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Emerging Infectious Diseases: It’s a small world….

Emerging Infectious Diseases: It’s a small world…. Timothy H. Dellit, MD Associate Professor of Medicine University of Washington School of Medicine Associate Medical Director Harborview Medical Center. Disclosure:

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Emerging Infectious Diseases: It’s a small world….

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  1. Emerging Infectious Diseases:It’s a small world…. Timothy H. Dellit, MD Associate Professor of Medicine University of Washington School of Medicine Associate Medical Director Harborview Medical Center Disclosure: Dr. Dellit has no financial interest in any of the products or manufacturers mentioned.

  2. Antimicrobial Resistance and Healthcare-Associated Infections(CLA-BSI and CA-UTI) Which of the following is NOT correct? • E. coli resistance to fluoroquinolones is 29-47%. • Pseudomonas aeruginosa resistance to fluoroquinolones is 30-35%. • Pseudomonas aeruginosa resistance to carbapenems is 20-25%. • Acinetobacterbaumanniiresistance to carbapenems is less than 10%.

  3. Rise of Acinetobacter • 1987-1996: 345 nosocomial Acinetobacter infections per year • By 2006-2007 • Fifth most common Gram-negative nosocomial pathogen • 8.4% of ventilator-associated pneumonia • 29% resistant to carbapenems • 2009-2011 NHSN • 60-75% resistance among CLA-BSI and CA-UTI Infect Control Hosp Epidemiol 2008;29:996-1011

  4. Acinetobacter and Military • Most common Gram-negative bacillus recovered from traumatic injuries to extremities during Vietnam War • 102 patients with Acinetobacter bacteremia at military medical facilities (Landstuhl and Walter Reed) between 1/02 – 8/04 • Service members injured in Afghanistan and the Iraq/Kuwait region • Environmental contamination of field hospitals and infection transmission within healthcare facilities • Only 1/49 soil samples positive and different PFGE pattern • Sites of isolates • 32% wounds • 24% airway • 11% blood • 2% urine • 31% unknown MMWR 2004;53:1063-1066 Clin Infect Dis 2007;44:1577-84

  5. Problematic β-lactamases *Monotherapy with penicillin or 3rd generation cephalosporin may be associated with inducible resistance

  6. 19 year old man s/p traumatic open injury in India arrives at HMC for surgical revision of his AKA with wounds infected with Pseudomonas, Klebsiella, E. coli, Morganella, and Enterococcus. Pseudomonas aeruginosa Escherichia coli Colistin MIC 4 mcg/mL Colistin MIC 2 mcg/mL

  7. New Dehli metallo-beta-lactamase (NDM-1) • Linked to receipt of medical care in India and Pakistan • Encoded on a plasmid -mobile genetic element

  8. Klebsiella pneumoniae Carbapenemase • First identified in 1996 • Encoded on a plasmid – mobile genetic element Lancet Infect Dis 2009 Apr;9(4):228-36

  9. Carbapenemase-Producing CRECarbapenem-Resistant Enterobateriaceae Tier 1: PCR positive for carbapenemase production (KPC, NDM-1, VIM, IMP, or OXA) • Roughly 6 cases of CP-CRE per year in WA Tier 2: CRE NOT due to carbapenemase production • Roughly 80 cases per year in WA Tier 3: Intrinsic resistance such as Proteus, Providencia, Morganella which are ONLY imipenem non-susceptible

  10. LTACH and KPC Point Prevalence Survey in Chicago • 24 acute care hospitals > 10 ICU beds • 7 long-term acute care hospitals LTACH: 10-54% colonization Clin Infect Dis 2013;57:1246-52

  11. CRE screening of samples sent for C. difficile testing • Two NYC Hospitals • CRE identified in 25/854 (2.9%) patients Infect Control Hosp Epidemiol 2014;35:82-84

  12. Options for Resistant Gram-Negative Bacilli Combination therapy with carbapenem +/- colistin +/- rifampin? *Not active against Proteus

  13. Getting to the correct therapy Rapid Microarray Assay on blood cultures to determine if resistance present J Clin Microbiol 2013;51:4008-4011 Clin Infect Dis 2014;59:272-278

  14. “MDRO Bundle” • Hand Hygiene • Contact precautions • Education • Minimize shared equipment • Environmental cleaning • Healthcare-associated infections preventive bundles • Catheter-associated BSI • Ventilator-associated pneumonia • Catheter-associated UTI • SCIP measures • Active surveillance cultures • Chlorhexidine baths • Antimicrobial stewardship Lancet 2000;356:1307-12

  15. Influenza Viral Structure WA: 2013-2014 Neuraminidase Hemagglutinin Main Types of Influenza • A - Humans, birds, pigs - Antigenic drift (minor changes) - Antigenic shift (major changes) • Pandemic • B - Humans only - Antigenic drift (minor changes) Minor changes each year result in need for annual vaccination Antigenic shift and reassortment with creation of novel viruses Mayo Clin Proc. 2010;85:64-76

  16. Antigenic Shift and Reassortment Swine Respiratory Epithelium Reassorted Virus

  17. Influenza Pandemics 1918 Spanish H1N1 (Avian Virus) 40-50 million deaths worldwide 500,000 deaths in US with case mortality 2.5% 1957 Asian H2N2 (Re-assorted Virus) 70,000 deaths in US 1968 Hong Kong H3N2 (Re-assorted Virus) 34,000 deaths in US 1977 Russian H1N1 2009 Triple-reassorted H1N1 (Swine-origin) 42,000 lab-confirmed hospitalizations in US 2,125 lab-confirmed deaths in US Case mortality < 0.1%

