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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]