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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) 1 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) 2 Infectious Diseases Handouts 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) 3 Infectious Diseases Handouts 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) 4 Infectious Diseases Handouts 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? 5 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) 6 Infectious Diseases Handouts 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) 7 Infectious Diseases Handouts 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) 8 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) 9 Infectious Diseases Handouts 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) 10 Infectious Diseases Handouts 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) 11 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) 12 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) 16 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! 18 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 ) 19 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) 20 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 ) 21 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 22 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) 23 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! www.NPcourses.com ~ THANK YOU ~ P.O. Box 69901 West Hollywood, CA 90069 1.866.938.5557 WWW.NPCOURSES.COM www.NPcourses.com 26