Download ID in the Elderly: GI,GU and Respiratory Infections

Infectious Disease in the Elderly
and Long Term Care Facilities
module 1
Gastrointestinal diseases
UNMC
Section of Infectious Diseases
Brandi L. Lesiak, PA-C, MPAS
Kim Meyer, PA-C, MPAS
Claudia Chaperon APRN, PhD
Ed Vandenberg M.D., CMD.
Updated 11-23-06
PROCESS
A series of modules and questions
Step #1: Powerpoint module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
Overview of Goals
• To review the major points of
Unit one
-GI infections: gastroenteritis/colitis, hepatitis
-GU infections: UTIs
Unit two
-Respiratory:
URIs, influenza, pneumonia,
& sinusitis
-Skin/soft tissue: shingles, scabies
• To emphasize the role these infections
play in the elderly/nursing home patients
Objectives for module one
Upon completion, the learner will be able to:
1) List the common causes of
gastroenteritis
2) Describe the diagnostic features of
noninvasive and invasive organisms
3) List the diagnostic tests and treatment for
infectious causes of gastroenteritis
Gastrointestinal infections
“Where will you be when your diarrhea
comes back?
Right here!!
Case #1
• 76 year old female in your nursing home
begins having diarrhea, 6-8 stools per day
• She has a low-grade temp, mild abdominal
cramping, no N/V or other symptoms
• She was recently treated for cellulits
secondary to a cat bite with Augmentin for
10 days, ending 5 days ago
• What are the possible causes of her
diarrhea?
• What tests would you order?
Gastroenteritis/colitis
• Epidemiology:
– Most infections occur
after oral ingestion
– Elderly at greatest risk
for mortality
– Outbreaks in long-tern
care facilities are of
major concern
Gastroenteritis/colitis
• Reservoirs
– Human
(person to person spread)
• Fecal-oral route
– Food/water
• Epidemic common-vehicle
• Common in LTCF setting
Source of Gastrointestinal
Pathogen
Reservoir : Food/Water
– Nontyphoid
Salmonella
– C. perfringens
– C. botulinum
– Yersinia enterocolitica
– Campylobacter
– Bacillus cereus
– E. coli 0157
Reservoir: Humans
Salmonella typhi
Viral gastroenteritis
Shigella
Staph aureus
Amoebae
E. coli
Giardia
Common Food Vehicles for Specific
Pathogens or Toxins
Vehicle
Pathogen or toxin
•
•
•
•
Undercooked chicken…  Salmonella spp
Eggs………………………  Salmonella spp
Unpasteurized milk……  Salmonella, Campylobacter, Yersinia
Giardia, Norwalk virus, Campylobacter,
Water………………….......
•
•
•
•
Fried rice………………….Bacillus cereus
Shellfish………………….. Vibrio spp, Norwalk virus
Campylobacter, C. perfringens,
Sushi……………………… Anisakis spp
Beef, gravy………………. Salmonella spp, Campylobacter,
Cryptosporidium, Cyclospora, Aeromonas
C. perfringens
Gastroenteritis/colitis
Pathologic Classification of Pathogens:
1. Enterotoxin-mediated watery diarrhea syndrome
2. Partial mucosal invasion
3. Complete mucosal invasion
Enterotoxin-mediated watery
diarrhea syndrome
• Preformed toxin:
– Staph aureus
– Bacillus cereus
• Toxin made in host
– Clostridium perfringens
– Vibrio cholera
– Enterotoxigenic Escherichia coli
The Dysentery Syndrome =
partial mucosal invasion
• Organisms include:
– Shigella**
– Campylobacter
– Entamoeba histolytica
– Clostridium difficile**
– Enterohemorrhagic E. coli**
Clostridium difficile
• A gram-positive spore-forming anaerobic
bacillus
• The most common identifiable pathogen
causing antibiotic-associated diarrhea and
colitis
Clostridium difficile
• Pathogenesis
– Disruption of normal bacterial flora of colon by
antibiotics, especially clindamycin, ampicillin,
amoxicillin, fluroquinolone and the
cephalosporins
– Some strains of C. difficile are nontoxinogenic, but the majority make 2
exotoxins: toxin A and toxin B
– Toxin A is mainly responsible for disease
Clostridium difficile
• Epidemiology
– 3 million cases of diarrhea and colitis in U.S.
each year
– Most in hospitals and long-term facilities
– Transmission ….patient to patient
– Cultured from environmental surfaces in
rooms of infected patients: hands, clothes and
stethoscopes
– Hospital personnel may carry the bacteria from
room to room and promote infection
Clostridium difficile
• Endoscopy…diffusely
thickened or edematous
colonic mucosa
• Clinical manifestations:
– Presentation…..variable :
diarrhea, colitis without pseudomembranes, psedomembranous
colitis, and fulminant colitis
– Systemic symptoms…. variable:
– cramps, diarrhea, fever,
nausea, anorexia, fatigue
– Diarrhea………………variable:
minimal to profuse diarrhea.
