Management of patient with Infectious Disease

1. Management of patient with Infectious Disease

2. Chain of Infection

3. The Infectious Process: • Chain of infection and heath care worker’s interventions to interrupt the chain: • A causative organism (Source of infection): Bacteria, Viruses, Protozoa, Fungi, and heliments. Prevention:Rapid accurate identification of organism • Reservoirs : people, Equipment, water, animal, plant. Prevention: Employee health, environmental sanitation, and Disinfection/sterilization. • Portal of Exit: excretion, secretion, skin, and droplets. Prevention: Hand washing, control of excretions and secretions, and trash and waste disposal

4. Cont… • Means of transmission: sexual or parenteral fluids, through direct skin-to-skin, close contact or exposure, through infectious particles in the air, and close noncontact or exposure, and airborn. Prevention: Isolation, food handling, airflow control, standard precautions, and sterilization, and hand washing • Portal of Entry: Mucous membrane, GI tract, UT, Respiratory tract, Broken skin. Prevention: Wound care, catheter care, and aseptic technique • Susceptible Host: Immunosuppression, DM, Surgery, Burns, Elderly. Prevention: Recognition of high risk patients, and treatment of underlying diseases.

5. Cont……. • Colonization:is used to describe microorganism present without host interference or interaction. • Infection:indicates a host interaction with an organism and is recognized both by host reaction (redness, heat, and pain) and by organism identification • Disease ( infectious disease): is the state in which the infected host display a decline in wellness due to infection.

6. Infection control and prevention: • Preventing Infection in the Community: A. Sanitation technique, regulated health B. practice ( handling, storage, packaging, and preparation of food), C. Immunization programs ( one of the most effective means of preventing infection in the community). • Vaccination program: smallpox, measles, mumps, rubella, polio, diphtheria, pertussis, and tetanus. • ( See recommended childhood immunization Schedule)

7. Contraindication Of vaccination: • Previous anaphylaxes ( anaphylactic reaction), • patient who have developed an encephalopathy within 7 days of previous DTP dose should not receive further dose, • Sever immunosuppressive people should not receive live vaccine, Pregnant women should not receive MMR.

8. Cont… 2.Preventing infection in the hospitals ( Nosocomial Infection): Acquire infection while hospitalized.

9. Specific organism with nosocomial infection potential: • Clostridium Difficile: gram-positive, spore forming bacterium. Cause pseudomembranous colitis causing destruction to the area which produce profound sepsis. Spores is relatively resistant to clean and hand washing agents and can be spread of health care workers and by contact with equipment that has been previously contaminated. • Methacillin-resistant staphylococcus aureus (MRSA): Colonizes the skin which make them wildly spread. Vancomycin is the drug of choice for treatment • Vancomycin-resistant Enterococus (VRE): Gram-positive bacteria, part of normal flora of the GIT. Resistance to all other antimicrobial therapies

10. 3.Preventing Nosocomial Bloodstream Infections (Bacteremia and Fungemia): A. Primary bloodstream infections:the host has no pre-existing infection and the bloodstream becomes contaminated through mechanic manipulation (vascular access devices) B. Secondary bloodstream infection: a host has another site of infection that can serve as a source of contamination to the bloodstream. • Disinfecting skin before inserting vascular access devices • Should not use Guide wires routinely for changes of Vascular access devices (central line) unless no evidence of infection. • Changing infusion sets should not be before 4 days, blood and lipid infusion set should be changed every 24 hrs. blood transfusion should be finished within 4 hrs. Use 70% alcohol to clean the injection port when ever used.

11. Isolation Precautions • Guidelines to prevent the transmission of microorganisms in hospitals 1. Standard precautions used for all patients • The primary strategy for preventing HAIs 2. Transmission-based precautions are for patients with known infectious diseases spread by airborne, droplet, or contact routes

12. Isolation Precautions: • Standard Precautions: a set of protective behaviors, replace the previously recommended 1.Universal precautions which were designed solely to prevent blood borne infections) and 2. body substance isolation( which was designed to prevent transmission of pathogens from moist body substance) • Hand washing: effective hand washing calls for at least 10 seconds of vigorous scrubbing with special attention to the area arround nail beds and between fingers where there is high bacterial burden. Hands should be thoroughly rinsed after this washing. Antimicrobial hand washing agents ( such as chlorhexidine gluconate, alcohol) should be used

