Download Infectious Diseases Handouts 1 INFECTIOUS DISEASES UPDATE

Infectious Diseases Handouts
DISCLOSURE SLIDE
INFECTIOUS DISEASES UPDATE
Thomas W. Barkley, Jr., PhD, ACNP-BC, FAANP
Professor of Nursing
Director of Graduate and Nurse Practitioner Programs
California State University, Los Angeles
and
President, Barkley & Associates
www.NPcourses.com
I have no current affiliation or financial arrangement
with any grantor or commercial
interests that might have direct interest in the
subject matter of this CE Program.
TOPICAL OUTLINE
Objectives
Upon completion of this session, the participant should be able to:
Influenza: What’s Next?
STDs/STIs: What’s New?
 Vaccines in Adults: Staying Up-to-Date
 Common I.D. Cases
 HIV: What’s to Watch
 Healthcare-Associated Disease
 Prevention Infectious Gastroenteritis and
Diarrhea?


1.
Identify various common emerging and re-emerging
infectious diseases.
2.
Describe relevant pharmacotherapeutic options and
controversies for the management of select emerging and
re-emerging infectious diseases.
3.
Recognize recent developing issues and trends relevant
to infectious diseases in clinical practice.
INFLUENZA: WHAT’S NEXT?
Seasonal deaths: 36,000/year in the United States
90% of associated deaths are aged >65 years
INFLUENZA:
WHAT’S NEXT?
Incidence: Symptomatic influenza A or B
20% children
5% adults
Transmission/infectivity: Respiratory droplets; 1 day prior
to symptoms to 5 days after onset of symptoms
Morbidity/mortality: Increases with age
Major factors for pandemic potential:
1.
2.
Antigenic shift
Antigenic drift
3. Animals
(Barkley, Jr., 2010b, 2010c; Engel, 2007b; Morens & Fauci, 2007; Winston, 2010b)
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Infectious Diseases Handouts
INFLUENZA: VIROLOGY REVIEW
INFLUENZA: VIROLOGY REVIEW
Hemagglutinin (HA): 16 subtypes that bind sialic acid (sugars)
Orthomyxovirus segmented into 8 RNA genomes (mix &
match potential)
What can happen?
Antigenic
SHIFT – undergoes re-assortment
Antigenic DRIFT – undergoes mutation
Which infect humans?
receptors on host cells
Neuraminidase (NA): 9 subtypes which cleave sugars from sialic
acid, assisting the release of virions from infected cells
Antibodies (what the vaccine targets) are protective
All HA & NA combinations exist,
but not all cause disease in humans
Humans: H1, H2, H3, N1, N2
Avian: H5N1
Types A (pandemics), B and C
(Engel, 2007b; Poland & Jacobson et al., 2007; Winston, 2010b)
Influenza: Strain name protocol
(Engel, 2007b; Stephenson, 2006; Winston, 2010b)
SEASONAL INFLUENZA:
HOW DID WE TREAT IT? ADAMANTANES
Amantadine (Symmetrel) & Rimantidine (Flumadine)
Were only effective against Influenza A
No longer recommended by the CDC (until susceptibility is reestablished)
Surge in rapid development of resistance
Numerous side effects (nausea, insomnia, dizziness, falls,
hallucinations, etc.)
Efficacy claim: Decreased fever by 1-2 days
(Engel, 2007b; Tsiodras & Mooney et al., 2007)
INFLUENZA: NEURAMINIDASE INHIBITORS
Zanamivir (Relenza)
INFLUENZA: “NEWER” MEDICATIONS
Neuraminidase Inhibitors
(inhibit viral release)
Oseltamivir (Tamiflu)
Generation
2nd
3rd
Indication
A&B
A&B
Approved for
> 5 years of age
> 1 year of age
Relieving flu
symptoms
62%
10mg/daily
61% - 75mg/daily
73% - 150mg/daily
Prophylaxis
effectiveness
70-80%
68-89%
Administration
Course
Cost
inhaler
oral capsules
5 days = twice daily
5 days = 10 pills
$50 = 5 day supply
$80 = 5 day supply
*Vaccination is far cheaper than either of these drugs*
(Barkley, Jr., 2010b, 2010c; Engel, 2007b, Moscona & McKimm-Breshchkin, 2007)
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INFLUENZA: WHAT’S NEXT?
SEASONAL INFLUENZA VACCINES
Indications:
All persons: > 6 months of age annually
Previous recommendations:
Adults: > 50 years
Healthcare workers
Long term healthcare facility residents
> 6 months with a chronic condition (including asthma)
Pregnancy during influenza season
Persons with high risk contacts
Many others…
Types of Influenza Vaccine
1.
Contraindicated in those allergic to eggs
2.
Live Attenuated: (FluMist) intranasal
Approved for non-pregnant healthy persons
ages 5-49, including healthcare workers
Contraindicated in those allergic to eggs
Clearly effective in children; in adults?
INFLUENZA: WHAT’S NEXT?
SEASONAL INFLUENZA VACCINE
(CDC National Immunization Program, 2008; Winston, 2007b; Winston, 2008b)
Inactivated: Injection
(CDC National Immunization Program, 2008; Winston, 2007b; Winston, 2008b)
Contraindications for Live Attenuated
Influenza Vaccine (LAIV)
Outside recommended age ranges
Allergy to eggs
Pregnant women
INFLUENZA A: DANGERS OF ANTIGENIC
DRIFT AND SHIFT
Chronic medical conditions (including asthma)
History of Guillain-Barre
Substantially immunocompromised individuals
INFLUENZA: WHAT’S NEXT?
SEASONAL INFLUENZA VACCINE
(CDC National Immunization Program, 2008; Winston, 2007b; Winston, 2008b)
INFLUENZA: WHAT’S NEXT?
Antigenic DRIFT – mutations in HA or NA
Allows virus to evade immune recognition
Major reason to revaccinate every year
Conditions necessary for pandemics:
Antigenic SHIFT – Reassortment of HA and/or NA genes
1.
When no pre-existing immunity exists in the population 
PANDEMICS occur
2.
3.
INFLUENZA A:
DANGERS OF ANTIGENIC DRIFT AND SHIFT
(Engel, 2007b; Johansson & Brett, 2007; Winston, 2010)
Virus must be able to replicate in humans
Person-to-person spread
Susceptible population
(Engel, 2007b)
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INFLUENZA: WHAT’S NEXT?

Spanish Flu (1918 Pandemic)



Avian influenza that jumped to humans
40,000,000 deaths!
Avian Influenza A (H5N1)

Jumped from wild birds  domestic birds  humans



1976: First report in China
1977: Jumped from poultry to humans in Hong Kong
Since 2003: NINE (9) major poultry outbreaks of highly
pathogenic H5N1

Human cases correlate with bird outbreaks
(Engel, 2007b)

After exposure to dying household chickens, an 11 year old girl became ill
and died.

Mother, with no poultry exposure and not living with child, arrived and
provided unprotected nursing care in the hospital and died.