– Laboratory…………..variable:
leukocytosis with left shift and
fecal leukocytes or no change
Clostridium difficile
• Diagnosis:
– Stool culture (rarely used)
– Tissue culture assay for cytotoxicity of toxin B
(most sensitive and specific test, but takes 1-3
days and need special equipment)
– EIA – most commonly used,
-sensitivity 71-94%
-(because of low sensitivity send 3 samples)
Clostridium difficile
• Treatment:
– Discontinue antibiotic if possible
– Supportive therapy
– Avoid antiperistaltic and opiate drugs
– Oral metronidazole is treatment of choice
– Avoid oral vancomycin if possible to prevent
selection out of VRE
Complete Mucosal Invasion
• Organisms include:
– Salmonella
– Yersinia
– Listeria
Viral Gastroenteritis
• Rotavirus and Norwalk virus most
common in outbreaks among elderly
• Not detected on routine stool cultures
• Special testing available
– Rotavirus direct Ag
– Norwalk RNA
• Sudden onset of nausea and vomiting
Treatment:
• Supportive care/hydration/hand washing
Diarrhea - Workup
Test
Potential organisms
Indication
Stool WBC
Invasive organisms
Screen for inflammation
Stool culture
Salmonella, Shigella,
Campylobacter, cholera, Yersinia
Fever, persistent diarrhea,
fecal WBCs
Culture
negative
diarrhea
E. coli 0157:H7 assay
Hamburger exposure,
Hemolytic Uremic Syndrome
C. dif EIA
Clostridium difficile toxin
Recent antibiotics
Stool for O & P Amebiasis, Cryptosporidium,
Giardia, Cyclospora
Travel, HIV risks
Stool for
viruses
Institutional outbreaks
Rotavirus
For Outbreaks – Norwalk,
adenovirus, calicivirus, astrovirus
Role of Antibiotics in Specific
Causes of Bacterial Gastroenteritis
Role of Antibiotics
Enteropathogen
Always indicated
Shigella
Listeria
Indicated in certain clinical
settings or hosts
Salmonella
Cryptosporidium
Campylobacter
Yersinia
Amebiasis
Cyclospora
Giardia
Clostridium difficile
Not indicated
E. coli 0157:H7
S. aureus
Toxin-mediated disease
Gastrointestinal infections
(1)
• Supportive care/treatment
– Adequate hydration is imperative, especially
in elderly patients
– Slow down bowel motility?
• attapulgite ( Kaopectate) or bismuth subsalicylate
both dosed as 1- 2 tablespoon every 30 min with
each loose stool
• As always, good hand washing is very
important!
• Infection control measures
• Appropriate contact isolation
Case #1
• 76 year old female in your nursing home
begins having diarrhea, 6-8 stools per day
• She has a low-grade temp, mild abdominal
cramping, no N/V or other symptoms
• She was recently treated for cellulits
secondary to a cat bite with Augmentin for
10 days, ending 5 days ago
• What are the possible causes of her
diarrhea?
• What tests would you order?
Case #1
• Stool is checked and positive for C. Diff
toxin
What important measures should you take?
• Contact isolation very important
• Watch for signs of dehydration
• Keep pt well-hydrated
• Alcohol-based hand gels do not kill C.
Diff— you need to use soap and water!
• Patient history and knowledge of any
recent infection outbreaks important
The End of Module One
on
Infectious
Gastrointestinal diseases
in the elderly
Post-test
• An 80-year-old woman is transferred from the hospital to
a chronic-care facility. She has Alzheimer’s disease with
severe memory impairment, malnutrition, and a pressure
ulcer. You subsequently receive a report that a stool
specimen obtained several weeks ago during
hospitalization was positive for Clostridium difficile toxin
A.
• The patient is eating well, and weight is increasing. She
has had a well-formed stool at least every other day
since admission, and her roommates have not had
diarrhea. She is afebrile, and no abdominal pain is noted
during physical examination. Leukocyte count is normal,
and no fecal leukocytes are detected. Which of the
following is the most appropriate next step?
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Which of the following is the most
appropriate next step?
A. Monitor the patient for a recurrence of
diarrhea.
B. Submit another stool specimen for C.
difficile testing.
C. Begin prophylaxis with Saccharomyces
boulardii
D. Begin therapy with metronidazole.
E. Begin therapy with vancomycin
Answer: A. Monitor the patient for a
recurrence of diarrhea.
C. difficile–associated diarrhea is common in
hospitalized older adults and residents of
nursing homes. An even greater proportion of
frail nursing-home residents carry toxin A–
producing strains for prolonged periods, without
symptoms. All such colonized nursing-home
residents do not appear to be at the same risk
for diarrhea. Recent antibiotic use is the greatest
risk factor for development of diarrhea, followed
by the presence of a feeding tube, incontinence,
and more than three comorbid illnesses.
• Monitoring for a recurrence of diarrhea is
most appropriate for this patient. Multiple
strains of C. difficile have been
documented in nursing homes with little
evidence of transmission among patients.
Universal handwashing, gloving, and
disinfection are appropriate strategies for
routine containment. Confinement of
patients to their rooms is not indicated
unless diarrhea is documented as a
problem in the facility.
• Stool testing for C. difficile toxins is not indicated in
patients with formed stools. If the patient has diarrhea
and a recent history of antibiotic therapy, submission of
multiple specimens is useful if a single specimen is
negative for toxin A. Treatment should be reserved for
patients with persistent or recurrent diarrhea.
Metronidazole is inexpensive and as effective as
vancomycin for antibiotic-associated diarrhea. A second
antibiotic course usually is effective for the 5% to 30% of
patients with recurrent diarrhea following therapy. If
retreatment is not effective, reestablishment of
nonpathogenic flora to rid the gut of C. difficile has been
attempted. Prophylactic colonization with S. boulardii has
had some success in preventing recurrent diarrhea.
• end
Readings and Resources
Recommended readings and resources;
Geriatrics at Your Fingertips 8th edition
2006-2007 pages 78-79