Dis 3, ofw058 (2016). Cowan, CID, 2016 Discontinuing Airborne Precautions 13

14 What to do with the results? > Easy: TB+ = treatment, continue AIIR > Not pulmonary TB = d/c AIIR Tests negative Pt improving on other therapies Alternative diagnosis > Possible TB: most challenging Thinking of Pulmonary TB on the DDx? > Standard and Airborne Precautions Surgical mask on the patient If the test is sent AIIR every time > HIV test > Sputum samples for testing > If any HCP or patients exposed, start a log of names and duration of exposure 14

15 Exposed HCP Actions > Refer back to the facility TB plan and protocol > Determine likelihood of pulmonary TB Definite, Probable, Possible, Unlikely If smear+, how much (1+-4+)? May require convo with med team or public health > Make a risk assessment Exposure Risk Assessment I > Smear negative, 1+, 2+, 3+,4+ > Cavitary disease, chest x-ray > Coughing? > Environment and duration w/o precautions 15

16 Exposure Risk Assessment II > High risk Loading dock, ~100 hours Classroom, ~24 hours patient room? Small space, ~18 hours > Medium risk = not high or low risk > Low risk = normal CXR, no cough, negative smears > No risk = extrapulmonary TB only Extrapulmonary TB > All patients with extrapulmonary TB on DDX should be evaluated for pulmonary TB with sputum testing even w/o any symptoms and/or a normal CXR > King County: ~60% pulmonary TB, ~35% extrapulmonary, ~10% both 16

17 Exposure Investigation > Inform Public Health > Inform all patients, HCP and other exposed individuals > Baseline TB screen (TST or IGRA) > Repeat TB screening at 3 months and 6 months > If positive evaluation, treatment, L&I > Re-evaluate TB Plan and risk assessment Special Cases > Otolaryngology clinics Laryngeal TB Neck masses > Operating room Aerosolization > Respiratory therapy > Laboratory 17

18 Thanks! > Questions or discussion welcome > 18