ID  BOARD REVIEW 2008

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CDC ISOLATION GUIDELINES. Isolation PrecautionsStandard precautionsAirborne precautionsSpecial airborne precautionsDroplet precautionsContact precautionsProtective precautions. STANDARD PRECAUTIONS. Hand hygiene: Before and after each patient contact

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ID BOARD REVIEW 2008

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1. ID BOARD REVIEW 2008 Amanda Peppercorn, M.D. Assistant Professor of Medicine University of North Carolina at Chapel Hill

2. CDC ISOLATION GUIDELINES Isolation Precautions Standard precautions Airborne precautions Special airborne precautions Droplet precautions Contact precautions Protective precautions

3. STANDARD PRECAUTIONS Hand hygiene: Before and after each patient contact & after gloves removed The wearing of artificial fingernails or extenders is prohibited (based on CDC guidelines) Gloves: When touching contaminated items (blood, body fluids, secretions, excretions) Mask, eye protection, face shield: Whenever splashes or sprays of body fluids possible Gown: Whenever splashes or sprays of body fluids possible

4. AIRBORNE PRECAUTIONS Isolation Private negative pressure room Direct out exhausted air N95 respirator Representative pathogens M. tuberculosis Varicella, Zoster (immunocompromised) Measles

5. SPECIAL AIRBORNE PRECAUTIONS Isolation Airborne + eye shields Representative pathogens Avian influenza Monkeypox SARS Co-V Smallpox Viral hemorrhagic fever (e.g., Ebola, Lassa)

6. DROPLET PRECAUTIONS Isolation Private room Mask Representative pathogens Invasive N. meningitidis RSV Bordetella pertussis Rubella, Mumps Group A streptococcal pharyngitis Invasive H. influenzae

7. CONTACT PRECAUTIONS Isolation Gloves Gowns Representative pathogens Clostridium difficile HSV Varicella/zoster VRE, MRSA MDR pathogens (resistant to two or more classes of pathogens)

8. BOARD REVIEW QUESTIONS: INFECTION CONTROL #42 – TB – airborne, removal isolation #61 – Varicella = airborne + contact #88 – Tularemia = no person-to-person #113 – C. difficile = contact + enhances environmental cleaning (spores)

12. POST-EXPOSURE PROPHYLAXIS Animal bite wound Anthrax Avian influenza Diphtheria Hepatitis A Hepatitis B HIV Human bite wound Influenza A Influenza B Measles Meningococcal infection Monkey bite (B virus) Monkeypox Pertussis (whooping cough) Rabies Smallpox Syphilis Tuberculosis (TB) Varicella (chickenpox) Zoster (shingles)

13. POST-EXPOSURE PROPHYLAXIS USING VACCINES Hepatitis B*: <7 days (alternative HBIG) Measles: <3 days (alternative Ig) Rabies*: ASAP (plus RIG); prior to symptoms Tetanus*: Post-wound (no time limit) Vaccinia: <4 days Varicella: <4 days (alternative VZIG or acyclovir) Outbreak control: Hepatitis A, pertussis, meningococcal * May need to be provided with an immunoglobulin preparation

14. POST-EXPOSURE PROPHYLAXIS USING ANTI-INFECTIVES Animal bite: Amoxacillin-sulbactam x 5 days Influenza: Oseltamivir or zanimivir Lyme disease: can offer Doxy 200 mg x 1 (with many caveats—definite Ixodes, long attachment—36hrs, high endemic region—20% ticks, present within 72hrs, adults and children>8, non-pregnant) Meningococcus: Ciprofloxaxin 400 mg (alternative ceftriaxone IM) Pertussis: Azithromycin x 5 days (alternative TMP-SMX for 7-14 days)

15. NO POST-EXPOSURE PROPHYLAXIS Adenovirus conjunctivitis Hepatitis C Mumps Parvovirus B19 Rubella Severe acute respiratory distress syndrome (SARS)