13. Cont… 2. Gloves use (latex): provide an effective barrier for hand from the microflora associated with patient care. Allergic reaction to latex increased in health care workers ( local skin irritation, general dermatitis, conjunctivitis, asthma, angioedema and anaphylaxis). For reducing the reaction the heath care workers should use of vinyl gloves, powder free gloves, or low protein latex gloves 3. Needlestick prevention: used needle should not be recapped 4. Avoidance of spray and splash Exposure: such as face mask and cover gown

14. II. Transmission-Based Precautions: when the microorganism are so contagious. • Airborne Precautions: are required for patients with TB, chickenpox, or measles. Patient should be in room with negative pressure, door should remain closed, health care workers should wear a mask • Droplet precautions: are used for microorganism that can be transmitted by close, face to face contact such as influenza or meningococcal meningitis. Face mask required • Contact precautions: spread by skin to skin contact such as antibiotic resistant organism. Contact isolation in private room to facilitate hand washing.

15. Diarrheal Diseases: • Mood of transmission: oral ingestion • Factors increasing the risk: • Food that neutralize the acidic environment • Decreased gastric acidity with disruption of normal bowel flora • Use of antimicrobial agent which decrease intestinal defence • Immune dysfunction of AIDS.

16. Specific Causes: • Viral: Rota virus • Bacterial: Esch. Coli and salmonella, shigella • Parasitic: Giardia, Entamoeba histolytica • Manifestation: diarrhea, Dehydration (dry mucous, sunken eyes, weakened pulse, and loss of skin turgor)

17. Sexual transmitted Diseases (STD): • Is a disease acquired through sexual contact with an infected person • Prevention: use of condom reduce the risk of transmission but not eliminate. • Human immunodeficiency Virus (AIDS): will be discussed later. • Syphilis: An acute or chronic infectious disease caused by the spirochete Treponema Pallidum. May be congenital in origion. • Stages: 1. Primary: 2-3 weeks after initial inoculation. Painless lesion at the site of infection is called a chancre. Untreated, resolved spont. Within about 2 months

18. Cont… 2.Secondary: hematogenous spread from the chancre leads to generalized infection. 2-8 weeks after chancre and involves the trunk and the extremities, including the palms of the hands and the sole of the feet. Transmission can occur with direct contact with the lesions. Generalized sign of infection may include lymphadenopathy, arithritis, meningitis, hair loss, fever, malaise and wt loss 3. Latency without S/S of syphilis may interrubted with secondary syphilis 4. Tirtialy syphilis: presents as a slowly progressive inflammatory disease with the potential to affect multiple organs. Manifestation include aortitis (most common), and neurosyplilis (dementia, psychosis, paresis, stroke, and maningitis)

19. Cont….. • Assessment and Diagnostic findings: Clinical history and laboratory evaluation ( microorganism identification from the chancre lesion of primary syphilis). Serologic tests used in the diagnosis of secodary ant tertiary. • Medical Management: Administration of Antibiotic ( penicillin G Benzathine is the drug of choice for syphilis of less than one year’s duration, IM at single dose). For more than one year, three injections at 1 week intervals. Doxycylin is used for pt allergic to peniciline • Nursing management: Reporting the case. Wearing gloves in direct contact with the pt, hand washing after removing the gloves, isolation in private room is not required

20. Gonorrhea: • Neisseria Gonorrhoeae is a gram-negative bacterium that is primary transmitted through sexual contact. Can also occur in neonates as a result of contact during birth. • Can cause mucosal, local, or disseminated infection and may be asymptomatic. • Clinical manifestation: • Local manifestations: Urethritis and epididymitis in men, Asymptomatic in women than in men • Uterine Cervix is the primary local site of infection, urinary tract infection, increased vaginal discharge, and itching in women.

21. Cont… • The most common complication of localized gonococcal infection in women is pelvic inflammatory disease (PID) in which the organism infect the uterus, fallopian tubes, or peritoneal fluid. PID is increased risk of ectopic pregnancy and bilateral tubal occlusion, which results in infertility. • If the infection is disseminated cause arthritis or dermatitis, and bacteremia, rare instances, valves of the heart can be infected, or meningitis can develop.

22. Assessment and diagnostic findings: • The patient is assed for fever, for urethral, vaginal, and rectal discharge, and signs of arthritis. • Cultural and sensitivity studies are the usual methods of diagnosis • in men the specimens are obtained from the urethra, Anal canal and pharynx • in women the specimen obtained from the endocervix, pharynx, and anal canal • Medical management: • Administration of Ceftriaxone ( or cefixime, ciprofloxacin, or olfoxacin) along with doxycyline • Serological testing for other STD such as syphilis and HIV • Nursing management: • Report the case to the public health department.

