Download RIPPED from the HEADLINES… - Mercy Medical Center Sioux City

RIPPED from the
HEADLINES…Infectious disease
updates
Barb Bancroft, RN, MSN, PNP
CPP Associates, Inc.
[email protected]
Legionnaire’s disease—2015
• South Bronx—July
• Mist from AC cooling towers at the Opera
House Hotel was the source of the outbreak
• Over 120 cases with ~ 10% mortality rate
Legionnaire’s disease—August 2015
• San Quentin Prison—California
• 1 confirmed case, 30 ill with pneumonia
• Friday, August 28, 2015
• 2 residents of an Illinois Veteran’s Home died
of Legionnaire’s disease in Quincy IL; 23
additional cases
Legionnaire’s disease—1976
• ~40 years ago the Pennsylvania branch of the
American Legion held its annual convention in
the Bellevue Stratford Hotel in Philadelphia
during the week of July 21-24. Within days of
the end of the convention (between July 24
and August 1), reports of conventioneers who
had developed an “atypical” pneumonia and
had died began to reach the headquarters.
Legionnaire’s disease—1976
• The search for a cause began shortly
thereafter, and it was soon realized that this
“new disease” was actually an old disease, but
was not recognized as such.
Legionnaire’s disease
• The earliest cases of Legionnaire’s have been traced
back to 1947, therefore it is a fairly “new” disease as
far as infectious diseases are concerned.
• Over 90% of cases of Legionnaires' disease are caused
by Legionella pneumophila
• Other types of Legionella cause a milder form of the
disease with flu-like symptoms; first recognized in
Pontiac, Michigan and is cleverly named Pontiac fever
• Legionella is not spread from one person to another.
What do we know? It’s a summertime
pneumonia!
• L. pneumophila thrives in aquatic systems. In the building
environment, central air conditioning systems in office
buildings, hotels, hospitals, and cruise ships are sources of
contaminated water.
• Other places it can dwell include cooling towers used in
industrial cooling systems, nebulizers, room-air
humidifiers, whirlpool spas (Lowe’s in Beckley WVA), water
heating systems, showers, windshield washers, fountains,
ice-making machines, misting systems typically found in
grocery-store produce sections, and dental drills
• It thrives in temperatures between 25 and 45 °C (77 and
113 °F), with an optimum temperature of 35 °C (95 °F).
The triad of symptoms for Legionella
pneumonia
• Have a high index of suspicion if pneumonia presents
in “air conditioning” season (or following a cruise or
“hot” vacation in the winter)
• Few bacterial pneumonias show the following triad of
findings:
• relative bradycardia in the presence of a high fever
(example: pulse of 80 with a temperature of 103.6º F,
(39.8º C)
• low serum sodium (hyponatremia) in the absence of
any obvious cause (and there are lots of causes)
• Elevated liver enzymes (AST, ALT)
Treatment
• Legionella multiply within the cell, so any
effective treatment must have excellent
intracellular penetration.
• Current treatments of choice are the respiratory
tract quinolones (levofloxacin (Levaquin),
moxifloxacin (Avelox), and gemifloxacin (Factive)
or the macrolides (azithromycin (Zithromax),
clarithromycin (Biaxin), and roxithromycin
(Acevor), and doxycycline.
• Most frequently used: levofloxacin,
doxycycline, and azithromycin
The HEALTH HAZARDS of AIRLINE
TRAVEL
• James Barbaree, a pathologist at Auburn University, and his
colleague Kiril Vaglenov applied smears of the bacteria,
MRSA (Methicillin-Resistant Staphylococcus aureus) and the
shiga-toxin producing E. coli strain O157:H7 to six airplane
surface types—armrests, plastic tray tables, toilet “flush”
buttons, window shades, and seat pocket cloths and
leather seats
• MRSA lasted for 168 hours, or if you do the math—7 days—
on seat pockets (where we put our iPADS, computers, and
reach for the airline magazine when bored)
• E. coli samples thrived for 96 hours (4 days) on armrests.
The HEALTH HAZARDS of AIRLINE
TRAVEL
• The second part of the study determined how
transmissible these pathogens were to human
flesh. The researchers couldn’t use human flesh
so they used the next best thing—pig skin which
has very similar properties to human flesh.