  18. Importance of Early Recognition and Clinical Judgment • Early treatment associated with better outcomes • Co-morbidities • All hospitalized patients, even if symptoms > 48 hours • First 15 deaths in King County during 2009 pandemic • Time from symptom onset to treatment • Mean 5.8 days (2-12 days) • 5 patients with predisposing risk factors presented with ILI and were not treated initially • Testing challenges • Rapid point of care tests 10-50% sensitive • FA and “inconclusive results” • Movement towards PCR testing • Upper vs. lower tract testing Epi-Log Dec 2009: Public Health Seattle & King County Critical Care 2009;13:R148 J Infect Dis 2011;203;1739-47

  19. World Distribution of H5N1 (Avian Flu) Through Nov 29, 2011 571 Cases 335 Deaths (59%) 2011 Egypt (34) Indonesia (11) Cambodia (8) Bangladesh (2) January 2014 Resident of Alberta Canada died after returning from Beijing Primarily contact with infected birds; very rare reports of possible human to human transmission

  20. 450 cases 145 deaths (32%)

  21. Avian Influenza Virus J Infect 2014 epub

  22. Healthcare worker returns from Saudia Arabia to Orlando FL and in route develops fever, muscle aches, cough. Which precautions should be implemented? • Patient should be placed in droplet precautions for influenza-like illness. • Patient should be placed in airborne isolation with use of N95 respirator • Patient should be placed in contact precautions due to concern for MRSA pneumonia. • Patient should be placed in airborne plus contact precautions with use of gown, gloves, and N95 respirator with eye protection.

  23. MERS Corona Virus Through June 13, 2014 • 701 cases • 249 deaths (27.1%) 2 US Cases (Indiana, Florida)

  24. MERS-CoV Characteristics Clin Infect Dis 2014;59:160-165

  25. Chikungunya Aedes mosquito Fever, joint pains, headache, muscle pain, rash

  26. Ebola Hemorrhagic Fever Outbreak in West Africa March – July 2014 1,323 cases 729 Deaths (56%) Incubation: 2 to 21 days

  27. Ebola (VHF) Precautions • Standard, Droplet, and Contact Precautions • Single room, door closed • All persons entering the patient room should wear at least: • Gloves • Gown (fluid resistant or impermeable) • Eye protection (goggles or face shield) • Facemask • Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to: • Double gloving • Disposable shoe covers • Aerosol generating procedures • N95 respirator or PAPR

  28. Pertussis Outbreak • Respiratory Etiquette • Droplet Precautions • Tdap 1943: routine use of whole-cell pertussis vaccine ACIP 2012: Tdap with every pregnancy • Optimally between weeks 27-36 • May prevent: - 906 infant cases - 462 hospitalizations - 9 deaths 2005: Tdap at age 11 or 12 J Infect Dis 2014;209;978-985

  29. 45 y o woman is hospitalized because of the acute onset of headache, malaise, chest pain, sore throat, abdominal pain, myalgias, and a dry, nonproductive cough preceded by a 2-day prodrome of coryza and some diarrhea. The US has been on a Code Red advisory alert for several weeks. T 40 C, HR 64, RR 24 Bilateral course rhonchi Blood cultures grow Francisella tularensis In addition to standard precautions, which type of isolation is most appropriate for this patient? • Contact precautions • Droplet precautions • Airborne precautions • No additional isolation precautions are required

  30. 27 y o veterinarian presents to ED in New Mexico because of dyspnea, fever, malaise, nausea, vomiting, and increased watery sputum that began last night followed by hemoptysis this morning. His mother, with whom he lives, died of pneumonia 4 days ago. US on Code Red advisory for past 10 days. T 39.8 HR 118 RR 32 BP 92/48 Lungs dull to percussion throughout left lung field with egophany CXR with LLL infiltrate Blood cultures later grow a Gram-negative rod Which of the following pathogen is MOST likely with the correct precautions? • Bacillus anthracis – droplet precautions • Bacillus anthracis – airborne precautions • Yersinia pestis – droplet precautions • Yersinia pestis – airborne precautions

  31. Pneumonic Plague • Usually 2-4 d incubation period • Fever, cough, dyspnea • Bloody, watery, or (less commonly) purulent sputum • GI symptoms may occur: N/V/D/pain • Rapidly progressive pneumonia JAMA (2000) 283:2281

  32. Inhalational Anthrax • Bacteria release toxin - Edema, hemorrhage, necrosis • Early symptoms: Fever, dyspnea, cough, H/A, emesis, abd/chest pain • Hemorrhagic mediastinitis • Hemorrhagic meningitis: 50% • Cyanosis, hypotension, death JAMA (1999) 281:1735

  33. Match the Precaution(In addition to Standard Precautions) MRSA Influenza Tuberculosis Disseminated varicella Tularemia Cutaneous anthrax Inhalational anthrax Pneumonic plague Viral Hemorrhagic Fever Prion (CJD) Rabies Standard only Contact Droplet Airborne

  34. Summary Continued emergence of antimicrobial resistance Multidrug-resistant Gram negative rods Carbapenem Resistant Enterobateriaceae (CRE) Emergence of novel viruses Importance of travel history as the world gets smaller Appropriate precautions (airborne vs. droplet) Bioterrorism

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