Then, an aunt arrived, lived with the girl, provided unprotected nursing
care, took oseltamivir and recovered.

All were positive for the same H5N1 virus.

Conclusion: Infection of the mother and aunt most likely resulted from
person-to-person transmission of the virus during unprotected exposure to
the critically ill child.
H5N1 INFLUENZA: WHERE ARE WE TODAY?
Relatively new virus for humans:



Thailand, 2005:
(Engel, 2007b; Ungchusak et al., 2005 )
H5N1 INFLUENZA: WHERE ARE WE TODAY?

INFLUENZA: H5N1 PERSON-TO-PERSON SPREAD
No pre-existing immunity
Aggressive clinical course with rapid deterioration (viral pneumonia,
multiple organ failure and death)
Highly virulent (~50% mortality)

Sporadic reports worldwide (< 500 cases worldwide)
Treatment:
Ban on importing birds/poultry products
Virus is killed by cooking
Neuraminidase inhibitors
Current person-to-person spread is very inefficient, BUT…
Drift (mutation) OR Shift (reassortment) = possible…
PANDEMIC
(Engel, 2007b; Ungchusak at al., 2005)
FDA APPROVES FIRST U.S. VACCINE FOR
HUMANS AGAINST AVIAN
INFLUENZA VIRUS H5N1

FDA Updates


Inactivated vaccine
Indicated: 18-64 years of age who are at increased risk of
exposure to the H5N1 influenza virus subtype contained in
the vaccine

Will not be available commercially

Purchased by the federal government for inclusion within
the nation's national stockpile
(Engel, 2007b; Ungchusak at al., 2005)
Swine influenza (H1N1)
Newest type A influenza virus
Origin: Pigs?
Components of virus have circulated for years
Recognized since ~ 1930
Re-assortment reminders:
H1N1 (most common today)
H1N2 (bird flu)
Current H1N1 strain: Thought to be a re-assortment of strains
from North American pigs, Eurasian pigs, birds and
humans
H1N1: “SWINE FLU”
(FDA, 2007)
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INFLUENZA
Initial groups (targets) for vaccination:
Pregnant women
Healthcare providers
Adults who live/provide care for infants < 6 months of age
Persons 6 months – 24 years of age
Persons 24 – 64 years of age with comorbidities
Persons with immune compromise
Later…(now)…
H1N1
Elderly
Everyone
(Winston, 2010b)
Signs/Symptoms:
Fever*
Cough*
Sore Throat
Runny/stuffy nose
Body Aches
Chills
Fatigue
Nausea, diarrhea and vomiting in some cases
Symptoms alone cannot distinguish swine flu from regular influenza
Diagnostics:
RT-PCR diagnostic test kit: Developed and distributed by the CDC
ABRUPT Onset:
 Fever*
 Cough*
 Headache
 Myalgias
 Coryza
 Anorexia
 Malaise
(Barkley, Jr., 2010b, 2010c)
Management:
Antiviral drugs (best given within first 2 days of symptoms):
Oseltamivir
Zanamivir
Anti-pyretic medications for fever relief:
Acetaminophen
Non-steroidal anti-inflammatory drugs
Amantadine and rimantadine – resistant to H1N1 strain
Seasonal flu is still deadly, annually killing 250,000-500,000
people (> 36,000 in the United States/year)
INFLUENZA
INFLUENZA
(Barkley, Jr., 2010b, 2010c; Winston, 2010b)
(Barkley, Jr., 2010b, 2010c; Winston, 2010b)
STDS/STIS:
WHAT’S NEW?
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Infectious Diseases Handouts
STDs/STIs: What’s New?
Expedited Partner Therapy (EPT)
Clinical practice of treating the
sex partners of patients
diagnosed with chlamydia or
gonorrhea
STDs/STIs: Expedited Partner Therapy (EPT)
The New England Journal of Medicine, 2005, 352(7), 676-685.
Methods:
Randomized trial of EPT vs. standard referral for patients
with GC or chlamydia
EPT  meds given to patient to deliver to partner (or staff
delivered) without physical exam
Standard referral  partner advised to refer partners for
care
Primary Outcome: Persistent or recurrent gonorrhea or
chlamydial infection in patients 3 to 19 weeks
after treatment
Conclusion:
EPT decreases the rate of re-infection and treatment
failures for gonorrhea and chlamydia
Allows providing prescriptions or
medications to the patient to take
to his/her partner without the
health care provider first
examining the partner
(CDC, 2006b)
(Erlich, 2007b, 2010c; CDC, 2006; Golden et al., 2005)
STDs/STIs: Re-Emergence of LGV in MSM
STDs/STIs: Chancroid
Chancroid:
Lymphogranuloma venereum (LGV) in men who have sex with
men (MSM):
Incubation: 3-10 days
Co-factor for HIV
Recent reports of outbreaks in Netherlands, San Francisco and
others
Chlamydia trachomatis serovars L1, L2, L3
Primary infection: Small painless ulcer
Enlarged inguinal lymph nodes (“bubo”)
Severe proctitis in MSM (blood, mucous in
stool, cramping)
Can lead to strictures, fistula, scarring
Tender, painful ulcer (deep or shallow)
Ragged ulcer edges
Tender, inguinal adenopathy
Recommended treatments – one of:
Azithromycin 1 g PO, single dose
Ceftriaxone 250 mg IM, single dose
Ciprofloxacin 500 mg PO BID x 3 days
Erythromycin base 500 mg PO TID x 7 days
Treatment:
Doxycycline 100mg BID x 3 weeks
Alternative: Azithromycin 1gm daily x 3 weeks
(CDC, 2004b; Erlich, 2007b, 2010c)
(CDC, 2006c; Erlich, 2007b)
HERPES SIMPLEX VIRUSES
Cause:
HSV-1

 Herpes
simplex virus (HSV) types 1 and 2
 90-95% of genital herpes caused by HSV-2


Reactivation factors:
 Stress
 Illness
Prevalence:
 Estimated
“Cold sores”
Trigeminal ganglia latent infection
(fever)
light exposure (fishing, tennis, camping, etc.)
Anatomical transference
 UV
infections in the United States:
 HSV-1:
~ 65% of the population is seropositive
 HSV-2: ~ 50 million Americans




(Barkley, Jr., 2010a, 2010b, 2010c; CDC, 2006c; Erlich, 2010c)
Genitalia
Herpetic whitlow
Other sites
(Barkley, Jr., 2010a, 2010b, 2010c; CDC, 2006c; Erlich, 2010c)
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HSV-1:
HOW DO WE TREAT?
WOULD SUPPRESSIVE THERAPY WORK?
HSV-1:
HOW DO WE TREAT?
ANTIVIRALS
WOULD SUPPRESSIVE THERAPY WORK?
YES!
HSV-2
HSV-2

Genital Herpes (vast majority)

Most common STD in the United States

~ 50 million Americans infected!