• As far as transmission to pig/human skin, they
found that the less porous the surface (tray
tables, window shades), the more transmissible
the bug.
• However, the bacteria survived longer on porous
surfaces (seat pockets)
Traveling on the airlines anytime
soon?
• So, it’s better to reach into the seat pocket
than to put your head down on that nasty tray
table to take a nap or to rest your head against
the window shade
• P.S. The government has NOT “yet” mandated
standardized cabin-cleaning regulations
Don’t panic
• And don’t yank out your alcohol swabs and
pound of Purell sanitizing wipes to scrub down
the seats, arm rests, window shades, and tray
table…
Digression: Are we too clean???
• Perhaps a little head rest on the tray table
and window shade is good for us…
• Are we overdoing the “clean” thing?
• More in a moment…
Let’s continue on airline travel for a
moment…
• Air travel is one of the major reasons why we can jet
set around the world so quickly…but it’s also why
infectious diseases can jet set around the world so
quickly with us…
• SARS was able to reach 29 countries in seven months
(including Canada) after it reared its ugly head in
China/Hong Kong in 2002.
• Ebola from Liberia—1st U.S. case was Thomas Eric
Duncan—flying from Liberia through Belgium to U.S.
via Dulles International Airport
• Patient zero brought the measles with him from the
Philippines to Disneyland…
So, are there any airports that we may
want to avoid?
• A engineer from MIT decided to model the
movement of a pathogen from a single site of
departure to junctions worldwide. He
predicted the flow of disease from a given
airport (# of people, # of flights, # of
countries) and ranked the most contagious
airports in the U.S.
• What did he find?
The most “infectious” airport is…
• John F. Kennedy (JFK) International airport in New
York emerged as number one. JFK has over 1,000
daily flights, connecting 200 airports in more than
60 countries.
• The number of international connections allows
passengers at JFK to come in contact with
individuals from many points of origin,
dramatically increasing the risk that infected
travelers could pass disease to uninfected
populations worldwide.
The most infectious airports…
• #2—LAX, Los Angeles International Airport is the
second major hub for infectious disease
transmission. LAX has more than 1,400 flights per
day and connects to 55 countries.
• #3 – Honolulu International airport. Even though
it gets only two-fifths of the traffic that JFK gets, it
poses a major risk because it has a high
proportion of long-distance flights, links to wellconnected airports (JFK, LAX, SFO) and a
geographic location that encourages an equal
diffusion of travels going east and west
And then there’s …
•
•
•
•
#4 – San Francisco
#5 – Newark
#6 – Chicago O’Hare
#7 – Washington, DC (Dulles Airport) (Thomas
Eric Duncan traveled through Dulles from Liberia
to Dallas—asymptomatic upon arrival)
• #8 – Atlanta (Even though the Atlanta is the
busiest airport in the world with 2,500 flights a
day, most of the flights are regional, in contrast to
NY, LA, Hawaii, Chicago, and Dulles. (Scientific
American November 2012)
Back to the question of “Are we too
clean today?”…
• Are we over-washing our hands? Are we oversanitizing our environment?
• Of course we should was our hands before we
eat and after we use the toilet…BUT the
mysophobic* Mom’s today scrub kids until
they’re raw…
• And… should we be slathering alcohol-based
gels on our body parts every time we turn
around?
What are the hazards of too much
hand washing?
• Hypersensitivity to components of alcoholbased gels
• Work stations are seeing an increase in grambacteria
• Mentally challenged individuals may eat it—
it’s toxic if eaten
• Igniting alcohol containing products—hit light
switch, hands can burst into flames
What are the hazards of too much
hand washing?
• Transdermal absorption of alcohol-based gels
and foams may possibly result in a false +
alcohol screening test (UALR)—If I washed my
hands every time ID tells me, I’ll be drunk)
• Development of resistant organisms
• SO as with everything in the
world…moderation is the key…
SO, we need to continue to play in the
dirt for 2 reasons…
• For our KIDS…The hygiene hypothesis— GUT
bacteria primes the immune system
• TH1 vs. TH2 pathway
• Cell-mediated immunity vs.
autoimmune/hypersen-sitivity/allergy
pathway
We need to continue to play in the dirt
for 2 reasons…
• Adults need to continue to play in the dirt to discover
new antibiotics!