16. Skin Structure Infections by Site

17. PATHOGENS ASSOCIATED WITH CELLULITIS Erysipelas: Group A streptococcus (less commonly groups B, C, G), S. aureus (group B associated with ESLD, etoh, DM) “Simple cellulitis”: Group A streptococcus (less commonly groups B, C, G), S. aureus* Body piercing: S. aureus, Group A streptococcus Dog or cat bite: Pasteurella multocida, Capnocytophaga canimorsus (lethal in setting of splenectomy) Periorbital cellulitis: Group A strep, S. aureus*, pneumococcus, sinus pathogens (gram positive anaerobes) Water exposure: Aeromonas hydrophila, Vibrio vulnifus

18. PATHOGENS ASSOCIATED WITH SKIN AND SOFT TISSUE INFECTIONS

19. PATHOGENS ASSOCIATED WITH SKIN AND SOFT TISSUE INFECTIONS

20. NECROTIZING INFECTIONS Necrotizing fasciitis, type 1 Mixed infection; anaerobes plus strep or GNR Incubation = 48-96 h; progression = hrs – days Marked pain, tenderness, swelling, crepitus, foul-smelling Necrotizing fasciitis, type 2 Grp A strep (“flesh-eating” bacteria) Incubation = 6-48 h; progression = a few days Often with toxic shock, bullae, no crepitus Pain out of proportion to exam

21. CA-MRSA: RISK FACTORS AND POPULATIONS Crowding: Correctional facilities Contact (skin to skin): Correctional facilities, sports participants, lap dancing, sexual contact Sharing of personal items: razors, towels Compromised skin integrity (cuts and abrasions): Sports participants, military recruits Cleanliness: Deficient hygiene practices Miscellaneous: Tattooing Children Rural Native Americans Homeless IDU Prisoners Household contacts Sexual contacts Sports teams Recipients of tattoos Military recruits

22. COMPARISON: CA-MRSA AND HA-MRSA

23. TREATMENT OF MRSA: ORAL THERAPY Oral regimens (use only after susceptibility testing) Linezolid (expensive) Clindamycin (use only if erythromycin susceptible or D test performed to confirm susceptibility) Trimethoprim-sulfamethoxazole Minocycline Monitoring Daptomycin: CPK each week; stop if CPK >5x ULN (symptomatic) or >10x ULN (asymptomatic) or >1000 U/L Linezolid: CBC with platelets each week; do not treat >28 days

24. BOARD REVIEW QUESTIONS: SKIN #68 – Osteo in drug user #71 – Human bite #83 – Cat bite #85 – IDU joint infection #94 – SA infection #107 - NTM

25. CAP: PATHOGENS

27. CAP THERAPY: OUTPATIENTS Previously healthy and no risk factor for DR-SPn No recent antibiotics: Macrolide (I), doxycycline (III) Recent antibiotics: FQ, advanced macrolide + high-dose amoxicillin, advanced macrolide + high-dose amoxicillin/clav Comorbidities: Chronic heart, lung, liver, or renal disease No recent antibiotics: Advanced macrolide, FQ Recent antibiotics: FQ (I), ?-lactam + macrolide (I), ?-lactam + doxycycline (II) {?-lactam = high dose amoxicillin or amox-clav} Regions with >25% high level macrolide resistant SPn use alternative agent

28. CAP THERAPY: INPATIENTS, NON-ICU Non-ICU FQ (I) ?-lactam + macrolide (I) ?-lactam = cefotaxime, ceftriaxone, ampicillin ICU ?-lactam + FQ (I) ?-lactam = cefotaxime, ceftriaxone, ampicillin-sulbactam ?-lactam + advanced macrolide (II) ?-lactam = cefotaxime, ceftriaxone, ampicillin-sulbactam Advanced macrolide = azithromycin or clarithromycin

29. BROAD SPECTRUM ANTIBIOTICS Carbapenems: Imipenem, meropenem (not ertapenem) Coverage: GPC, GNRs, P. aeruginosa, anaerobes Holes: MRSA, Listeria, Legionella Piperacillin-tazobactamn (not ticar/clav or amp/sulbactam) Coverage: GPC, GNRs, P. aeruginosa, anaerobes, enterococci Holes: MRSA, Listeria, Legionella Tigecycline Coverage: GPC (including MRSA, VRE), GNRs (including ESBL producers and Acinetobacter), anaerobes Holes: Pseudomonas aeruginosa, Proteus spp.