Notable factor for HIV transmission

Asymptomatic viral shedding occurs in ~ 10% of patients
(Barkley, Jr., 2010a, 2010b, 2010c; CDC, 2006c; Erlich, 2010c)
HSV-2 GENITAL HERPES: PRESENTATION




Pruritic vesicles
Vesicles rupture to form
shallow ulcers
Resolve spontaneously
Viral shedding occurs
intermittently without clinical
symptoms






Inguinal adenopathy present
with initial case
Fever/chills
Headache
Malaise
Dysuria
Dyspareunia
(Barkley, Jr., 2010a, 2010b, 2010c; CDC, 2006c; Erlich, 2010c)
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HSV LABS/DIAGNOSTICS
HSV TREATMENT
No cure

1.
Viral culture (exudative lesions)
2.
DFA staining (crusted lesions; antigen detection)
3.
IgG antibody testing
2.
4.
PCR (DNA testing; expensive)
3.
Antivirals

1.
4.
Emotional support

www.herpes-foundation.org
www.HerpesDiagnosis.com
www.HerpesDate.com



(Barkley, Jr., 2010a, 2010b, 2010c; CDC, 2006c; Erlich, 2010c)
Acyclovir
Famciclovir
Valacyclovir (asymptomatic shedding)
Other “-virs”
(Barkley, Jr., 2010a, 2010b, 2010c; CDC, 2006c; Erlich, 2010c)
VACCINATIONS IN ADULTS:
STAYING UP-TO-DATE
A 28 year-old male presents to your office today for his
yearly physical exam. He was recently married and hopes
to have his first child within the next year or two. He
states that he had “all his vaccinations as a child” but
wants to make sure he is up-to-date with the latest
recommendations as an adult. He has a history of
childhood chickenpox, received 2 doses of MMR, and his
last tetanus shot was in 1997. Given this information,
which vaccinations should he receive today?
TRIVIA ANALYSIS
(Winston, 2007b)
A.
Tetanus + diptheria + acellular pertussis (Tdap);
meningococcus; consider hepatitis A & B
B.
Tetanus + diptheria + acellular pertussis (Tdap); consider
hepatitis A & B
C.
Tetanus + diptheria (Td) + Gardasil
D.
Tetanus + diptheria (Td); consider hepatitis A & B
E.
None
TRIVIA ANALYSIS
(Winston, 2007b)
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Infectious Diseases Handouts
VACCINATIONS FOR MILITARY/LAB WORKERS AND
OTHER SPECIAL GROUPS
VACCINATIONS IN THE UNITED STATES

Tetanus
Diptheria
Measles
Mumps
Rubella
Varicella
Pertussis
Meningococcus
Pneumococcus
Hepatitis A








Hepatitis B
Haemophilus influenzae
type B
Inactivated polio
Influenza
Rabies
HPV
Typhoid
Yellow fever
Japanese encephalitis
(CDC National Immunization Program, 2008; Winston, 2010c)







Plague
Tularemia
Smallpox
Anthrax
Botulism
Tuberculosis – BCG
(Adenovirus) – looking for new
manufacturer
(CDC National Immunization Program, 2008; Winston, 2010c)
EPIDEMIOLOGY CHANGES: MUMPS

CDC RECOMMENDED ADULT
IMMUNIZATION SCHEDULE
Mumps vaccine not as protective as thought?

Mumps outbreak in N.Y. & N.J. (6/09-1/10)

1,521 cases; almost all in tradition-observant Jewish community
[males 76%; 7-18 years (61%)]

88% had received one does of mumps vaccine; 75% had two doses; no
deaths

Travel: Best risk factor

Most patients in U.S. have been vaccinated: 3 doses of mumps vaccine
under investigation
http://www.cdc.gov/vaccines/schedules/index.html
CHANGES/CLARIFICATION: MUMPS
VACCINATION
FOR HEALTHCARE WORKERS
If born before 1957: Consider 1 dose of vaccine unless evidence of immunity
Immunity = clinical-diagnosed mumps OR positive serology
Unless immune, employ 2 doses during mumps outbreak
If born during or after 1957: 2 doses of vaccine (if not previously given) unless
immunity can be documented
Note: Post-vaccination serology may be negative (vaccination gives lower antibody
titers than natural infection)
(Barkley, Jr., 2010a; CDC National Immunization Program, 2008; Winston, 2007b; Winston, 2010c)
Pneumococcal Polyvalent Vaccine (Pneumovax):
Decreases pneumococcal bacteremia (may decrease mortality)
Does not decrease pneumonia in the elderly
More effective with younger adults (e.g., crowded living conditions)
Revaccination has been questionable
More widely employed in North America
CLARIFICATION: PNEUMOCOCCAL
VACCINE
(Barkley, Jr., 2010a; CDC National Immunization Program, 2008; Winston, 2010c)
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Pneumococcal Polyvalent Vaccine:
Indications:
1. > 65 years of age
2. Patients with chronic conditions involving the heart,
lungs, liver or kidneys
3. Adults 19-64 years of age with asthma
4. Smokers 19-64 years of age (4 x greater risk for
PNEUMOVAX: WHEN TO REVACCINATE?

pneumococcal disease)
5.
Routine vaccination of Alaskan natives and
American Indians is no longer recommended.
CLARIFICATION: PNEUMOCOCCAL
VACCINE
(Barkley, Jr., 2010a; 2010b; 2010c; CDC National Immunization Program, 2008; Winston, 2010c)
(Barkley, Jr., 2010a; CDC National Immunization Program, 2008; Winston, 2007b; 2008b)
NEWER MENINGOCOCCAL VACCINES:
TETRAVALENT PROTEIN CONJUGATES
Who should receive Meningococcal Polysaccharide Diphtheria
Toxoid Conjugate Vaccine (Menactra?)
Approved for ages 2-55 years (10/07)
Recommended routinely for adolescents at 11-12 year visit
“Catch up” at high school or college
Also for special populations: Military, immunodeficiencies,
asplenia, travelers (Africa), etc.
Clinical efficacy not completely determined; high cost?
Revaccination recommended as reasonable after 5 years for
adults and adolescents remaining at increased risk (but not
college catch ups)
One time revaccination after 5 years for:
 CRF or nephrotic syndrome
 Asplenia
 Immunosuppression
 Chronic steroid use
 Others (e.g., long term care facilities, etc.)
 If at least 65, one time revaccination if vaccinated 5 or
more years previously < 65 at the time of the initial
vaccination.
NEWER MENINGOCOCCAL VACCINES:
TETRAVALENT PROTEIN CONJUGATES




Newest:
Meningococcal oligosaccharide diptheria CRM197
conjugate vaccine (Menveo) (2/10)
Licensed for persons 11-55 years of age
May boast a higher seroresponse than meningococcal
polysaccharide diphtheria toxoid conjugate vaccine (at
least one bactericidal assay) for three serogroups