• Teixobactin (investigational)—a recently discovered
compound derived from the soil bacterium, Eleftheria
terrae (January 7, 2015, Nature)—effective against
gram + bacteria only (Staph, MRSA, strep, C. diff,
anthrax, and TB)
• Interrupts cell wall synthesis—so far no evidence of
developing resistance, but it just might take a few years
• is the first member of a novel class of peptidoglycan
synthesis inhibitors (Ling et al., 2015).
• Not yet available…Novobiotics Pharmaceuticals
The hospital patient room as a
harbinger of infectious diseases
• The most dangerous bacteria are the ones that survive
on nutrient-free, inorganic surfaces such as TV
remotes, telephone handsets, IV poles, glass surfaces,
metal bedrails, keyboards, and privacy curtains. YIKES.
• A study at the University of Iowa Carver College of
Medicine (April 2012), found that 95% of the privacy
curtains in 30 rooms harbored either VRE (VancomycinResistant Enterococcus*) or MRSA, or both. When the
curtains were replaced with brand-spanking new clean
“sterile” ones, 92 percent became re-contaminated
within a week.
The hospital patient room as a
harbinger of infectious diseases
• A strain of VRE that caused a significant outbreak in the
Netherlands grew in a lab dish for 1,400 days after
being dried in a test that mimicked what might happen
in a patient’s room.
• A review article in 2011 found that 10 percent of hard
and soft surfaces in hospital rooms were contaminated
with highly resistant gram-negative bacteria
(Escherichia coli, Klebsiella, Pseudomonas, and
Acinetobacter). Approximately 15% were contaminated
with Clostridium difficile, also known as “C-diff”.
• *It took 35 years for bacteria to become resistant to
Vancomycin…
New technologies for cleaning the
surfaces are being tested
• The anti-septic properties of two metals—
copper and silver—have been known for
years. The ions of these metals interfere with
essential proteins used by bacteria. Memorial
Sloan-Kettering Cancer Center in New York
City demonstrated an association between
copper-coated “high touch” surfaces (call
buttons, bed rails, and IV poles) and lower
infection rates.
New technologies for cleaning the
surfaces are being tested
• PurThread Technologies is developing a
proprietary alloy of copper and silver, which it
melts into polyester and spins into yarn that is
eventually woven into textiles ranging from
sheets to hospital scrubs to hospital privacy
curtains. (Interestingly, Lulu Lemon—the highend athletic clothing company—uses the same
technology for their exercise clothing to
prevent the development of infections in highrisk body parts).
YIKES…get me outta this room and to the
GI lab to get scoped and go HOME…
• So that I can get out of this room!
• CRE (carbapenum -resistant enterobacteriaceae and
duodenoscopes for ERCP* procedures)…UCLA medical
center
• The very first cases of CRE were reported in 2001 in North
Carolina. Not too much brouhaha over those cases until the
summer of 2012 when an outbreak occurred at the
National Institutes of Health. Seven ICU patients died from
a CRE-resistant strain of Klebsiella pneumonia. Another
outbreak followed the NIH cases in the ICU at the
University of Virginia in Charlottesville, VA and you know
THE REST OF THE STORY…
• *endoscopic retrograde cholangiopancreatography
CRE, VRE, C. Diff
• Hospital-acquired infections, treatmentacquired infections…
• C. diff—the antibiotic-associated diarrhea;
antibiotics kill the normal healthy microbiome
providing the opportunity for C. diff to wreak
havoc
• Can be mild…can be life-threatening
C. difficile
• Significant diarrhea (“new onset of more than three
partially formed or watery stools per 24-hour period)…if
the patient has a formed stool, don’t bother to send it to
the lab for a C. diff test…they’ll throw that stool right back
at ‘cha…
• Rectal exam (Mom)
• Recent antibiotic exposure
• Abdominal pain, high fever (up to 105 or 40.5)
• Distinctive foul odor to the stool resembling horse manure
Bomers M. (April 2015). Rapid, Accurate, and ON-Site
detection of C. difficile in Stool samples. Am J Gastro
110(4):588-594
C. difficile
• 20% relapse rate
• Fecal transplants are the rage
• Not so fast…although curative for chronic C.
