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Case discussion

Case discussion. Michael Gardam University Health Network. Do you have any cases you would like to discuss?. Case 1. 53 year old male presents with a 6 week history of cough, worsening malaise, weight loss, maybe low grade fever CXR shows a right upper lobe infiltrate.

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Case discussion

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  1. Case discussion Michael Gardam University Health Network

  2. Do you have any cases you would like to discuss?

  3. Case 1 • 53 year old male presents with a 6 week history of cough, worsening malaise, weight loss, maybe low grade fever • CXR shows a right upper lobe infiltrate

  4. You are worried about TBWhat information would help you?

  5. Things to think about • Where is the patient from? • Where have they travelled? • Are they immunocompromised? • History of contact with an active case? • Occupation? • Smoker? • Homeless?

  6. The medical team’s differential diagnosis is: • Lung cancer • Community acquired pneumonia • Tuberculosis • Blastomycosis • They order appropriate tests including sputum cytology and sputum for AFB

  7. What else? • Airborne isolation? • Wait for the sputum smear result and then put in airborne isolation if positive? • Ask the team to plant a tuberculin skin test? • Collect additional sputum samples?

  8. Results • Patient is placed in airborne isolation • Sputum cytology pending • AFB smear negative • The team have started moxifloxacin to treat community acquired pneumonia • The team wants to discontinue airborne isolation.

  9. What do you think? • Stop isolation? • If not, why not? • Await cytology result first? • Is Moxifloxacin a good choice in this setting? • Ask for molecular testing on the sputum sample?

  10. Update • Patient still in airborne isolation • Sputum cytology comes back negative • Second AFB smear negative • Some improvement after 5 days of moxifloxacin • Team really wants to discontinue isolation.

  11. What do you think? • Discontinue airborne isolation now? • If not why not? • If not, when would you feel comfortable discontinuing? • Can you review the case with someone?

  12. Resolution • Smear grows MTB after 17 days

  13. Case 2 • A patient on your complex continuing care ward develops two episodes of loose stool. • Chronically receives laxatives • Currently receiving Ancef for an infected heel ulcer

  14. You are worried about C. difficileWhat information would help you?

  15. Things to think about • Any cases of C. difficilerecently on that ward? • Patient history of C. difficile? • Other signs or symptoms beyond loose stool? • Abdominal pain • Fever • Increasing white count? • Place in contact precautions now?

  16. Update • Stool sample using EIA is negative • Patient has another bought of loose stool • Patient has no other symptoms • Patient has been placed in contact precautions • Physician has started flagyl

  17. What now? • Send another stool specimen? • How many until you are satisfied it is negative • Continue contact precautions?

  18. What if? • Stool testing was done using PCR or culture instead of EIA? • What if the result was positive but the patient’s diarrhea resolved after the first day? • Can you have a positive test result but not be a C. difficilecase?

  19. Case 3 • You are called by the laboratory regarding a patient who has meropenem-resistant Klebsiella to isolated from a wound. • The patient is currently in a 4-bedded room

  20. What now? • Do nothing? • Move the patient to a single room/institute contact precautions? • Bedside contact precautions? • Screen roommates for carriage of the organism? • Screen clinical isolates of roommates for the organism?

  21. What if? • The patient is asymptomatically colonized? • The organism is sensitive to other classes of antibiotics? • Resistance is due to • a klebsiella pneumonia carbapenemase? • Metallobeta-lactamase? • OXA carbapenemase?

  22. PHAC recommendations • Colonized or infected patients should be placed on contact precautions in institutional settings • Including prolonged contacts of known cases and patients with suspected (but not yet confirmed) carbapenemase resistant organisms • Colonized patients do not required contact precautions in the prehospital and homecare settings

  23. In this case: • Clinical screening of contacts and send clinically–relevant specimens • This does not mean surveillance for asymptomatic colonization • Review laboratory records • Strongly consider active surveillance of contacts if you find ≥ 2 clinical cases with the same strain • Do not screen family, staff, visitors or environment in absence of a major outbreak

  24. Other recommendations • Clean your hands… • Single room or cohort with the same organism • Gloves ± gowns • Dedicated equipment • Twice daily cleaning with usual disinfectant • Normal laundry/waste management

  25. Other recommendations • Discontinuing contact precautions • Unknown, likely continue for whole hospitalization • If readmitted within 1 year, consider re-isolation • Oh yeah, you should have an antimicrobial stewardship program in place

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