Clinical relevance: Unknown at present
(Barkley, Jr., 2010a, 2010b, 2010c; CDC National Immunization Program, 2008; Winston, 2008b)
Resurgence in pertussis incidence
~ 600,000 cases/year in 19-64 year olds
Immunity diminishes over time
Children = DTaP
(diptheria + tetanus toxoids + acellular pertussis)
Age group: 19-64 years – 1 dose Td booster every 10 years;
Substitute 1 dose of Tdap for Td
If missed, may give at 2 years after last tetanus-containing
vaccine
Wound management or if series unknown – substitute 1 dose Tdap
for Td
Adults = Td and now, Tdap
For adolescents, give Tdap instead of Td at routine 11-12 year visit
(tetanus toxoid + reduced dose diptheria toxoid +/- reduced
dose of acellular pertussis antigens)
Tdap (Boostrix) approved for ages 10-64
Tdap (Adacel) approved for ages 11-64
No current booster recommendations – back to Td
UPDATES: PERTUSSIS VACCINE
(CDC National Immunization Program, 2010; Ward et al., 2005; Winston, 2010c)
Not licensed for ages > 65
Recommended for healthcare workers with patient contact
UPDATES: PERTUSSIS VACCINE
(Barkley, Jr., 2010a, 2010b, 2010c; CDC National Immunization Program, 2008; Winston, 2010c)
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UPDATES: PERTUSSIS VACCINE

Pertussis immunity wanes over time

*New: Tdap can be given at any interval after last Td

Recommended for adults who have contact with infant(s)
< 12 months old

Varicella virus vaccine live (Varivax)
Now recommended as 2 doses for adults
Recommended for all ages (not just 13 and up)
*Multiple dose recommendations may be forthcoming


VARICELLA VACCINES
Zoster vaccine live (Zostavax)
Advisory Committee on Immunization Practices:
Reduces zoster > 50%
Reduces post herpetic neuralgia > 65%
> 65 years? (supported to give by most)
Not contraindicated in pregnancy
Single dose for adults > 50, even if prior history of zoster
The older the patient, the perhaps less efficacious
Should not be given concurrently with pneumococcal vaccine
polyvalent (decreased immunogenicity of zoster vaccine live)
(Barkley, Jr., 2010a, 2010b, 2010c;Winston, 2007b, 2008b, 2010c)
Reports of outbreaks
HPV Vaccines
~ 75% cases < 20 years of age
Often associated with:
Foreign traveling (89%)
Unvaccinated or status not known
HPV: A Closer Look

2nd most prevalent STI (HSV-1 = #1)

Easily transmissible; condoms not fully protective

> 20 million infected in the USA; > 100 types of HPV in
humans

MEASLES
(Winston, 2010c)
Worldwide prevalence: 9%-13% (630 million infected
individuals)
(Ekeowa-Anderson et al., 2007, Erlich, 2010a, 2010c)
HPV Vaccines
Role
HPV Vaccines
in anal, vaginal and vulvar cancers
Oncologic
2006:
HPV
strains: HPV 6, 11, 16, 18, 31, 33, 45, others
1st HPV vaccine (Merck)
6 & 11 are benign genital warts while 16 & 18 are cancerous =
human papillomavirus quadrivalent vaccine (Gardasil)
Females:
Males:
2009: 2nd HPV vaccine (GSK)
HPV
16 & 18 = human papillomavirus bivalent (Types 16 and 18)
vaccine, recombinant (Cervarix)
Females
9-26 years of age
10-25 years of age
Now approved to be given to for ages 9-26 years to protect
against genital warts
(CDC, 2006c; Erlich, 2007b, 2010a, 2010c)
(CDC, 2006c; Erlich, 2007b, 2010a, 2010c)
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Infectious Diseases Handouts
A 28-year-old male presents to your office today for his
yearly physical exam. He was recently married and hopes
to have his first child within the next year or two. He
states that he had “all his vaccinations as a child” but
wants to make sure he is up-to-date with the latest
recommendations as an adult. He has a history of
childhood chickenpox, received 2 doses of MMR, and his
last tetanus shot was in 1997. Given this information,
which vaccinations should he receive today?
TRIVIA ANALYSIS
(Winston, 2007b)
A.
Tetanus + diptheria + acellular pertussis (Tdap);
meningococcus; consider hepatitis A & B
B.
Tetanus + diptheria + acellular pertussis (Tdap); consider
hepatitis A & B
C.
Tetanus + diptheria (Td) + meningococcal
oligosaccharide diptheria CRM197 conjugate vaccine
D.
Tetanus + diptheria (Td); consider hepatitis A & B
E.
None
TRIVIA ANALYSIS
(Winston, 2007b)
COMMON I.D. CASES

Pharyngitis

Cellulitis

Pneumonia
PHARYNGITIS
Consider the following adult patients presenting with a chief
complaint of a “sore throat”…
TRIVIA ANALYSIS
A.
Streptococcal pharyngitis
B.
Parapharyngeal abscess
C.
A viral infection
D.
Epiglottitis
E.
Mononucleosis
WHICH OF THE FOLLOWING IS YOUR MOST LIKELY
DIAGNOSIS GIVEN THE CLINICAL PICTURE?
(Jacobs, 2008)
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Infectious Diseases Handouts
Important “PEARLS” to the
Most Likely Differential:
A.
Streptococcal pharyngitis
[fever, pharyngo-tonsillar exudate, anterior cervical adenopathy]
B.
Group C and G strep, gonococcus, Arcanobacterium
haemolyticum, C. diphtheriae, Mycoplasma, Chlamydia
Viral:
Rhinovirus, coronavirus, adenovirus, influenza, parainfluenza,
HSV, EBV, CMV, HIV
Parapharyngeal abscess
[odynophagia, dysphagia, muffled voice, lateral bulging of the
posterior wall]
C.
Bacterial: 5-15% GABHS
A viral infection
Many Others:
Para/retropharyngeal abscess, epiglottitis, foreign body, Ludwig’s
angina, thyroiditis, GERD, etc.
[fever, rhinorrhea, cough, myalgias, coryza]
D.
Epiglottitis
[worst sore throat of one’s life, minimal physical exam findings
other than a red throat, severe odynophagia, dysphagia]
E.
Mononucleosis
[Most common in 15-24 year olds, malaise, fatigue, white tonsillar
exudates, posterior cervical adenopathy]
(Barkley, Jr., 2010a, 2010b; Jacobs, 2008, 2010)
ACUTE PHARYNGITIS:
DIFFERENTIALS/ETIOLOGY
(Jacobs, 2008, 2010)
“F-L-E-A”
A.
Clinical presentation
B.
Rapid strep test
C.
Culture
D.
All of the above
Fever over 38 degrees C
Lack of cough
Pharyngotonsillar exudate
Anterior cervical adenopathy
WHICH OPTION IS BEST FOR DIAGNOSING
STREPTOCOCCAL PHARYNGITIS?
AMERICAN COLLEGE OF PHYSICIANS’ KEY
PREDICTORS OF GABHS PHARYNGITIS
The Centor Criteria:
(Jacobs, 2008)
Culture
Centor criteria
Gold standard
Sensitivity: 90-95%
If 3-4 criteria present: ACP
recommends broad spectrum
coverage
Rapid strep test
For empiric treatment:
More expensive than culture
Sensitivity: 80-90%
Specificity: > 95%
Use PCN or cephalosporin
[rather than a macrolide
(resistance)]
(Barkley, 2008; Centor, 2009; Jacobs, 2010)
CELLULITIS
ABSCESS
MSSA
MRSA
CA-HRSA
HA-MRSA OR
WHAT???
GABHS DIAGNOSTICS
(Center, 2009; Jacobs, 2008, 2010)
13
Infectious Diseases Handouts
ALL PATIENTS WITH CELLULITIS LOOK THE
SAME:
WHAT’S THE ETIOLOGY?
OFTEN CITED WORK:
MASQUERADERS OF INFECTIOUS CELLULITIS
FALAGAS & VERGIDIS, ANN INTERN MED 2005; 142:47