diff in 93-97% of the patients
• Changing the microbiome may have
interesting consequences in some patients…
• Significant weight gain is one of those
consequences…
Let’s try to prevent infections…don’t mess
with our natural barriers of defense
• A major defense barrier we have is our gastric
pH of 2-ish
• Keeps a lot of bugs OUT due to the high
acidity
• So, why in the world do we give PPIs to every
Tom, Dick, Harry, Sally, and Susie that are
admitted to the hospital? NOT the best
move…
The BARRIERS
• Proton pump inhibitors stop all acid secretion
in the stomach after 4 to 7 days—increased
risk of food-borne illnesses – Salmonella,
Shigella and every other little ‘fella’
• Increased risk of pneumonia
• Increased risk of C. difficile
PPIs and Inappropriate subscribing in
hospital patients
• Reid M et all. Inappropriate prescribing of
proton pump inhibitors in hospitalized
patients. J Hosp Med 2012 May/Jun 7:421
• Herzig SJ et al. Acid-suppressive medication
use and the risk for nosocomial
gastrointestinal tract bleeding. Arch Intern
Med 2011 Jun 13;171:991.
We’re living LONGER!! 100 is the new
60…Seriously?
• It’s projected that the number of centenarians
will increase by 6-fold in the next 35 years.
The earliest estimate of centenarians was in
1950 when the U.S. only had 2,300. There
were 104,754 in the U.S. in 2009, and that
number will be at least 601,000 in 2050*.
Which means there will be tens of
thousands of 100-year-old urinary tracts
and respiratory tracts
• And one heck of a lot of lower UTIs,
pyelonephritis’, and pneumonias
• A couple of things to know about the geriatric
patient…
• The 1% rule
Senescence and normal aging...
the 1% rule
Peak at 24, 6 good years, gradual decline to baseline of ~
1% per year; reach baseline around 72-77 (75)
FC%
Baseline function
1yr
30
75 yrs
38
But between 24 and 30…
• We’re cookin’ on all burners…
• Our brain, our kidneys, our hearts, our
lungs…
39
Variation on the theme: senescence accelerates
with chronic disease (DM, COPD)...
Reach baseline a decade sooner…
FC%
Baseline function
1yr
30
75 yrs
40
Senescence and gender
differences...the demise of the ovary
Gender differences—the ovary (51.3 +/- 2.7)
FC%
Baseline function
1yr
30
75 yrs
41
Estrogen’s effects on the lower urinary
tract
• Maintains the pH of the urine—an acid pH keeps
the BUGS away…
• Estrogen receptors line the urethra and help
prevent E. Coli from ascending into the bladder
• E. Coli from the colon would love to change
environments—and does so once estrogen
protection falters—”I’ll take the bladder…”
• Increased urinary tract infections in peri- and
postmenopausal females…
Hold that thought…
• The incidence of hypertension increases as we age—
especially in women (it’s believed that 70% of all
primary hypertension is due to an upticking of the
renin-angiotensin-aldosterone system)
• The incidence of heart failure increases in both sexes—
heart failure is a hyper-reninemic state—upticking of
the RAA system
• Type 2 Diabetes is prevalent in the elderly—
hyperinsulinemia increases angiotensin 2
• A patient with any of these conditions is a candidate
for inhibiting the renin-angiotensin-aldosterone system
“PRILS” to the rescue!