23. Chlamydia Trachomatis: • Is bacterium that requires attachment to the host cell, invasion, intracellular growth, and replication. • Clinical manifestation: • In women: PID, long term effect include, chronic pain, increased risk for ectopic pregnancy, post partum endometritis, and infertility. Transmission to vaginally born infant is common, which causes chlamydial conjunctivitis, and chlamydial pneumonia. • In men: urethritis, is the most common illness in heterosexual man, the rectum is the common site of infection among homosexual men

24. Assessment and diagnostic findings: • Cell culture technique, and nunculture technique, including immunologic assays, DNA probes, and enzyme sensitive tests. • Medical Management: • Administration of doxycyline or azithromycin.

25. Home-Based care of the patient with an infectious Disease: • Health care workers should follow standard precautions in the home setting • Patient and family teaching:see Chart 70-4 • Establish an environment that facilitates hand hygiene and aseptic technique • Family caregivers should receive annual influenza vaccine • Equipment care • Implement “Common sense cleanliness” • Exercise food preparation and personal hygiene • Establish reasonable barriers to protect family members

26. Nursing Process—Assessment of the Patient With Sexually Transmitted Disease (STD) • Protecting confidentiality and privacy is an important component in the assessment of a patient with STDs • Communication needs to be culturally and emotionally sensitive and clarification of terms may be necessary • Presenting symptoms • Specific information regarding sexual contacts • Patient knowledge • Physical examination: include rashes, lesions, drainage, inguinal nodes, genitalia, rectum, mouth and throat; women need abdominal and uterine exams

27. Nursing Process—Diagnosis of the Patient With Sexually Transmitted Disease (STD) • Deficient knowledge • Anxiety • Noncompliance with treatment

28. Collaborative Problems/Potential Complications • Increased risk for ectopic pregnancy • Infertility • Transmission of infection • Neurosyphilis • Gonococcal meningitis • Gonococcal arthritis • HIV-related complications

29. Nursing Process—Planning the Care of the Patient With Sexually Transmitted Disease (STD) • Major goals include increased patient understanding of the natural history and treatment of the infection, reduction in anxiety, increased compliance with therapeutic and preventive goals, and absence of complications

30. Interventions • Education about STDs and the spread of infection • Reduce anxiety • Encourage patient to discuss anxieties and fears • Provide factual information and individualized teaching • Assist in planning discussion with partners • Provide referral to social worker or other specialist • Increase compliance • Provide patient teaching in group or individual settings • Provide referral to appropriate agencies

31. Immune System(chap 50) • Immunity: the body’s specific protective response to invading foreign agent or organism • Factors affecting the immune function: • Age: with increasing age the problem with immune system is increased. Production and function of T and B lymphocytes may be impaired, increase incidence of autoimmune disease with age • Nutrition: adequate nutrition is essential for optimal functioning of the immune system, such as Vitamines. Excess or deficiency of trace elements such as copper, iron, manganese, and zinc in the diet generally suppresses immune function.

32. Infection and immunization: • Allergy: • Disorders and diseases: Autoimmune disorders, Neoplastic disease, Chronic illness and surgery • Medications and blood transfusion. • Lifestyle

33. Immune Function • Natural immunity: nonspecific response to any foreign invader • White blood cell action: release cell mediators such as histamine, bradykinin, and prostaglandins, and engulf (phagocytize) foreign substances • Inflammatory response • Physical barriers, such as intact skin, chemical barriers, and acidic gastric secretions or enzymes in tars and saliva • Acquired immunity: specific against a foreign antigen • Result of prior exposure to an antigen • Active or passive

34. Defenses • Phagocytic immune response • Humoral or antibody response • Cellular immune response

35. Cellular Immune Response • B lymphocytes: humoral immunity • Produce antibodies or immunoglobulins • T lymphocytes: cellar immunity • Attack invaders directly, secrete cytokines, and stimulate immune system responses • Helper T cells • Cytotoxic T cells • Memory cells • Suppressor T cells (suppress immune response)

36. Non-T and Non-B Lymphocytes Involved in Immune Response • Null cells • Destroy antigen coated with antibody • Natural killer cells • Defend against microorganisms and some malignant cells

37. Management of Patients With HIV Infection and AIDS

38. Acquired Immunodeficiency Syndrome (AIDS)Human Immunodeficiency Virus (HIV) infection • HIV is a specific type of virus called retrovirus in which the virus carry its genetic material in the RNA rather than the DNA • HIV invades the helper T cells (CD4) to replicate itself • AIDS limits the body’s ability to fight infection • A person with AIDS has a very weak immune system • NO cure