Superficial and deep thrombophlebitis
Contact dermatitis
Insect stings/bites
Drug reactions
Gouty arthritis
Carcinoma erysipeloides
Urticaria
Lupus erythematosus
Sarcoidosis
Paget disease
Panniculitis
Others
(Falagas & Vergidis, 2005; Jacobs, 2007, 2010)

Outpatient

Strep. pyogenes (Gp A strep)
S. aureus (less common)
 Other strep types B, C, G (rare)



Hospital-associated

Decubitus/diabetic/vascular
ulcers
Gram negative organisms (E. coli, Klebsiella, Pseudomonas,
Enterobacter)
Staph (MSSA, MRSA)
 Strep

(Isu & Ichimura, 2007; Jacobs, 2007, 2010; Stevens et al., 2005)
ALL PATIENTS WITH CELLULITIS LOOK THE
SAME:
WHAT’S THE ETIOLOGY?

Pasteurella multocida
(< 24 hours)
 Staph
 Strep
 “Mouth” anaerobes
later
including:
 Staph
 Strep

 Enteric
gram-negatives
 Pseudomonas
 Anaerobes
(Isu & Ichimura, 2007; Jacobs, 2007, 2010; Stevens et al., 2005)
COMMUNITY-ASSOCIATED MRSA?
(Falagas et al., 2005; Jacobs, 2007, 2010)
Human bites
Aerobic and anaerobic
mouth flora
 Eikenella corrodens

(Isu & Ichimura, 2007; Jacobs, 2007, 2010; Stevens et al., 2005)
MANAGEMENT OF CELLULITIS:
COMMON BACTERIOLOGY
Antibiotic Choices for Soft Tissue Infections
Many are mixed: S. aureus + Group A strep
If MRSA is prevalent, treatment should include either:
Clindamycin (85-95% active against CA-MRSA)
TMP-SMX (95-100% active against CA-MRSA)
Doxycycline/minocycline (90-95% active against CA-MRSA)
But, TMP-SMX and doxy/minocycline may/usually have poor activity
against Group A strep. [If you use, must add a beta-lactam such as a
PCN, amoxicillin, or first generation cephalosporin (Keflex)]
*Clindamycin has good activity against both S. aureus and Group A
strep
Animal bites

 Polymicrobial,
 Enterococcus
Usually caused by:

ALL PATIENTS WITH CELLULITIS LOOK THE
SAME:
WHAT’S THE ETIOLOGY?

Usually caused by:


Outpatient
 TMP-SMX or doxy/mino + beta lactam (e.g.,
PCN, amoxicillin, or first generation
cephalosporin]
OR
 Clindamycin (also for PCN allergic patients)
 Duration of therapy = 5 days (vs. 10 days)
Hospital-associated
 Vancomycin +/- a 3rd generation
cephalosporin
(Barkley, Jr., 2010c; Jacobs, 2008; Jacobs, 2007, 2010; Robinson et al., 2007; Stevens et al., 2005)
14
Infectious Diseases Handouts
COMMUNITY ACQUIRED PNEUMONIA
Pneumonia and influenza: 7th most common cause of
death
The most common cause of death from infectious disease
PNEUMONIA: OUTPATIENT OR INPATIENT?
> 85 year of age: At least 1/20 hospitalized each year
More common in winter months
Inpatient mortality: 2-30% (~14%)
Outpatient mortality: < 1%
Chest PE: Not sensitive or specific to ascertain diagnosis
(Barkley & Myers, 2008; Winston, 2007a; Winston, 2008a)
COMMUNITY ACQUIRED PNEUMONIA
Acute lung tissue infection (at least 2 new
symptoms)
Fever and/or hypothermia
Rigors and/or diaphoresis
Sputum production or color change
Cough
Chest pain
Dyspnea
Abnormal chest exam and/or new infiltrate by CXR
No other exposure (hospitalization or nursing
home) in 2 weeks prior to symptom onset
Pneumonia Severity Index Calculator: About.
December 2003. Agency for Healthcare Research
and Quality. Rockville, MD.
http://pda.ahrq.gov/clinic/psi/psicalc.asp
PNEUMONIA SEVERITY INDEX
CALCULATOR
(Barkley, Jr., 2010a; Erlich, 2007; Johnson-Mallard et al., 2007; Mills & Laing, 2006; Winston, 2007a,
2008a)
PNEUMONIA
SEVERITY INDEX CALCULATOR
PNEUMONIA
SEVERITY INDEX CALCULATOR
15
Infectious Diseases Handouts
Outpatient treatment:
Co-morbid conditions, immunosuppression or
antibiotics within 3 months:
Select a different class
*Respiratory fluoroquinolone: Moxifloxacin,
gemifloxacin, or levofloxacin (750 mg)…OR
Outpatient treatment:
*ß-lactam (especially high dose amoxicillin) PLUS a
macrolide (1st choice ) or doxycycline
Previously healthy, no antibiotics in 3 months:
Macrolide (1st choice) or
Doxycycline
__________________________________________
CAP EMPIRICAL TREATMENT: IDSA/ATS
CONSENSUS GUIDELINES
(Barkley 2010a; Barkley & Myers, 2008; Mandell et al., 2007)
Doxycycline in pill form
CAP EMPIRICAL TREATMENT: IDSA/ATS
CONSENSUS GUIDELINES
(Barkley & Myers, 2008; Mandell et al., 2007)
CAP EMPIRICAL TREATMENT: IDSA/ATS
CONSENSUS GUIDELINES
Inpatient treatment, non-ICU:
___________________________________________________________

A respiratory fluoroquinolone…OR
ß-lactam (cefotaxime, ceftriaxone, or ampicillin;
consider ertapenem)
PLUS
A macrolide (1st choice) or doxycycline
 ß-lactam
(cefotaxime, ceftriaxone, or ampicillinsulbactam)
PLUS
 Azithromycin OR
 A respiratory fluoroquinolone
______________________________________
 For penicillin allergy:
CAP EMPIRICAL TREATMENT: IDSA/ATS
CONSENSUS GUIDELINES
(Barkley & Myers, 2008; Mandell et al., 2007)
 Respiratory
fluoroquinolone + aztreonam
(Barkley & Myers, 2008; Mandell et al., 2007)
CAP EMPIRICAL TREATMENT: IDSA/ATS
CONSENSUS GUIDELINES