• MECHANISM of action! Inhibit ACE? Inhibit
angiotensin 2 and aldosterone
• No Angie? Vasodilate, SVR is reduced, BP falls,
decreases “load” on failing heart, and reduces
intraglomerular blood pressure
• No “AL”—excrete sodium and water (diurese)
and “SAVE” potassium—decrease BP
• Serum K+ levels rise
Who are the ACE inhibitors?– the “prils”
•
•
•
•
•
•
•
•
•
•
•
Captopril (Capoten)(1981)
Enalapril (Vasotec)(1983)
Cilazapril (Inhibace)
Fosinopril (Monopril)
Lisinopril (Prinivil, Zestril)
Perindopril (Aceon, Coversyl)
Moexipril (Univasc)
Benazepril (Lotensin)
Quinapril (Accupril)
Trandolapril (Mavik)
Ramipril (Altace)
If you can’t tolerate a PRIL, take a
“Sartan”—Angiotensin II Receptor Blockers
• Angiotensin receptor blockers (bypass ACE) and work by
blocking the angiotensin II receptors on tissues
• Who are they? The “Sartan Sisters”…
• losartan—Cozaar
• valsartan—Diovan
• candesartan—Atacand
• irbesartan—Avapro
• telmisartan—Micardis*
• eprosartan -- Teveten
• olmesartan—Benicar, Olmetec
• azilsartan -- Edarbi
And,…
• Some patients need additional aldosterone
inhibition…so, spironolactone (Aldactone) is
added…
• It’s known as a K+ sparing diuretic
• OK, OK, OK…so you didn’t need a primer on
hypertension, heart failure and kidney
disease, but…
UTI + ACE or ARB + Aldactone
• Trimethoprim, a component of the antibiotic
trimethoprim-sulfamethoxazole (TMP-SMX) slows
urinary excretion of potassium and increases the
risk (by 12-fold) of hyperkalemia-related
hospitalizations. In one study, 11% of the patients
on spironolactone received prescriptions for
TMP-SMX. AVOID this combination at all costs.
• Nitrofurantoin is also associated with
hyperkalemia.
UTI + ACE or ARB + Aldactone
• Use either norfloxacin or amoxicillin. Neither
of these antibiotics increase serum
potassium.
• (Antoniou T et al. TMP-SMX induced hyperkalemia in
elderly patients receiving spironolactone. BMJ 2011
Sep 12)
Do the testicles die at 51.3 +/- 2.7
years? NOOOOOOOOOOOO
However…an exception to the 1% rule
in men…the PROSTATE GLAND
• It enlarges with aging… increasing the risk of
UTIs and prostatitis—same warning with
antibiotics and the ACE inhibitors and ARBS
• So, be aware of antibiotic interactions with
numerous drugs taken by patients over 65
• Another example: Dig + clarithromycin =
hospitalization with dig toxicity…
However…an exception to the 1% rule
in men…the PROSTATE GLAND
• And, the increased use of the ED drugs in the
over 65-crowd has resulted in increased STDs in
that same over 65-crowd
• BABY BOOMERS GONE WILD…
• Incidence of syphilis is up 52%, chlamydia up
32%; most prevalent in retirement
communities—Arizona reported a 87% rise in
STDs from 2005-2009; Central Florida 71% rise,
Southern Florida 60% rise…
• Medicare now offers free STD screening for
Seniors but only 5% have taken advantage…
One more STI update—The newest
HPV vaccine—Gardasil-9
• HPV-9 is here (6, 11 (warts), 16, 18 + 31, 33, 45,
52, 58 (oncogenic)) (Joura EA, et al. NEJM 2015,
Feb.19)
• Gardisil and Cervarix target the two most
oncogenic types, HPV 16 and 18—responsible for
70% of cervical cancers
• The 9-valent vaccine targets an additional 15%20% of cervical cancers and an additional 5 to
20% of other HPV-related cancers—
oropharyngeal, anal, penile, vulvar…
HPV-related cancers--2010
(NIH Cancer Statistics Working Group)
•
•
•
•
•
•
Cervical cancer (>90% HPV-induced)
Vulvar (~69% HPV-induced)
Vaginal (~75% HPV-induced)
Penile (~63% HPV-induced)
Anal (~91% HPV-induced)
Oropharyngeal – 2370 (~72% HPV-induced) (6-7 x
more common in men)
“Well, I’m going to be a virgin when I get
married…”
• HPV vaccine has to be given before the boys
and girls start having SEX…98%+ effective if
administered before sexual activity; less than
17% effective once HPV is established
New vaccine for malaria
• Approved July 24th,2015 in Europpe
• Mosquirix—27 years in the making
• In 2013 alone malaria killed 600,000, mostly
African children and sickened 2,000,000.