30. NOT SO BROAD SPECTRUM ANTIBIOTICS 3o/4o Cephalosporins Agents: Ceftriaxone, ceftazidime, cefotaxime, cefepime Coverage: +S. aureus, GNRs, P. aeruginosa (ceftazidime, cefepime) Holes: MRSA, Listeria, Enterococcus, Legionella, Bacteroides

31. BROAD SPECTRUM ANTIBIOTICS: USES Sepsis of unknown etiology (GPC, GNR) Neutropenic fever (GNR, PA, SA) Severe intra-abdominal infections (GNR, Enterococcus, anaerobes) Gangrenous soft tissue infections (diabetic) (GNR, PA, SA)

32. Endocarditis Updated Duke Criteria: 2-1/3-5 (major/minor criteria) Major: sustained bacteremia by organism known to cause endocarditis (SA, S viridans, enterococcus, HACEK, CNS with pv), endocardial involvement seen by echocardiogram (vegetation, abscess OR new valvular regurgitation*) Minor: predisposing condition (PPM/vascath, HD, IVDA), fever, vascular signs (septic emboli, janeway lesions, mycotic aneurysms), immune complex phenomena (osler nodes, roth spots, glomerulonephritis) +blood culture not meeting standard criteria Categories: native valve (bicuspid, calcification, prior endocarditis, any valvular disease), prosthetic valve (high mortality, need rifampin/gent, often requires surgery), IDU (can use shorter course of treatment with right sided) Culture negative: q fever, brucella, bartonella, legionella, chlamydia, HACEK, nutritionally deficient strep Indications for valve surgery: persistent bacteremia, refractory CHF, myocardial abscess/purulent pericarditis, difficult organisms (PsA, yeast, MRSA), recurrent septic embolic complications, large vegetation

33. Tuberculosis PPD treatment: >5mm: HIV, immunosuppressed (TNF inhibitor, prednisone 15 mg/d x 1 month), known close contact >10mm: all other high risk populations (prisoners, healthcare worker, RF, homeless, immigrants, DM, malignancy, hx gastrectomy, malnutrition, etoh, long-term care) >15mm: everyone else Treatment: rule out active disease by CXR and symptom screening TB considerations: BCG (no change in interpretation, esp if >5 years ago), prophylaxis and treatment in setting of MDR Primary disease?dissemination?control or active disease (lungs, LNs, pleurisy, CNS—tuberculomas, basilar meningitis, GI, GU—uterine, kidneys, bone—Potts disease, neck LN—Scrofula), HIV, miliary

34. Miscellaneous Remember syphilis!! African tick fever—R. africae (look for eschars, early fever/myalgias)—Amblyoma tick, doxycycline Other tick borne diseases—R. rickettsia (dog tick, RMSF), Erlichia (deertick—Ixodes), Borrelia (Lyme, Ixodes), Babesia (protozoa looks like malaria, only in NE, fatal in asplenic pts, Ixodes scapularis) Anthrax—cutaneous (Edema toxin), eschar Smallpox versus Chickenpox—degree of fever and early timing of systemic symptoms, stage of lesions UTIs: complex (pregnancy, pyelo, men, structural issue, indwelling catheter) versus simple; impacts treatment; midstream collection versus first void (prostatitis, STDs) Drugs: daptomycin contraindicated for MRSA pneumonia, follow CPK Linezolid—thrombocytopenia, bone marrow suppression, serotonin syndrome HIV meds—abacavir (fatal hypersensitivity syndrome, HLA B5701), protease inhibitors—elevated lipids, DM, nucleoside RTIs—mitochondrial toxicity (lipodystrophy, visceral adiposity, myalgias, neuropathy), nevirapine (fatal liver failure esp in women with high CD4)

35. Thank You

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