Inpatient treatment, ICU:
_________________________________
CAP EMPIRICAL TREATMENT: IDSA/ATS
CONSENSUS GUIDELINES
For Pseudomonas, consider:
An antipneumococcal, antipseudonomal ß-lactam
(piperacillin-tazobactam, cefepime, imipenem or
meropenem) + either ciprofloxacin or levofloxacin (750
mg)

OR
 The above ß-lactam + an aminoglycoside and

 EITHER
Azithromycin OR
 An antipneumococcal fluoroqinolone
 (for PCN-allergic patients, substitute aztreonam for
above ß-lactam)


Concern for CA-MRSA? For inpatients…
 Add
vancomycin or linezolid to the regimen you
chose
 Recommended as a routine measure for patients
admitted to the ICU; then Gram stain
sputum/tracheal aspirate
(Barkley & Myers, 2008; Mandell et al., 2007)
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Infectious Diseases Handouts
Blood
Semen
Breast Milk
Vaginal Secretions
HIV: WHAT TO WATCH
Flu-like symptoms: Think seroconversion
How long does it take?
Early signs and symptoms:
Fever
Night sweats
Weight loss
Opportunistic infections
HIV/AIDS EPIDEMIOLOGY
(Barkley, Jr., 2010a; Barkley, Jr., & Myers, 2008; Erlich, 2010; Mandell et al., 2007)
HIV + VS. AIDS?
Needle stick risk = 1:350
Rule of 3’s:
HBV+
HCV+
HIV+
HIV+ (splash)
~ 30%
~ 3%
~ 0.3%
< 0.1%
Eye: Highest risk
HIV is not transmissible for saliva, urine or stool skin
splashes
PEP: Initiate within one hour!
HIV: WHAT TO WATCH

AIDS Definition: CD4 (T cell) count < 200 cells/uL and/or the
presence of an opportunistic infection

Labs/Diagnostics

Historic mortality: ~55%

(CDC: All persons aged 16-64 should be screened at least
once for HIV)
1.
ELISA – sensitivity > 99.9%
2.
Western Blot – CONFIRMATORY test
(Barkley, Jr., 2010a; Barkley, Jr., & Myers, 2008)
HIV + VS. AIDS?

Important Ongoing Diagnostics
1.
Absolute CD4 lymphocyte count: Normal >
800 cells/uL
2.
CD4 lymphocyte percentage: Risk of
progression to AIDS is high when < 20%
3.
Viral load: Ideally < 5,000 copies, “zero” or
“undetectable”
Management:
Opportunistic infections
Treat infection as it occurs
Pneumocystis jiroveci (PCP)
Prophylaxis: TPM-SMZ
Antiretroviral therapy (ART)
When to start remains controversial
Start at the time of diagnosis (HIV+)?
CDC: CD4 reaches 350/uL
Resistance: Meds taken exactly as prescribed!!!
HIV: WHAT TO WATCH
(Barkley, Jr., 2010a; Barkley, Jr., & Myers, 2008)
17
Infectious Diseases Handouts
HEALTHCARE SYSTEM OF THE PAST
HEALTHCARE-ASSOCIATED
DISEASE PREVENTION
Home
Care
Outpatient/
Ambulatory
Facility
Tranquil Gardens
Nursing Home
Acute Care
Facility
Long Term Care
Facility
(Weber, n.d.)
CURRENT HEALTHCARE SYSTEM
Acute
Care
Facility
Home
Care
CAMPAIGN TO
PREVENT
ANTIMICROBIAL
RESISTANCE
Outpatient/
Ambulatory
Facility
Centers for Disease Control and Prevention
National Center for Infectious Diseases
Division of Healthcare Quality Promotion
Tranquil Gardens
Nursing Home
Clinicians hold the solution!
Long Term Care
Facility
(Weber, n.d.)
ANTIMICROBIAL RESISTANCE:
KEY PREVENTION STRATEGIES
KEY PREVENTION STRATEGIES
Susceptible Pathogen
Antimicrobial-Resistant Pathogen
Prevent
Transmission
Prevent
Prevent
Infection
and treat infection
effectively
Use antimicrobials wisely
Prevent transmission
Infection
Antimicrobial
Resistance
infection
Diagnose
Effective
Diagnosis
& Treatment
Optimize
Use
Antimicrobial Use
Clinicians hold the solution!
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Infectious Diseases Handouts
12 STEPS TO PREVENT ANTIMICROBIAL RESISTANCE:
HOSPITALIZED ADULTS
12 Break the chain
11 Isolate the pathogen
Prevent
Transmission
10 Stop treatment when cured
9 Know when to say “no” to vanco
8 Treat infection, not colonization
Use Antimicrobials
Wisely
7 Treat infection, not contamination
6 Use local data
Prevention
IS PRIMARY!
5 Practice antimicrobial control
4 Access the experts
3 Target the pathogen
2 Get the catheters out
1 Vaccinate
Diagnose & Treat
Effectively
Protect patients…protect healthcare personnel…
promote quality healthcare!
Prevent Infections
Division of Healthcare Quality Promotion
National Center for Infections Diseases
(Hinman & Orenstein, 2007; Campaign to Prevent Antimicrobial Resistance)
KEY CITED WORK:
EASY EXAMPLE OF EFFECTIVENESS
WHAT ELSE IS CURRENTLY UNDER WAY
TO HELP INPATIENTS?
Infectious Disease Society of America and the Society for
Healthcare Epidemiology of America Guidelines for
Developing an Institutional Program to Enhance
Antimicrobial Stewardship

Pronovost, P., Needham, D., Berenholtz, S.,
Sinopoli, D., Chu, H., Cosgrove, S., et al.
(2006). An intervention to decrease
catheter-related bloodstream infections in
the ICU. New England Journal of Medicine,
355(26), 2725-2732.
Dellit, T. H., Owens, R. C., McGowan, J. E., Gerding, D. N., Weinstein, R. A., Burke, J. P. et al.
(2007). Infectious Disease Society of America and the Society for Healthcare
Epidemiology of America guidelines for developing an Institutional program to
enhance antimicrobial stewardship. Clinical Infectious Diseases, 44, 159-177.
(Albrecht et al., 2006)
AN INTERVENTION TO DECREASE CATHETERRELATED BLOODSTREAM INFECTIONS IN
THE ICU
Measures:
Multilevel Poisson regression modeling was used to compare infection
rates before, during, and up to 18 months after implementation of the
study intervention.
 Rates of infection/1000 catheter-days were measured at 3-month
intervals, according to the guidelines of the National Nosocomial
Infections Surveillance System.