• Funded by the Bill and Melinda Gates Foundation
• GSK + PATH Malaria Vaccine Initiative
• Not perfect (30% effective and protection wanes
over time, but it’s better than the NOTHING that
was available up to now…
PEARL…
• Unexplained fever, anemia, and an enlarged
spleen in someone who has traveled to an
endemic area—consider MALARIA
Speaking of vaccines-“Herd” immunity
• “Herd” immunity (the population immunity level
needed to interrupt transmission)
• In other words, if you vaccinate enough people in
a community the virus/pathogen can’t spread
• The herd-immunity threshold for measles is 9294% to prevent sustained spread of the virus;
• Currently only 91% of kids in the U.S. are
vaccinated against the measles
• The average person with measles is capable of
infecting 12 to 18 other people if all his or her
contacts are susceptible.
Herd immunity
• Mississippi? 99.5% of kids are vaccinated (because there
are no legitimate reasons to OPT out, except for age and an
immunocompromised status);
• California? Less than 92%--(parents opting out for
“religious” reasons, personal reasons, “the risk of autism”,
blah, blah, blah…)92% of the 2015 January cases are traced
back to the Southern California outbreak, where the most
fervent antivaxxers live
• Just passed a law that if you opt out you either move out of
the state or home school the children
• Index case for the recent measles epidemic was a child
from the Philipines with measles visiting Disneyland in
Anaheim, California)
The lack of “herd” immunity
• Schools in some of Los Angeles wealthiest
neighborhoods now have similar vaccination rates to
developing countries like Chad and South Sudan. At the
Kabbalah Children’s Academy preschool in Beverly
Hills, 57% of parents have filed a personal belief
exemption from vaccinations as have 68% at the
Waldorf Early Childhood Center in Santa Monica.
• In other words, more parents have had BOTOX shots
than their kids have had vaccines in LA
• This will change with the new legislation
• Hollywood Reporter The WEEK 2/13/15
Measles vaccine
• The first live attenuated measles vaccine was
released in 1963. Current vaccines are highly
effective—about 94% for a single dose, if it’s
administered in the second year of life. With
two doses administered on or after the first
birthday and at least one day apart, almost all
immunocompetent children are protected
against measles for life.
• Greater than 95% protection
Measles infection—the long lasting
effects on the immune system
• Anti-vaxxers trivialize the measles as just another
childhood disease that kids recover from without
sequelae. Once again, they are wrong…an acute
case of the measles can not only cause lasting
cognitive impairment, it can also kill you.
• But it’s not just the acute infection with the
measles that’s dangerous in kids—even three
years after suffering a measles infection kids are
about twice as likely to die from other infectious
diseases as children who haven’t had the
measles.
Measles infection—immune amnesia
• Prior to the mass vaccination campaign of the 1960s,
approximately 650 children died from measles per year.
Once the vaccine campaigns took place around the world,
childhood mortality rates from infectious diseases dropped
more than expected.
• The reason for the drop was unknown at the time, but
researchers have found a link between measles cases and
children who subsequently died from other infectious
diseases. The theory is that the measles virus kills the
memory cells from past infections. So kid’s immune
systems have trouble remembering previous infections as
well as fending off future microbial infections after having a
case of the measles. This is referred to as “immune
amnesia.”
Measles infection—the long lasting
effects on the immune system
• The biggest killers post-measles infections were
pneumonia, diarrheal illness, and meningitis. The
effect observed was so large (Mina’s study) that
when measles was common, the team calculated
that it was implicated in approximately 50% of all
childhood deaths from infectious disease.
• (New Scientist, May 16, 2015; Science News, May
30, 2015; Mina M, May 8, 2015 Science;
doi.org/4jq)
Bottom line…
• Stay out of hotels and hospitals in the summer
• If you’re traveling on an airline, DON’T travel
through JFK, LAX, Honolulu or Chicago
• Don’t touch the tray table!
• Wash your hands when you’re working but don’t
over do it!
• Don’t live to be 100 years old
• Practice safe sex in the nursing homes
• Vaccinate, vaccinate, vaccinate
Thank you.
• Barb Bancroft, RN, MSN, PNP
• www.barbbancroft.com
• [email protected]