39. HIV Infection: • Mode of transmission: • Through body fluids: Blood products, semen, vaginal fluids, breast milk • Through IV drug use: sharing needles without sterilization • Through sex: intercourse, oral, anal, digital sex • Mother-to-baby: before birth, during birth, post partum • HIV cannt be transmitted through sweat, saliva, tears, urine, Mosquito bites • Casual contact does not cause transmission • Breaks in skin and mucosa increase risk

40. High-Risk Behaviors • Sharing infected injection equipment • Having sexual relations with infected individuals

41. Prevention Of HIV Infection: • Education: • Safe sexual practice (use latex condom intercourse) • Avoiding sexual contact with multiple partner or people who are known to be HIV positive • Instruct people who are HIV positive or use injection drug not to donate blood or share drug equipment with others • Instruct drug user on methods to clean their syringes • Instruct people to not share needles, razors, toothbrushes, or other blood-contaminated articles.

42. Prevention cont.. • Related reproductive education: • Inform the pregnant women that need to have adequate information about the risks of transmitting HIV infection to partner, and their future children • Teach the pregnant women about the benefits of antiretroviral agents in reducing perinatal HIV transmission • Instruct that the condom has been the only method that has proved to decrease the risk of sexual transmission of HIV infection • Inform women that certain contraceptive methods may pose additional heath risks for women (Estrogen in oral contraceptive and intrauterine contraceptive device (IUD)

43. Prevention cont… • Transmission to health care providers: • Standard precaution: • Were developed to prevent the transmission of infection during pt care for all pt, regardless of known or unknown infectious status • Standard precautions apply to blood, all body fluids, secretions, and excretions, except sweat. • Including hand washing, gloves, mask, eye protection, face shield, gown, pt care equipment, environmental control, linen, and pt placement

44. Prevention cont… • Postexposure prophylaxis for health care providers: • Offer all health care provides who have sustained a significant exposure to HIV anti-HIV postexposure prophylaxis • Wash the affected area with soap and water, • inform you supervisore, identify the patient, report to the employee health services, • give consent for baseline testing for HIV, hebatitis B, and hebatitis C, • Start prophylaxis immediately after exposure to HIV within 2 hrs (before 72 hr of exposure), follow up with postexposure testing at 6 weeks, 3 months, and 6 months and perhaps one year, • and document the exposure in details.

45. Prevention cont… • The medications recommended for postexposure prophylaxis are those used to treat established HIV infection • Encourage pt to take prescribed medications for 4 weeks • Prepare those who choose postexposure prophylaxis for the side effects of the medications because HIV often become resistant to the medications used to treat it

46. Stages of HIV disease • Primary infection ( acute HIV infection or acute HIV syndrome): • The period from infection with HIV to the development of antibodies to HIV • There is intense viral replication and widespread of HIV throughout the body • Short, flue-like illness, occur one to six weeks after infection • No symptoms at all • Infected person can infect other people • Viral set point: balance between amount of HIV and the immune response

47. 2. HIV Asymptomatic: • CDC category A (asymptomatic) • Last for an average of ten years • More than 500 CD4+ T lymphpocytes/mm3 • Free of symptoms • There may be swollen glands • By about 6 months, the level of HIV in the blood drops to very low levels • HIV antibodies are detectable in the blood • The immune system rarely if ever fully eliminate the virus

48. 3. HIV symptomatic: • CDC category B (Has HIV symptoms, need treatment for complications of HIV • 200 to 499 CD4+ lymphpocytes/mm3 • CD4 T cells gradually fall • The symptoms are mild • The immune system deteriorates • Emergence of cancer and opportunistic infection (OI) organism ( illness caused by various organisms, some of which usually do not cause disease in persons with normal immune system)

49. 4. HIV……….> AIDS: • CDC C category ( Aids-Indicator condition) • The immune system weakens • The illness become more sever leading to an AIDS diagnosis. • Less than 200 CD4+ lymphocytes/mm3 • As levels drop below 100 cells/mm3, the immune system is significantly impaired

50. Diagnostic findings: • EIA (enzyme immunoassay) or ELIZA test (enzyme-linked immunosorbent assay): Antibodies are detected • Western blot: antibodies detected to confirm ELIZA • Viral load: measure HIV RNA in the plasma • CD4/CD8 ratio: lymphocytes, HIV kills CD4 cells