Data:

Reported from 103 ICUs:
 1981 ICU-months
 375,757 catheter-days
(Pronovost et al., 2006 )
An Intervention to Decrease CatheterRelated Bloodstream Infections in the ICU
Results:
(catheter-related bloodstream infections/1,000
catheter-days)
Median rate (p = 0.002)
Baseline: 2.7
3 months after intervention: 0 (p = 0.002)
Mean rate (p < 0.002)
Baseline: 7.7
16 to 18 months of follow-up: 1.4
(Pronovost et al., 2006 )
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Infectious Diseases Handouts
An Intervention to Decrease CatheterRelated Bloodstream Infections in the ICU
An Intervention to Decrease CatheterRelated Bloodstream Infections in the ICU
Results:
Conclusions:
Regression model revealed:
A large and sustained reduction in
catheter-related bloodstream infections
occurred with the implementation of
evidence-based intervention (up to 66%).
Significant decreases in infection rates
Incidence-rate ratios continuously decreasing:
3 months after: 0.62 (95% confidence interval
[CI], 0.47 to 0.81)
Results were successfully maintained
throughout the 18-month study period.
16-18 months after: 0.34 (95% CI, 0.23 to 0.50)
(Pronovost et al., 2006 )
(Pronovost et al., 2006 )
INFECTIOUS GASTROENTERITIS
AND DIARRHEA
Major Players:
1.
Hospital-Associated
2.
Protozoal

Bacterial
 Viral
Rarely caused by bacteria, parasites or fungi
Antibiotic-associated

Clostridium difficile

Others (e.g., Cytotoxin-producing Klebsiella
oxytoca…)
3.
Drugs (other than antibiotics)
4.
Healthcare related (e.g., diagnostics, contamination
issues)
GASTROENTERITIS: HOSPITALASSOCIATED
CLOSTRIDIUM DIFFICILE
CLOSTRIDIUM DIFFICILE:
IT’S STILL HERE…
IT’S GAINING FORCE…
AND IT’S DIFFERENT?

Clostridium difficile: Gram-positive, spore forming, anaerobic bacillus

First described in 1935

> 300,000 cases/year in the U. S.


Rarely seen before 2000
Deaths ~ 5,500/year

Mean cost ~ $4,000/case

Prolonged hospital stay by ~ 3.6 days

One of the most common causes of diarrhea in hospitalized adults in North
America
(Stobe, 2008; Jodlowski et al., 2006)
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Infectious Diseases Handouts
C. DIFFICILE - ASSOCIATED DISEASE (CDAD)
RISK FACTORS
Antibiotic, chemotherapeutic or
immunosuppressive exposure
 Surgery
 Host immunity
 Exposure to gastric acid suppressants
 Advanced age
 Low serum antitoxin A immunoglobulin levels

C. DIFFICILE ISSUES

Emergence of this more virulent strain of C. difficile
(BI/NAP1) was noted producing:

Up to 23 times the amount of toxins

A binary toxin
As well as

Response to therapy, historically ~ 90%:



Issues:


(Jodlowski et al., 2006)
Oral vancomycin or
Metronidazole
Metronidazole failure rates ~ 22-28%
Vancomycin 8-18% (major $)
(Bartlett, 2006; Jodlowski et al., 2006)
C. DIFFICILE: VANCOMYCIN VS.
METRONIDAZOLE
Equally
Vancomycin (oral)
Only drug FDA approved
Exhibits quicker response and
decreased time for toxin and
pathogen eradication
Not absorbed by the GI tract
effective
Equal

Metronidazole (oral)


Recommended by CDC, Society
for Healthcare Epidemiology of
America and the Infectious
Diseases Society of America
Less expensive by acquisition
cost
(Guglielmo, 2007)
frequency of relapse (20-25%)
Neither
drug superior to the other
C. DIFFICILE: VANCOMYCIN
VS. METRONIDAZOLE
(Guglielmo, 2007)
C. DIFFICILE: COST OF THERAPY
Regimen
Rifaximin 200 mg tid x 10 days
Nitazoxanide 500 mg bid x 10 days
IVIG 400 mg/kg 1-6 doses
Cost
$124
$312
$2,835-$17,010
Tinidazole 500 mg bid x 10 days
$95
Tolevamer (Phase III current study)
$N/A
*Standard therapy*
*Vancomycin 125 mg qid x 7-14 days
$452-$905
*Metronidazole 500 mg tid x 7-14 days
$14-$29
GASTROENTERITIS: PROTOZOAL
(Pepin, 2006 )
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Infectious Diseases Handouts
GASTROENTERITIS: PROTOZOAL
GASTROENTERITIS: PROTOZOAL
(CONSIDER PARTICULARLY IF SYMPTOMS > 7 DAYS)
(CONSIDER PARTICULARLY IF SYMPTOMS > 7 DAYS)
1.
Giardia




Risks: Children* (adults with close
contact), campers, travelers, poor water
sanitization
Incubation period ~ 7 days
Usually lasts 1-3 weeks!
Tx:
2.
Entamoeba histolytica






Supportive: Fluids/rehydration
 Metronidazole
 Tinidazole
(Antibiotics speed recovery by only 1-2 days)

(Branda et al., 2006; CDC, 2010a, 2010bm 2010c, 2010d; Engel, 2010; Lacasse, 2009)
GASTROENTERITIS: PROTOZOAL
(CONSIDER PARTICULARLY IF SYMPTOMS > 7
DAYS)

Risks: Tropical areas, poor
sanitary conditions
Only 10-20% become ill
Gastroenteritis
Tx:
Supportive: Fluids/rehydration
For symptomatic patients:
 Metronidazole or tinidazole
followed by iodoquinol or
paromomycin
(Branda et al., 2006; CDC, 2010a, 2010bm 2010c, 2010d; Engel, 2010; Lacasse, 2009)
GASTROENTERITIS: PROTOZOAL
(CONSIDER PARTICULARLY IF SYMPTOMS > 7 DAYS)
4.
Cryptosporidium

 Risks:
Farm animals, contaminated food or water,
etc.
 Low ID50
 Persistent/recurrent diarrhea
 Tx:
 Supportive:
Microsporidia



Identified world wide
Many species: “Clump” name
Diarrhea, multi-organ involvement
possible
Tx:


Supportive: Fluids/rehydration
Albendazole (Albenza): FDA
approved (investigational)
Fluids/rehydration
(Alinia): FDA approved
 Nitazoxanide
GASTROENTERITIS: BACTERIAL
(CONSIDER PARTICULARLY IF SYMPTOMS > 3 DAYS)
1. Salmonella
GASTROENTERITIS: BACTERIAL





Contaminated food outbreaks common in the
media
Incubation period ~ 12-72 hours
Usually lasts 4-7 days!
Diarrhea, fever, abdominal cramps
Tx:



Supportive: Fluids/rehydration
Usually resolves in 5-7 days spontaneously
Antibiotics only for severe cases
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Infectious Diseases Handouts
GASTROENTERITIS: BACTERIAL
(CONSIDER PARTICULARLY IF SYMPTOMS >
3 DAYS)
GASTROENTERITIS: BACTERIAL
(CONSIDER PARTICULARLY IF SYMPTOMS > 3 DAYS)
2. Campylobacter




Risks: Raw, uncooked poultry meat
N, V, D, fever, abdominal cramps
Usually lasts ~ 7 days
Tx:


Supportive: Fluids/rehydration
Erythromycin or fluoroquinolones are
rarely needed

3. Shigella
 Risks:
Children (stool from fingers/hands to
mouth), food workers (contamination), poor hand
hygiene
 Diarrhea (often bloody), fever, abdominal cramps
 Incubation period ~ 1-2 days
 Tx:
 Supportive:
 Antibiotics
Fluids/rehydration
for more severe cases (resistance?)
GASTROENTERITIS: BACTERIAL
(CONSIDER PARTICULARLY IF SYMPTOMS > 3 DAYS)
4. E.
coli

Shiga toxin-producing E. Coli (STEC)

Risks: Human or animal feces (very
small amounts)
Abdominal cramps (severe), diarrhea
(often bloody),
vomiting, mild/no fever
Most resolved ~ 5-7 days
5-10%: Hemolytic uremic syndrome
(HUS)  life threatening
Tx:





E. Coli 0157:H7
GASTROENTERITIS: VIRAL
Supportive: Fluids/rehydration
Hospitalization for HUS patients
 Antibiotics are not used


Major Pathogens
1. Caliciviruses
Norwalk: Mosquito transmitted
Norovirus: Most common
cause of infectious, acute
gastroenteritis
Sapovirus: Mild gastroenteritis
in children
Gastroenteritis: Viral
(Consider particularly if symptoms < 3 days)
2.
Rotavirus: Leading cause
of gastroenteritis in
children 3-15 months of
age
3.
Adenovirus: Children < 2
years of age
GASTROENTERITIS: VIRAL
(CONSIDER PARTICULARLY IF SYMPTOMS < 3 DAYS)
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Infectious Diseases Handouts
Major Pathogens
1. Caliciviruses
Norwalk: Mosquito transmitted
Norovirus: Most common
cause of infectious, acute
gastroenteritis
Sapovirus: Mild gastroenteritis
in children
VIRAL DISEASES: NOROVIRUS
•
•
Responsible for the most common cause
of infectious acute gastroenteritis
First outbreak: Norwalk, OH 1968
Previously known as Norwalk-like virus
•
GASTROENTERITIS: VIRAL
Often mistakenly referred to as “stomach
flu” –
has no relation to influenza
(CONSIDER PARTICULARLY IF SYMPTOMS < 3 DAYS)
(CDC, 2007; Engel, 2007b; Isakbaeva et al, 2005)
VIRAL DISEASES: NOROVIRUS
WHY SUCH A PROBLEM?
VIRAL DISEASES: NOROVIRUS

•
•
Virus attaches to the outside of the cell’s lining of the
intestine  transfers genetic material  reproduces 
kills human cells to release new copies and to multiply
~ 23 million cases/year of acute gastroenteritis in the
United States
Highly infective, environmentally persistent, resistant to
sanitary measures and disinfectants
(CDC, 2007; Engel, 2007b; Isakbaeva et al, 2005)
Environmentally
Low ID50 (only a few particles needed)
Found in stool and vomit (airborne vomitus
particles)
 Contaminated food or drink
 Contaminated surfaces or eating utensils
(counters, salad bar utensils, etc.)
 Eating uncooked or contaminated shellfish
 Commonly occurs on cruise ships


(CDC, 2007; Engel, 2007; Minnesota Department of Health, 2005)
Common:
stable and resistant to:
Nausea
Vomiting
Watery diarrhea
Stomach cramps
Dehydration
Commonly used disinfectants
Temps up to 60 degrees C
Freezing
Direct
contact with infected people
Close living quarters – most predictable risk is a
roommate who is sick
VIRAL DISEASES: NOROVIRUS
WHY SUCH A PROBLEM?
(CDC, 2007; Engel, 2007b; Minnesota Department of Health, 2005)
An electron micrograph of the Norovirus
VIRAL DISEASES: NOROVIRUS
CLINICAL PRESENTATION
(CDC, 2007; Govoni. 2007)
24
Infectious Diseases Handouts
VIRAL DISEASES: NOROVIRUS
CLINICAL PRESENTATION

Incubation:
24-48 hours after exposure
(may be as early as 12
hours)
Less Common:






Duration: 1-2 days
Muscle aches
Chills
Low-grade fever
Headache
Fatigue
Contagious: Up to 3 days
after recovery
Immunity:
Unlikely
Many different strains
30%: Asymptomatic carriers
(role uncertain)
VIRAL DISEASES: NOROVIRUS
CLINICAL COURSE
(CDC, 2007; Govoni. 2007)
(CDC, 2007; Govoni, 2007)
HANDWASHING
is key!
No antiviral medications!

VIRAL DISEASES: NOROVIRUS
TREATMENT
No vaccine!
Especially after restroom
visits, when changing
diapers, preparing food and
before eating
VIRAL DISEASES: NOROVIRUS
PREVENTION
No antibiotics!
(CDC, 2007)
(CDC, 2007)
“Cook it,
Food:
Wash
fruits/vegetables
oysters
Steam
Contaminated surfaces:
Use bleach-based
cleaners
boil it,
peel it, or
VIRAL DISEASES: NOROVIRUS
PREVENTION
(CDC, 2006)
Contaminated clothing/linens:
Immediately remove and
wash in soap and hot water
forget it!”
Vomit/stool:
Flush/discard in the toilet
and disinfect surrounding
areas
“Cook it,
boil it,
peel it, or
forget it!”
VIRAL DISEASES: NOROVIRUS
PREVENTION
(CDC, 2006)
25
Infectious Diseases Handouts
Although a ship underwent a week of sanitization, the
norovirus still remained prevalent on the ship, consecutively
contaminating 6 cruises, same ship.
# of passengers
infected
# of crew
infected
Cruise 1
175
28
Cruise 2
192
23
513 passengers
74 crew
After 1 week cleaning
Cruise 3
55
6
Cruise 4
33
7
Cruise 5
37
4
Cruise 6
21
6
VIRAL DISEASES: NOROVIRUS
PREVENTION?
(Isakbaeva et al., 2005)
TOPICAL OUTLINE
Influenza: What’s Next?
 STDs/STIs: What’s New?
 Vaccines in Adults: Staying Up-to-Date
 Common I.D. Cases
 HIV: What’s to Watch
 Healthcare-Associated Disease
 Prevention Infectious Gastroenteritis and
Diarrhea?

24/7 Online Pharmacology
Continuing Education Updates
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Infectious Diseases
Exploring the Top 20 Drugs
Prescribing Controlled Substances
What's Hot and What to Watch
Top Killers and Top Prescriptions
Prescribing Errors and Polypharmacy
Ethnopharmacology
Psychopharmacology
Top Drugs in Acute Care
Top Pediatric Prescriptions
Top Gerontological Prescriptions
Top Drugs in the Women’s Health
Antibiotics Update and more!
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